Multidisciplinary Coordination in High-Risk CSCC

In this video, the panel highlights the importance of early multidisciplinary collaboration in the management of high-risk cutaneous squamous cell carcinoma (CSCC). The experts discuss evolving referral patterns, the role of the tumor board, and the importance of coordinated patient education and treatment planning across specialties and practice settings.  

This is Part 3 of 5:

• Part 1: Recognizing High-Risk CSCC
• Part 2: Integrating Adjuvant Therapy in High-Risk CSCC
• Part 3: Multidisciplinary Coordination in High-Risk CSCC
• Part 4: Applying High-Risk Criteria in CSCC Practice
• Part 5: Safety Monitoring in High-Risk CSCC

Dr Wong: It's requiring that we collaborate together earlier in the treatment planning phase. I think we're moving away from, okay, dermatologist, dermatologist passes on to head and neck surgeon, head neck surgeon passes on to radiation oncologist. Oftentimes, for CSCC, medical oncology is not so important in the locally advanced, high-risk setting, but now it's like with the incorporation of adjuvant, the ability to use adjuvant therapy and things like that. 

Dr Strasswimmer: I think a real benefit from this is to get us in dermatology finally understanding the language of non-dermatologists, because oftentimes I think if we saw somebody with a bad cutaneous squamous cell carcinoma and a positive node, most dermatologists and most surgeons were done with the patient at that point. You need to go see the medical oncologist or the radiation oncologist. And at least now that we have the C-POST data there and a potential therapeutic option for patients now, that gets us to be aware of where these patients might be. 

Dr Wong: To your point, I think the referral patterns are evolving. 

Dr Patel: For me, the discussion starts very early. And we have great dermatology colleagues that will set the stage, so to speak, as you had mentioned. When I see the patient and if there's any inclination that either this is recurrent or there's significant risk factors, as we alluded to, I reach out to my radiation oncology colleagues and medical oncology colleagues well ahead of time. I also set the stage with the patient and explain the rationale, that you are going to meet these folks, these specialists. They may not be necessarily involved in your care right now, but they may be after the surgery if we're looking at surgery. And so that's the patient-facing role. And then behind the scenes, when we have our multidisciplinary tumor boards, which are typically once a week, we as a group discuss so that the patients are on everybody's radar. 

Dr Barker: Yeah, there's variation, I think, at our institution. Periodically, there'll be an outside specialist, outside of our cancer center, who wants my specific opinion about radiation therapy. But upon meeting the patient, I'll recognize that, oh, this patient might actually benefit from more surgery or a systemic therapy, and so I'll involve those specialists as need be. Sometimes the patient's referred in, and just upon hearing about them, we immediately recognize the need for all the specialists to be involved. And so upfront, they're meeting with everyone in rapid succession. 

So sometimes they're starting with Mohs team, and the Mohs team is then triaging on to other specialists after surgery's done. So I would say there's a variety of ways this can happen. I think the most important thing is just keeping those lines of communication open, knowing who's there to help you and how, that whether the patient's seeing you first or you're the last person to see the patient is the most important thing that we've found has led to success. 

Dr Strasswimmer: And ultimately, at your institutions, patients, all roads lead to Rome, right? They all end up in a multidisciplinary evaluation. And where I practice, we don't have, geographically, access to a really primary, great, renowned academic medical center. So as a consequence, what we've done in the community, we've known who our colleagues are, who welcome these patients. And especially ever since COVID, we've begun to do things more virtually. I used to go regulate to a tumor board once a week that I started, but with COVID, things changed. We can initiate that multidisciplinary work. And in our practice, when I have one of these patients, they get a handful of cards that say go see you, you, you, and then we help coordinate those visits so that we can get that team-based input. 

Dr Wong: Yeah. So there's certainly the traditional multidisciplinary tumor board, but then there's also more and more informal, very practical,… 

Dr Strasswimmer: Right. 

Dr Wong: …daily tumor boards, if you will, ad hoc, right? But I think that's really important, because if you have a patient who needs treatment, right, because they have a high-risk malignancy, it's nice to be able to move their care forward efficiently and not have to wait for the patient to get put on the tumor board schedule for discussion and then wait for referrals to go through to see each of the other specialists. So I think definitely there's a very important role to have multidisciplinary communication outside of formal once-a-week tumor board discussions. 

I think from a provider perspective, involving the multidisciplinary team early is really important. But I think it also is really important from the patient perspective, because for them to walk in and have an understanding of what's the big picture treatment plan I think is really critical. Because a lot of times, patients, by the time they come to me, if they've never heard of a year of adjuvant cemiplimab, says, "I went through surgery and radiation, and now you want me to do a whole year of adjuvant therapy?" I think that's, patients need to, if they have some awareness of what the overall plan is, they're much more receptive to it. 

Dr Barker: Setting the stage for the patient's important, giving them an understanding of what this journey could look like. I would say this is not something that I as a radiation oncologist am the only one that can tell them about radiation therapy. No. I know something about surgery. I know something about systemic therapy. And so I think to have a team of physicians who understands the role of these various modalities, what's involved is important because I think the more consistency the patients are hearing these things with, I think the better understanding they come to, the better questions they're asking, the better primed they are to meet with the medical oncologist. 

Dr Strasswimmer: And in our dermatology practice, we do exactly that. 

Dr Wong: Yeah. 

Dr Strasswimmer: Because I am aware that in the pre-immune therapy era, the type of therapeutic options, cytotoxic chemotherapy, a lot of patients might've had family members who went through that. As a dermatologist, and I don't prescribe, I don't administer immune therapy, but I share with them that the patient experience of receiving it, and sometimes they even phrase that, you need to go through a pretty aggressive surgery and then your radiation is going to be pretty intense for a while. The third aspect, if it's appropriate for you, which is the immune therapy, you might find is actually, from your perspective, the least challenging to go through. 

Dr Patel: And oftentimes, it's repeating the information, right? I think, which is also helpful from the patient’s and their family's perspective on what that journey looks like along the way. 

Dr Strasswimmer: It's been my practice ever since we had indications for immune therapy for locally advanced or metastatic cutaneous squamous cell carcinoma, we see these patients back in our dermatology practice. So even though they've had the visit from my other colleagues and maybe now they're under their main therapeutic intervention is from our medical oncologist, we see them back historically because, first of all, our staff likes to see these patients. We're in some ways the primary care doctor of their tumor, right? These are people with whom we have a long-term relationship. 

Dr Wong: And I think that's a testament to the fact that our treatments these days are better. Patients are doing well, they're living longer. And so they do need that continuity of care with derma... I don't think we're in the period anymore where we can just hand off the patient's care to the next person… 

Dr Strasswimmer: That's right. 

Dr Wong: ...especially in the area where we have multiple therapeutic options to offer.