Jennifer Atlas, MD: Let's review treatment options for patients with locally advanced basal cell carcinoma such as we've described in this clinical scenario. Dr Babakoohi, what do you see as the role of radiation therapy in basal cell carcinoma?

Shahab Babakoohi, MD: Radiation therapy is very effective way to treat basal cell carcinoma. Response rate is great, but less than standard surgical excision when you do radiation because you have not removed the tumor so when you do follow up, you need close attention to the area for discovery recurrence at the site of radiation because radiation can cause some skin changes like that fibrotic tissue and scar like tissue that happens in the area. You need very close dermatology follow-up for very close monitoring to make sure the tumor is not back. Radiation also, it's not feasible in all the patients. For example, patients who received radiation before in that area, many times our radiation oncology colleagues are not able to provide further radiation in the same area. Also, there are some tissue scars from previous surgeries and radiation oncology colleagues sometimes hesitate to radiate the area which is already traumatized. For this purpose, also in my experience for younger patients with history of multiple skin cancers, that can be another challenge because you foresee multiple other cancers coming up and radiation several times on usual sensitive areas like face is not easily feasible. Obviously, this is something in the area of radiation oncologist specialty so they may be able to give more insight than me, but this is the experience that we see in daily practice or meetings in our multidisciplinary team meetings. Also, radiation itself after several years can increase skin cancer in radiation. For example, people who get radiation for breast cancer after 20 years there is a chance of developing skin cancers at the area of radiation. If you have a patient who is very young and you give too much radiation, you should consider that in several years, some skin cancers also can happen in that area. Overall, radiation has been beneficial in many patients, mostly in patients who are at higher risk on more your side regarding their age. And I have seen good results with radiation.

Jennifer Atlas, MD: Can you tell me about the goals of surgery for basal cell carcinoma and who's considered a surgical candidate?

Shahab Babakoohi, MD: Surgery is a standard of care for skin cancer and the goal having free margins. If they removed the tumor and stop pathology shows free margins you pretty much, most likely cured the cancer, although the risk of recurrence exists in any surgery and depending on the location. In some locations, like for example, on your shoulder or your back, because the surgeon has the luxury of having enough tissue. The chance of recurrence is less because they can have very safe margin. But when they do, for example, surgery, more sensitive area, like in most micrographic surgery, close to the eyelid then it's very hard to get very large safe margin, but overall, the goal of surgery, having free margins and having no tumor more left, which is the goal.

Jennifer Atlas, MD: Are there any limitations to different surgical approaches in treating basal cell carcinomas, especially the low risk versus high-risk disease?

Shahab Babakoohi, MD: Yes. Standard excision that is considered you summarize where nicely the lowest basal carcinomas surgical excision, which is standard excision, just have a safe margin and take the lesion off, stitch it off or send it to pathology. That's a standard of care and can be successful in low-risk areas. It high rate of success, but for sensitive areas, like as you mentioned, face, genitalia in patients for high risk or immunocompromised the chance of having the perennial invasion or more infiltrated extension of the tumor is higher. And in these people, most micrographic surgery usually is the treatment of choice because during the procedure you look under microscope to make sure your margins are free and if not, you go back to their room and take more tissue. These 2 techniques should be used appropriately depending on the histopathology patient demographic and clinical features.

Jennifer Atlas, MD: And certainly, for patients who do not meet candidacy for either curative surgical resection or radiation, then we fall back onto our systemic therapy options, which come in the form of hedgehog inhibitors and now anti PD1 antibody dosing with some cemiplimab. Those exist for patients who once again have locally advanced disease, including those with regional involvement of lymph nodes, or are metastatic patients, which is a small fraction of what we see. I see more locally advanced patients, but who may have surgeries or radiation that is being looked at in sensitive areas like we've mentioned previously, or there's a high risk that there's going to be positive margins or morbidity involved with those local regional treatments. Systemic therapy may be optimal first choice for them.

Transcript edited for clarity.