Infusion Therapy for Non-Melanoma Skin Cancer: A Dermatologist’s Guide

Learn how one dermatology practice integrates in-office infusion therapy into daily clinical workflows. This video explores the practical aspects of treating advanced non-melanoma skin cancers with systemic therapy, including a firsthand account from a patient undergoing infusion.

Dr George Murakawa: Hi, I'm George Murakawa, and I'm a board-certified dermatologist as well as a board-certified Mohs micrographic surgeon. Our practice here, we do a number of things, including dermatologic surgery, complicated medical dermatology, and we handle a number of difficult and interesting cases. One of the things that we do is infusion therapy, and today we're going to infuse a patient who has an aggressive basal cell carcinoma.

Sarah Collins: I am Sarah, I'm a registered nurse here, and I administer the infusions. And we will walk you through how we do that here today.

Dr George Murakawa: We've been infusing in our office since 2005, the first year we opened up here. We started doing it because infliximab first got approved for psoriasis and psoriatic arthritis. And then we've taken on a number of other medical diseases and used a number of other infusion medications. With infliximab and with rituximab, they're a little more complicated, but the current medications—the newer biologic medications we use to treat both advanced basal cell carcinomas and squamous cell carcinomas, as well as for Sézary syndrome and mycosis fungoides—they are much easier to infuse, take a lot less time, and we really have not had any immediate adverse reactions to it, so we're very comfortable in doing it.

You have to make sure that it works for your practice. It works okay for us. There’s medications where we don’t get reimbursed the full cost of the medication, and then we do it as a pharmacy benefit. Now, the other issues are the infusion process itself—do patients have infusion reactions, do they have other incidents. With the other biologic medications that aren't fully humanized, sometimes they do get infusion reactions. We're very capable of handling it. We just slow down or stop the infusion for a bit. We may hydrate them, give them a little bit more Benadryl, or might give them some Solu-Medrol, and then we try to restart it. We've had a couple of cases where they'd start to hive up right away and start to feel not right. We terminate it if we need to, but in general, we've had very few issues. With these newer medications, including those used for aggressive basal cell and squamous cell carcinomas, we have not seen this at all.

Now the longer-term issues that you see, and the autoimmune reactions, those aren't acute, and that you’re going to have to confront regardless of whether you're infusing or not. But as far as the infusion process itself, it’s actually pretty straightforward and pretty easy to do. We see a lot of patients with basal cell carcinomas and squamous cell carcinomas, some a lot more aggressive than others. Now, you know the bad cases when you see them, and sometimes they're just not excisable with Mohs or any other modality. And some of them have bad perineural invasion, extend down into bone—we know we’re not going to clear them. In those cases, infusion therapy using monoclonal antibodies are highly effective and pretty straightforward and simple to use. That’s when you’re going to reach into your bag of tricks and add that into the arsenal.

Nick: Hi, I'm Nick. I'm a patient of Dr Murakawa’s, and I've been receiving infusion injections. I've been a patient of his for 6 weeks now, and this will be my third injection. The infusion takes about an hour and 10 minutes or so. There's 30 minutes where you receive a saline solution, and then you get a break to check your vitals, and then you get another 30 minutes of the actual drug infusion.

Sarah Collins: Alright, so we are here today to do our infusion. Today is the third infusion, correct? 

Nick: Correct, yep.

Sarah Collins: Okay. How did everything go last time? Any issues?

Nick: None. It went great.

Sarah Collins: Good. Do you have a preference on which arm? It looks like the left one here.

Nick: We’ll do the left arm, if that’s ok. 

Sarah Collins: Perfect. Alright, I’ll put a pillow under you here. So what we’re going to do, like last time, we’ll get the IV started. Dr Murakawa does want to do a little bit of blood work on you here today.

Nick: Okay.

Sarah Collins: Just check your levels and make sure everything’s going okay. So, we’ll start the IV, we’ll get some bloodwork on you, and then we’ll hang that hydration bag, like we did last time. It runs about 30 minutes or so. And then we’ll get you pre-medicated with some Benadryl and Tylenol and get things rolling.

Okay. So right now, we are starting the IV. So usually you don’t have to do a specific gauge. It’s just what the patient’s veins look like and what they can handle, so we do anywhere between a 24 gauge and a 20 gauge depending on what the patient looks like. Right now I’m just priming the tubing here to get the air bubbles out. Then we’ll put a tourniquet on the patient, and it helps make the veins pop out so we can see them easier. A little tight here—is that okay for you?

Nick: That feels fine.

Sarah Collins: Okay. You’re just going to feel me touch you here. Alrighty. So next, what we’re going to do is just clean the IV site to prevent an infection. You have great veins—it makes my job easy, so thank you. 

Nick: Oh, that’s good.

Sarah Collins: Alright, I'm going to go with a 20-gauge needle here today just because it’s a pretty large vein we are working with. Alrighty, here we go Nick—1, 2, 3, poke. So you insert the needle until you get a flash, pull it out, occlude until you get the hep lock on. Alrighty. Cleaning up my mess here—doing okay, Nick?

Nick: Fine.

Sarah Collins: Perfect. We are in. I’m just going to secure it with a Tegaderm. Pull the tourniquet off. Alrighty. And then what we do is we draw back just to make sure we’re in. Perfect. Alrighty, the IV is started here Nick, you did great. I’m just going to tape this up so it doesn’t pull on you here. Alrighty, any issues at all? Feels okay?

Nick: Feels fine.

Sarah Collins: Perfect. Alright, let me get rid of this here and then I’m going to start prepping the hydration bag. I’ll be right back, okay? 

Nick: Fine.

Sarah Collins: Okay, Nick, here is your hydration bag here. This is just a normal saline, so there’s no medication in it. It is going to run over about a half hour here. And what I did to prepare this bag here is we just spike a 250 normal saline bag, we prime the tubing to get all the air bubbles out, and then we hook up to the IV here. I usually do it wide open. So we do everything by gravity here. So now I’m going to get the Benadryl and the Tylenol ready for you and we’ll pre-medicate you with those drugs, okay?

Nick: Okay, fine.

Sarah Collins: So I have the Benadryl and the Tylenol here that we’re going to premedicate you with. 

Nick: Okay.

Sarah Collins: So what we do is we do 50 mg of Benadryl right through the IV, and this is to prevent any sort of infusion reaction. You just want to nip it in the bud. We haven’t had any infusion reactions, but we’ve had this on board just in case. As well as the Tylenol, it’s going to prevent if he were to get any fevers or anything like that, Tylenol is on board already. So I got you a glass of water here, 2 tabs of Tylenol for you—we’ll have you take that by mouth. Perfect.

And then I’m going to put the Benadryl, we do 50 mg of Benadryl right through the IV. So we’ll scrub the port here just to ensure no infections.

Alrighty, Nick, 50 mg of Benadryl going right on in—you shouldn’t even really feel this. I push it slow just so the patient doesn’t feel it.

Nick: So far, I’ve never felt anything from it.

Sarah Collins: Good. Sometimes people can have an adverse reaction to Benadryl and it can make them more hyper or it can knock you out.

Nick: Yeah, I lean more toward relaxed.

Sarah Collins: The knocking out? Good. Alright, Benadryl is in here Nick. So I’m going to start prepping the infusion here. Is there anything you need? Blanket? Are you comfortable?

Nick: Very comfortable, I feel fine.

Sarah Collins: Good. Alright, here is a stool for your feet, if you want to rest them. You don’t have to, but it’s there if you need it, okay?

Nick: Thank you.

Sarah Collins: And I’ll be back in just a few minutes.

Alrighty Nick. So it looks like your hydration bag is finished. I’m going to disconnect you here. Still doing alright?

Nick: I’m doing fine, thank you.

Sarah Collins: Doing good? Okay, perfect. So, this particular infusion here comes in a 7 mL bottle. So we just draw it up here. Scrub the top of it, just using a 10 cc syringe here, put air into the vial, and then we draw it up. You want to use the entire bottle here, so all 7 mL. And this is going to go into a 100 mL normal saline bag. Take the cap off, clean it, and then we put the medication right into the bag, all 7 mL, and then this goes in the sharps container. And that is the whole prep of the medication. So now we just spike the bag, prime the IV tubing, and then this will run over 30 minutes infusion here. So spiking it, and then we prime the line to get the air bubbles out. I’m going to scrub the hub here before attaching, so just an alcohol prep pad. Attach it, and then I do tape it up to the patient’s shirt just so it’s not pulling on the patient just to ensure more comfort for them. Right there for you. And this is going to run over about a half hour as well.

Alrighty, so infusion is started. I’m going to take your vital signs—we’ll do blood pressure on you, is this arm okay? 

Nick: Fine.

Sarah Collins: And I’m going to be doing your vitals every 15 minutes while the infusion is running, okay?

Nick: Okay.

Sarah Collins: We’ll take your temperature as well. Good. Alright, so this is going to run about a half hour. I’ll be back in about 15 minutes to check on you. We’ll do vital signs again. Let me detach this just so you’re not hooked up on both arms here.

Nick: Alright, thank you.

Sarah Collins: And you’re doing okay? There’s nothing else I can get for you at this time?

Nick: I feel fine.

Sarah Collins: Okay, perfect. I will be back, okay?

Okay, we are about halfway through, so I’m going to take your vital signs again. How are things going?

Nick: Just fine, thank you.

Sarah Collins: Doing well? No issues?

Nick: No issues. No discomfort.

Sarah Collins: Perfect. So we’ll do your blood pressure, I’m going to get your temperature here again. Good. And we should be done in about 15 minutes, okay?

Nick: Ok, fine. Thank you.

Sarah Collins: You’re welcome. Can I get you anything at all?

Nick: No, I’m doing good.

Sarah Collins: No? Okay, good. Good, good, good.  It looks like we are right on schedule here, halfway through. Good.

Alrighty. Looks like infusion is finished here. How are you feeling?

Nick: I feel fine.

Sarah Collins: Feeling good—alrighty. So what I’m going to do, we’ll pull this IV out and then I’ll take one last set of vitals on you, okay?

Nick: Alright.

Sarah Collins: Alright. Just disconnecting the IV here. Alright. So we just pull the tape off, put a little piece of gauze, and just pull the IV straight on out. Nick, I’m going to have you hold pressure here for me for about 5 seconds. 

Nick: Alright.

Sarah Collins: Thank you. And this goes in the sharps container. Perfect. And then we’ll do your vitals one last time here, and you will be all set to go, okay?

Nick: Alright.

Sarah Collins: Alrighty, I’m going to borrow that arm one last time from you. Okay, go ahead and relax. And then temperature one last time—good. Alright, vital signs look perfect.

Alright, and If you’re feeling well enough, you’re able to stand on up and get out of here, okay? I will see you in 3 weeks, and we’ll do the next infusion, okay?

Nick: Alright, thank you very much.

Sarah Collins: You’re welcome. Have a great rest of your day.

Dr George Murakawa: All of my personnel here, they’re very well trained and cross-trained, so they can manage most circumstances. And I think one of the big things is that when you’re taking care of complicated patients, you just have to stay calm. And so, If there’s any issues, they know to get me. They can handle all the other things—they’re very, very able and qualified for running lines, keeping tabs on patients, and making sure that they stay well.

So one of the nice things for us in doing infusions is that we do it in the middle of clinic. And we can run them without putting a hitch into our practice. And things run very, very smoothly. So at the same time while we’re infusing, we’re seeing general dermatology, we’re doing Mohs cases, we doing all sorts of—everything that you can imagine, and we really don’t miss a beat while we do it. So, it’s not very difficult to incorporate this into the middle of your practice.