Locally Advanced Disease: I/O or Surgery Decision Factors
A discussion on the use of immunotherapy and surgery in locally advanced cutaneous squamous cell carcinoma (CSCC), and the decision factors for treatment selection.
PUBLISHED June 15, 2020
Anna C. Pavlick, DO: When you look at a patient who’s got locally advanced disease—I think we’ll take metastatic disease out of the picture right now—let’s say multifocal lesions on the scalp or even some local lymph node disease, I’m essentially thinking about these head and neck carcinomas that are really pretty common. At least they are for me. Is there any variable that would sway you to not want to give people immunotherapy and think about if we should do surgery instead, or talk about radiation rather than immunotherapy for this local control, because it’s just too diffused for you to manage it surgically?
Anthony Rossi, MD, FAAD: Now we are having even better discussions with the patient, mainly the shared decision-making, as we like to call it. Really engaging the patient to see what their wishes are. Surgery is feasible in many cases, however, it’s not without its morbidity, especially when these tumors are close to the eyelid, close to major structures like the nose. If you proceed with surgery, while you may be able to achieve negative margins, you may be actually removing critical structures. That has a lot of quality-of-life issues down the road and even just morbidity for the patient.
If we have good preoperative staging and we know that these tumors are deeply invasive, then we know there’s an increased risk of local recurrence or even regional metastasis to the lymph nodes. At that point it’s really crucial to present the patient with all these options, including immunotherapy, because if they do have a good response to immunotherapy, they may be able to forgo the radical resection.
Anna C. Pavlick, DO: I agree, and I’ve recently come across a couple of patients, because I think it’s very important that patients truly understand the potential benefit of immunotherapy. Not all patients are going to respond to immunotherapy—only about 50% will. But we also have to thoroughly go through the potential side effects, because even though they are small, some of them may be lifelong, such as the endocrinopathies.
When you deal with older patients, some of them are more willing to accept more risk with respect to immunotherapy toxicity because they don’t want surgery. But I’ve seen a lot of younger people say, “I really don’t want to take the chance of being subjected to insulin-requiring diabetes,” even though it’s a very, very small risk. It is a risk, and they would opt more to have a surgical excision than be subjected to the risk of a lifelong medical issue.
Anthony Rossi, MD, FAAD: Agreed. Age is an important factor, though we are seeing squamous cells now even presenting in younger patients. Granted, those are usually very early, which are curable with regular surgery. But even in our middle-aged patients or patients who are maybe considered older but still have an active lifestyle, a large resection of the entire scalp with lymph node removals, that can predispose them to a lot of morbidity later on. These are all important questions that we need to ask, not only the patient but ourselves, to see what the best initial treatment might be in these larger, more complex locally advanced disease.
Anna C. Pavlick, DO: That really is the take-home message: this is not a unilateral physician decision. It’s not really a group of physicians making that decision. Yes, we can give our recommendations, but as health care providers really need to incorporate the patient into that decision-making process, because even though my inclination might be, “Yes, I really think you should do immunotherapy,” I’ve had some patients say, “I think I’d really opt for radiation therapy.” Many times they do have a valid reason, and many times they don’t. But it really is such a multilevel discussion about the right option because there is no right answer.
Anthony Rossi, MD, FAAD: Agreed. Just knowing their home situation is important for all these treatments. How they’re going to get back and forth to the hospital or how they’re going to get to someone’s office. These are all smaller points, but they really build up a bigger picture.