Nonsurgical skin cancer care welcomed by elderly patients

Key Points

Topical and oral medications are useful if skin cancer is in a delicate area, enabling clinicians to eliminate the tumor or shrink it so it can be removed surgically. Topical or oral treatments also can be used to treat or prevent squamous cell carcinomas in situ.

Furthermore, nonsurgical treatments can be used in "knife-shy" patients or those with an unmanageable number of skin cancers resulting from immunosuppression, genetic conditions or other circumstances.

By treating the whole field with a treatment for precancerous cells and skin cancer, the clinician can prevent future carcinomas, he says. Many of these treatments are off-label, however, and are not approved by the Food and Drug Administration for these indications.

Range of alternatives

Clinicians have a number of treatment options from which to choose. Topical imiquimod is a common choice.

"It has been used successfully, and there are case reports that it's being used successfully for sun-induced squamous cell carcinomas and for basal cell carcinomas," he says.

Acitretin is a nonimmunosuppressive therapy that has effectively reduced the frequency of squamous cell carcinomas in transplant recipients and basal cell carcinomas in patients with conditions such as basal cell nevus syndrome, Dr. Lebwohl says. Because retinoids such as acitretin work only while patients are taking the drug, however, long-term treatment is necessary, he says.

Rapamycin (sirolimus), an immunosuppressant used in transplant recipients, suppresses the development of skin cancers, unlike other immunosuppressive agents that cause more squamous cell carcinomas to develop, Dr. Lebwohl says.

"That's yet another drug in this armamentarium of agents that we can try to suppress the development of squamous cell cancers," he says.

Researchers continue to study new options. Dr. Lebwohl and his colleagues participated in a clinical trial to treat basal cell carcinomas using a hedgehog inhibitor, which has not yet been approved.

The trial revealed two scenarios in which the hedgehog inhibitor was particularly promising, he says. The drug was used in a patient who had hearing in only one ear and who had a large basal cell carcinoma invading the canal of that ear. With treatment, the tumor resolved.

"That's the kind of patient who would be a perfect candidate for an oral agent like the hedgehog inhibitor," Dr. Lebwohl says.

The drug also was used in a patient with dozens of basal cell carcinomas. The tumors resolved with treatment, and the patient stopped getting new carcinomas. "Even when he was off it, it was a long time before he got a new one," Dr. Lebwohl says.

Ingenol mebutate (LEO Pharma), which has not yet been approved, is being proposed to treat precancerous skin lesions; it acts more rapidly than imiquimod.