Locally Advanced Basal Cell Carcinoma - Episode 5

Cemiplimab for Treatment of laBCC

An expert discusses treatment options available for patients with locally advanced basal cell carcinoma (laBCC) who don’t respond or are intolerant to the first-line therapy option.

Anna C. Pavlick, D.O.: Fortunately, for us, there have been advances with the treatment of locally advanced or metastatic basal cell carcinoma. We have now completed studies that allow us to use what are called checkpoint inhibitors, or anti-PD-1 inhibitors, when treating patients with locally advanced or metastatic basal cell cancer. These are, in fact, intravenously given immunotherapies. What does that mean? It means that what we are going to do is wake up a patient’s immune system and get that immune system to go out and attack the tumor with T cells and memory cells and be able to really harness a patient’s immune system to attack the cancer. It is very different than a pathway because we are not putting up a blockade in the signal. It is not like chemotherapy because we are not causing cellular damage which is what chemotherapy does. We are just waking up a patient’s natural immune system and getting it to make more T cells, more memory cells, and more natural killer cells that are going to go out there and try to attack the tumor.

Some people will tell me that an advantage to an intravenous therapy is that you come into the office, you are there for 30 minutes, you get it, and then you forget that you have cancer for the next 3 weeks. Whereas when you must take a pill every day, it is a reminder that you have cancer every day. It really is a personal preference. The infusions are over 30 minutes, given once every 3 weeks. Although immunotherapies are not targeted therapies and they are not chemotherapies, they will also have potential side effects as well that we need to discuss with patients. However, the frequency at which they happen is low. Still, patients do need to know that there are side effects that go with immunotherapy.

The FDA [Food and Drug Administration] approval of cemiplimab [Libtayo] for the treatment of basal cell carcinoma has really helped revolutionize what we can offer patients for this type of disease. When we talk about the potential side effects, we have to think about what immunotherapy can do, and essentially the answer is it causes a lot of inflammation. We cause a lot of these inflammatory cells to get released and to go attack the tumor. The side effects that occur as a consequence of cemiplimab are really immunologically driven, so the most common side effect that we see is really in the skin. Patients can get rashes. They can get little red rashes. They can get red rashes that cover their chest wall or their arms and their legs. Those rashes may or may not be itchy.

I think one of the most bothersome side effects for most patients is when they have itching but they do not have a rash. It is OK if you itch because you have a rash and you can see it, but what happens when you just wake up and you are just itchy but there’s no rash? A lot of people are very hesitant to talk to their oncologist about that because they do not have a rash but they are itchy. Why? Again, the answer is that we are stimulating the immune system and, as a consequence, we can stimulate itching without that rash.

In rare cases, some of the other inflammatory things that we can cause are inflammation of the inside of the lungs. That is called pneumonitis. That happens very, very rarely but when we see our patients we ask them, “Do you have any cough? Do you have any shortness of breath?” Pneumonitis can present itself in such a way that patients will just have a persistent dry cough. It will not be productive of any mucus, but they will be very short of breath, especially when they try to exert themselves. Another side effect is colitis or an inflammation of the colon. This presents itself as diarrhea and the diarrhea can just happen overnight. It is not very common with these medicines. However, there are some patients who do have some underlying bowel issues that these drugs can perturb and cause to have diarrhea.

Again, we know how to manage these side effects. Patients just really need to tell us about them.

Transcript edited for clarity.