Q&A: DaRT Guidelines for Nonmelanoma Skin Cancer Care

The Dermatology Association of Radiation Therapy (DaRT) recently published new clinical guidelines¹ for the treatment of nonmelanoma skin cancers, basal cell carcinoma and squamous cell carcinoma.

The guidelines focus on the use of image-guided superficial radiation therapy (IGSRT), which combines high-resolution dermal ultrasound with superficial radiation therapy for precise cancer targeting, and a multidisciplinary approach for treatment and care.

Read more from Dermatology Times.

Dermatology Times recently spoke with Jacob Scott, MD, a physician scientist at the Cleveland Clinic and the president and chairman of DaRT, to discuss the role and implications of these guidelines for clinicians and patients alike.

Q&A

Q: Can you provide an overview of the new clinical guidelines for treating nonmelanoma skin cancer that DaRT has recently published?

A: I think the main takeaway for the guidelines that we've produced for everyone is really to allow for a standardization in the field. SRT [superficial radiation therapy] without image guidance has been used for close to 70 years by dermatologists, and has been a mainstay of therapy for nonmelanoma skin cancers. The recent addition of image guidance to that in the literature has shown and has provided a massive increase in the overall cure rates and success rates of the therapy. We're seeing a shift, I think, since historically, SRT was moved out of the first line by Mohs because of the improved survival that Mohs offered to SRT.

But now, with the advent of image guidance and standardization, we're seeing that those cure rates and success rates are becoming equal. Further, we're seeing a massive increase in utilization of this new technology. What I think is most important, and what we feel is most important, is that in order to maintain the high cure rates, we have a standard protocol. In radiation oncology, this is bog-standard for any malignancy. We don't make up our fractionation and doses. We use these in the course of standard guidelines and even in trials over the years, and so the same needs to be true in this case.

We feel that in order for us to truly move the field forward, we need to begin a standardization so that physicians can really practice in a guidelines-based way or an evidence based way. Based on the evidence that we're seeing in the literature and the use patterns of this, 3 or 400 physicians who are now in the field using this technology, we decided really to put forward a set of guidelines so that everyone who uses the technology can be on the same page.

I think that's really important in the modern era of medicine, especially with technologies that are advancing, because if we use a new technology haphazardly, I think it calls into question the efficacy: Is the decline or increase in efficacy due to poor or good protocols? This is really a way for us to bring the field together so we can all move forward together, allowing us to do research that's comparable to one another, and allowing us to really just move forward in a state, in a way, that's commensurate with modern medicine.

I think the other important part is that really, because of the complexity of technology that moves as it does, it's really important, and the guidelines include this, which is that this is really a team effort. It's not simply a therapist or a single physician inventing a dose or fractionation schedule or a schema, but really it's an entire cancer center- like approach, in which a team of folks that include oversight from medical physics, oncologists, dermatologists, and radiation therapists, all work together, maybe not exactly in the same location, maybe some of that's more oversight from from afar or a team specialty, but it allows the opportunity for individual practitioners to participate in larger scale tumor boards for difficult cases. It allows them to contribute to our understanding and the knowledge and move forward together.

Q: What motivated the creation of these new guidelines, and how do they build upon previous recommendations or practices?

A: The important part here is that there really haven't been standardly-accepted or group approved levels of protocols for this therapy. This is really a technology that's only 7 or maybe 8 years old, and so certainly in the literature, there exists a number of different protocols for SRT without image guidance that have been published over the years by individual groups. You can see those in the literature, and that's good, but I think that that's not taking into consideration this newer technology, and therefore this is really just the first time that the communities have come together to put forth guidelines. It's really an important time in our field to see where we can really start to come together, practice the same way, and then report on our outcomes. I think a democratization of those reports and outcome measures is super important for the next steps, and that's just how oncology has always moved forward and how it needs to.

Q: How should dermatologists, radiation oncologists, and radiation therapists integrate these new guidelines into their clinical practice?

A: Of course, we still live in a free society, and physicians are free to practice as they as they wish within reason and within their license. But I think that when new technologies are available, in this case with image guided SRT, I think that having a place to start when it comes to formal protocols is super important, and specifically when you're having conversations with patients, I think patients are always at ease when they know that their physicians are basing their decisions off of larger guidelines and evidence. I think that each physician should read the guidelines and the evidence themselves, but our intention is for this to be a single place for physicians who want to use this technology to go to understand what the standard protocol recommendations are from the consensus of experts, and also as a repository for all the newest literature. Of course, as an organization like DaRT, we really would love more input from the community and more membership and further feedback if people have specific things they want to discuss about the guidelines. We're all ears. That's the point of this: to get our recommendations in one place and then to continue to evolve. Recommendations and guidelines are living, breathing entities, and do change over time as new evidence comes to bear, and we're eager to hear to make changes when needed.

Q: How do you anticipate these guidelines will impact the daily practice of dermatologists and radiation therapists?

A: These are, of course, primary skin lesions, and so they have long been, and still should be, the under the purview of skin specialists, dermatologists, cutaneous oncologists, if you will. But that said, radiation oncologists and surgical oncologists have also played a role, especially in the more advanced nonmelanoma skin cancers. I think that for the most part, the stage I and II and low risk lesions have been handled by individual practitioners, and probably still should be going forward. But the opportunity to submit challenging cases to a larger community is super important, and further to involve all parts of the community in the research, so we can better establish which patient needs which treatment at the right time.

In no way, shape, or form are we suggesting that this is a replacement for Mohs surgery, but we do believe that, and the literature bears out, that this is a new technology that provides equivalent outcomes and should be used for the correct patient at the correct time, just as it just as is the case for Mohs. I think that having the team approach, there's lots of parallels to this in oncology, for example, surgery and radiation have similar outcomes for prostate cancers, and the list goes on and on. But that doesn't mean that one of those treatments isn't better for the patient in front of you. Until we all work together and have the opportunity to refer to one another and to learn from each other about different options, patient choice cannot be included until we have those teams working together. Patient choice, when you have a situation where you have equal outcomes, should be top of the list.

Q: Is there anything else that you feel is important for fellow dermatology clinicians to know?

A: I think that it's an exciting time in this field. Whenever a new technology comes on the scene, there's always a mixture of excitement and trepidation. We have early adopters and late adopters, and this sort of cycle of testing and either acceptance or rejection of new technologies, is not unique to this situation, but it's important. The most important thing is that we have open, transparent conversations with each other from different specialties, and really listen to each other, and listen to our patients, and listen to the data.

This publication of guidelines is an opportunity for a conversation, both between patients and their providers, but also between providers from different disciplines. I think that through those conversations and further research, the only thing that can happen is that we can get better at what we do and take better care of our patients. That's really the hope and goal behind all of this, is to really empower patients to seek out treatments that they want and to make sure that everyone understands the outcomes that each treatment provides, and for us to push that research into more hands.

Reference

1. Dermatology Association of Radiation Therapy. DART clinical guidelines for nonmelanoma skin cancer. Accessed August 1, 2024. https://dermassociationrt.org/guidelines/