Experts Review Treatments, Directions in Basal Cell Carcinoma

Pharmacists can play an essential role in the management of basal cell carcinoma (BCC) by providing guidance for treatment, according to experts who gathered for a recent Pharmacy Times® Clinical Forum event to discuss their experiences in the field. Moderator Scott A. Soefje, PharmD, MBA, BCOP, FCCP, FHOPA, director of pharmacy cancer care services at the Mayo Clinic in Rochester, Minnesota, led the discussion and started with a brief overview of the disease landscape. Soefje noted there are more patients with BCC in the United States than all other cancers combined, with BCC and squamous cell carcinoma totaling approximately 3.3 million patients. Notably, BCC accounts for approximately 80% of all skin cancers, he said.

Although BCC is generally curable and rarely metastatic, it can be a devastating disease for patients. Soefje listed several risk factors for BCC, emphasizing radiation from cancer treatments or sunlight. This risk is especially notable among individuals with fair skin or those with lymphoma or other cancers who underwent radiation at a younger age.

Patients can develop BCC several decades after radiation treatments for cancer, according to Soefje.

Investigators are also beginning to understand the genetics behind BCC, including new knowledge about the Sonic hedgehog signaling pathway.

“PTCH1...is a mutation associated with the nevoid [BCCs] and plays a part in [BCC] through the whole process. We also believe there are other mutations,” Soefje said.

When working with BCC, Soefje said to first stratify the risk based on the location and size.

These factors determine the surgical approach and whether the tumor has perineural involvement or is more aggressive or poorly differentiated. Patients with a history of prior radiation or recurrent disease and those receiving immunosuppressive drugs are also at high risk for more severe disease.

In the very early stages, dermatologists may be comfortable treating BCC with topical treatments, according to Melissa Pozotrigo, PharmD, BCOP, senior clinical oncology pharmacist at OncoHealth.

A dermatologist may then refer patients to oncologists while staying on the multidisciplinary team. Following this overview, attendees turned to the treatment landscape in BCC. In the first line for BCCare surgical approaches, which are how solid tumors become curable.

When done correctly, surgical approaches lead to high 5-year cure rates, Soefje said.

Various surgical approaches are also available for BCC, each appropriate for different patient needs. Excising and managing the margins are typically used for patients who are low or moderate risk, whereas Mohs surgery is reserved for patients who are high risk or those who are ineligible for excision-type therapy.

Cryosurgery and electrodissection may also be performed for some patients, though Soefje noted that cryosurgery tends to leave more significant blemishes that patients may elect to avoid.

However, because of location or size, some patients may be ineligible for surgical approaches. Pharmaceutical approaches can include a hedgehog (Hh) signaling pathway inhibitor, such as vismodegib (Erivedge; Genentech), which is the first FDA approved Hh signaling pathway inhibitor for the treat ment of locally advanced or metastatic BCC. Sonidegib (Odomzo; Sun Pharmaceutical Industries Limited) is also available and indicated for the treatment of adults with locally advanced BCC that has recurred following radiation or surgery or for patients who are ineligible for radiation or surgery.

Although adverse effects (AEs) are similar for both treatment options, Soefje noted they have different dosing requirements, timing recommendations with food, and drug interactions.

Additionally, several panelists noted that they almost exclusively use vismodegib, with 1 explaining that his reasoning for this preference is because of concerns regarding potential drug interactions with sonidegib. For example, sonidegib should not be administered in combination with strong cytochrome P450 3A4 inducers or inhibitors.

Soefje also asked the panelists whether they hadseen patients switch from either sonidegib orvismodegib to the other, particularly because ofexperiencing intolerance.

The panelists said that despite the availability of an alternative Hh signaling pathway inhibitor, they were more likely to take patients off therapy temporarily rather than switching to another option.

Furthermore, after experiencing challenging AEs, some patients have also expressed hesitation about switching to another drug in the same class of medications, the panelists said.

One of the most common AEs experienced by patients on either sonidegib or vismodegib is a loss or change in the ability to taste. In particular, difficulty tolerating foods or having foods taste bland can be a challenge, so including a dietitian or nutritionist on the multidisciplinary team could help patients maintain a healthy diet and weight.

Furthermore, muscle spasms can also be a challenge for patients on sonidegib or vismodegib, and panelists noted that this AE can cause patients to discontinue therapy. However, amlodipine or L-carnitine can help manage these, they said.

Because of low response rates, chemotherapy is not typically recommended for patients with BCC. Immunotherapy may be a better option. Cemiplimab (Libtayo; Regeneron and Sanofi) is the only approved immunotherapy indicated for advanced BCC.

One panelist said that he has found the fixed-dose formulation convenient, especially when administered every 3 weeks.

However, he noted that clinicians should remain aware of immune-related AEs and occasional infusion-related reactions that can occur.

Finally, the panelists discussed the pharmacist's role in BCC treatment. They all agreed that pharmacists should be involved from the beginning, even during the diagnostic phase.

One panelist noted that some skin cancers could bedrug induced, so pharmacists can be essential in helping identify causes and treatment approaches.

Pharmacists are also crucial when it comes to educating patients about financial barriers, preventive measures, and treatments.

Because of the nursing shortage, one panelist noted that he found pharmacists were becoming more involved in patient education, opening opportunities to demonstrate their value on multidisciplinary patient care teams.