Do patients with advanced, metastatic, or recurrent basal cell carcinoma need to be seen by medical oncology?

Referral to Medical Oncology for Advanced Basal Cell Carcinoma

Yes, patients with metastatic or locally advanced basal cell carcinoma that is unresectable, has recurred after surgery, or where surgery would cause substantial deformity should be referred to medical oncology for multidisciplinary management and consideration of systemic therapy with hedgehog pathway inhibitors. 1

When Medical Oncology Referral is Indicated

Metastatic Disease

• All patients with metastatic BCC require medical oncology consultation to coordinate systemic therapy with hedgehog pathway inhibitors (vismodegib or sonidegib) as the primary treatment. 1, 2
• When metastatic disease is limited to regional lymph nodes, surgery and/or radiation remain most appropriate when feasible, but should still be managed by a multidisciplinary tumor board that includes medical oncology. 1
• For distant metastases, multidisciplinary consultation is essential to guide treatment with hedgehog pathway inhibitors. 1, 2

Locally Advanced Disease Requiring Systemic Therapy

• Medical oncology referral is indicated when:
  • Surgery and radiation are contraindicated or inappropriate for locally advanced BCC 1
  • Residual tumor persists following surgery and/or radiation therapy and further surgery/radiation are contraindicated or inappropriate 1
  • Clear margins cannot be achieved after Mohs micrographic surgery or resection with complete circumferential peripheral and deep margin assessment 1
  • The lesion has recurred after radiotherapy (unless radiotherapy was contraindicated) and is either unresectable or surgical resection would result in substantial deformity 3

Role of Multidisciplinary Tumor Board

• Nodal or distant metastases should be managed by a multidisciplinary tumor board that considers systemic therapy with hedgehog pathway inhibitors or treatment in clinical trials. 1
• The board should include dermatologists, surgeons, medical oncologists, pathologists, radiologists, and radiation oncologists to address the spectrum of management issues. 4
• Evaluation by experienced physicians and/or multidisciplinary tumor board for possible curative/definitive surgery with or without radiation is recommended before initiation of systemic therapy. 5

Systemic Therapy Options Requiring Oncology Management

First-Line: Hedgehog Pathway Inhibitors

• Vismodegib (FDA-approved) demonstrated 30-33% objective response rate in metastatic BCC with median response duration of 7.6 months. 1, 2, 3
• Sonidegib (FDA-approved) is an alternative hedgehog pathway inhibitor. 1
• These agents showed 37.9% overall response rate in the STEVIE trial for metastatic disease. 1, 2
• Medical oncology expertise is essential for managing these therapies, as 36% of patients discontinued treatment due to adverse events including muscle spasms, alopecia, dysgeusia, and weight loss. 2

Second-Line Options

• If hedgehog pathway inhibitors are not feasible or fail, platinum-based chemotherapy may be considered under oncology guidance. 1, 2
• Best supportive and palliative care should be coordinated to optimize symptom management and quality of life. 1, 2

Common Pitfalls to Avoid

• Do not use systemic therapies in place of curative procedures when surgery or radiation can achieve cure, even if these procedures are extensive. 5
• Do not delay multidisciplinary evaluation for patients with advanced disease, as early coordination improves treatment planning. 1, 4
• Do not underestimate the need for long-term monitoring by medical oncology, as systemic therapies require regular assessment for side effects, benefit, and compliance. 5
• Ensure proper counseling for patients of child-bearing potential regarding birth defects and need for contraception with hedgehog pathway inhibitors. 5

Follow-Up After Treatment

• Close follow-up remains essential as 30-50% of BCC patients develop another BCC within 5 years. 1, 2
• Complete skin examinations should occur at least every 6-12 months during the first 2 years. 1, 2
• Continued surveillance by both dermatology and medical oncology is recommended for patients treated with systemic therapy. 1, 2