Shahab Babakoohi, MD: For these patients, we have very close monitoring. We usually do not necessarily follow the standard rule that when you have a normal skin cancer, for example, have a skin check every 6 months. This is not the case in these situations. We see these patients much more frequently. I see them at least a couple of months after starting inhibitor therapy. Sometimes we see that they're clinically not responding. In that case, we don't need even to do a biopsy. We see that for example, large ulcerating lesion staying same, but in some cases that we see a great response, or we see a clinical feature that can be consistent with response. I proceed with scalping biopsies depending on the size of the lesion. Many times, frequently I get like 5 biopsies at the center and then 12, 3, 6, 9 o'clock to evaluate all the margins on the center for the response to see if there is any tumor present or not. The patient continues inhibitor therapy or prefers to have some type of no treatment because of adverse effects or for any other reason. We keep close monitoring. We do imaging, we take pictures frequently. I know you also do that. Make my life easier when I see your patients. This is important because we need to see the trend of changes and different pictures to not to put the patient through numerous biopsies, if we don't need that. And photo documentation, which fortunately we have the technology these days is one of the, in my opinion, necessary tools in monitoring these patients.

Jennifer Atlas, MD: What would you say as far as would you expect to see a recurrence job? It's really variable and since kind of using an upfront neoadjuvant systemic approach here those objective response rates, we do see excellent responses. But that's including both stable disease, partial responses and complete responses. It’s hard to give definitive hard numbers there because there's not any neoadjuvant trial.

Shahab Babakoohi, MD: I agree. I remember that when hedgehog inhibitor therapy came, there was one case series in Israel, 9 patients just off top of my head, then couple of more case 3 reports and case series came and obviously basal cell carcinoma frequently, because this is not very aggressive, especially if get hit by some treatment frequently maybe this patient don't show up for follow up. Many times, they go with other providers if they move to another city, because this is sometimes a chronic disease. It's not like some other cancers that takes people's life in matter of weeks or month. We don't know exactly how much the rate recurrence is because it's a relatively new treatment option that we have. We have that the standard numbers based on literature for a decade that for example, most micrographic surgery, 98 to 99% chance of cure or excision 95% these are traditional numbers or radiation oncology people have some numbers off top of my head. I'm not radiation oncologist at 90% depending on the location and the type of tumor. But I agree with you that we do not have solid data, obviously with a large tumor in a high-risk area. We always expect some recurrence, but I don't think there is any solid data.

Jennifer Atlas, MD: What I can say is that the prognosis for locally advanced basal cell carcinoma is that amongst those 40 to 44% patients for locally advanced disease are going to have a response to a hedgehog inhibitor. The responses can be durable, and we do have a percentage of those that will have complete responses and not go on to need any additional local regional management. In my clinical practice most of these patients who have a locally advanced tumor, what my goal is from a medical oncology standpoint is in an ideal world to have a complete response, if not to try to get a partial response and work with my multidisciplinary team to go for curative therapy that may include surgery, radiation, most surgery in some format.

Transcript edited for clarity.