Q&A: Jeffrey Stricker, DO, MBA, Discusses Study on Image-Guided SRT in Non-Melanoma Skin Cancers

SkinCure Oncology recently announced the publication of new data on image-guided superficial radiation therapy (SRT) in non-melanoma skin cancers (NMSCs).¹

The study, "Understanding the Importance of Daily Imaging in the Treatment of Non-Melanoma Skin Cancer with Image-Guided Superficial Radiation Therapy," was published in the journal Dermato² and found that daily depth fluctuations in tumors were common, with 92% of lesions showing such changes.

Dermatology Times recently spoke with Jeffrey Stricker, DO, MBA, CPE, FCAP, a board-certified dermatologist at Dermatology Specialists of Alabama, lead study author, to discuss the findings and their significance.

Stricker is also an advocate for integrating radiation therapy into skin cancer treatment. He explained that while radiation therapy was once less effective and fell out of favor, advancements over the past 10 to 15 years have significantly improved its precision and effectiveness. Modern photon-based radiation techniques, combined with high-resolution imaging technology, have enhanced the ability to target tumors accurately, yielding cure rates comparable to Mohs surgery.

"The cure rates initially were not as good, but with proper use of imaging technology, we were able to get that cure rate to roughly equal Mohs, in the very high 90%—98-99%," he said.

Q&A

Q: The study found that 92 percent of NMSC tumors exhibited changes in depth during treatment. How did these changes impact the overall treatment efficacy and patient outcomes?

Everything's going to be dynamic in this, so the radiation is going to change the tumor size. It's going to change the surrounding tissue as we're going along; and thus, if we're getting rapid response to that radiation early on, it gives us the opportunity to back off on the dose a little bit. By backing off on the dose, we're actually backing off on side effects, risk of recurrence, etc. With 92% of them showing changes during the during the treatment, instead of just picking your course and going forward, we're able to utilize the technology to get better outcomes.

One way to think about it is: If you're on the interstate, you don't just lock your steering wheel in and then go back to the back seat, make a sandwich or something. You need to be able to adjust your speed as you go along; things may come up that we weren't expecting. On the other hand, if we get a tumor and we see that it's not progressing like we want it to, sometimes we actually boost the dose. We may go a little bit deeper.

The other thing that we found, and this wasn't necessarily the focus of the study, but it's very important. As a dermatologist, we'll take a biopsy, and often the base of that biopsy is involved with tumor. The depth of penetration of that tumor may be unknown, and by using the high resolution ultrasound, we could say: Wait a minute. Our biopsy results say that this is in situ, but we're seeing about 2 millimeters of depth in here.

Q: Were there any unexpected findings or challenges related to monitoring tumor depth and repopulation using high-resolution dermal ultrasound?

The 92% needing dose adjustment was a little surprising to me, because in my practice, I really don't adjust on 92 out of 100 patients. I was really expecting it to be close to half, just based on my own personal experience. When we found 92%, it does make us focus a little bit better on ultrasound technology, making sure that our probe's in the right place, that our technicians are doing the right thing, and then we ourselves are up to date. Ultrasound is one of those things that doesn't show up a lot in dermatology training, so it is something that we really need to bone up on. The newer technology does make it easier than when I went first through training, so it does kind of guide you. With that being said, most dermatologists are not as comfortable identifying radiographic studies as say, a radiologist would be.

Q: What are the implications of this study for future clinical practice in treating NMSC with image-guided SRT?

I think the future of this is that we have shown that we can get very, very good cure rates in an office setting without necessarily needing to resort to surgery. Surgery carries its own implications and issues. I do Mohs myself. I think it's a great technique, but it's really not appropriate for everybody. We have an aging population. I can't tell you the number of times I've had to answer the question: "Well, what if I do nothing? I'm 92 years old. Why should I have to do this?" They have a good point. If we have a non-surgical option, I think we can get more patients to consider treatment. I think the implication, more nationwide, is that we can get more dermatologists to offer this as part of their treatment, particularly if they're in a setting where maybe they do not have access to colleagues that can perform specialized services.

One of the other things that I've always been very interested in is rural health care. Dermatology is very urban based. There was a study that came out maybe a month ago, and it was on psoriasis. It pointed out that 95% of dermatologists are generally in urban areas, and folks in rural areas had very little access to dermatologists willing to prescribe the newer medicines for psoriasis. That can be extrapolated to dermatologists willing to treat non-melanoma skin cancer, as well. We know that skin cancer affects people who have more sun exposure. That's going to be people in rural areas that work outside, so farmers, ranchers, folks that work construction, sailors, etc. By offering this treatment where they live, we'll be able to get to it a lot better.

I think that as we get more comfortable with this, I think dermatologists will become more comfortable with the technology, and dermatologists are notorious for loving to play in the sandbox. Once we get a tool or we get a drug, we say, "Hey, it works pretty well with this. Let's try it for this thing over there." I would love to see us look at other skin lesions that maybe could benefit from this. I think that there's several fields that this could go into, but really tackling the skin cancer problem. That's a big enough push right there, and a big enough lift, that if we can make a big impact and get folks treated earlier, particularly in rural settings, we should be able to get bid cost curves down. We can get morbidity down.

Q: What else would you like to share with dermatology clinicians?

Every dermatologist is at least familiar with Mohs technique; they may not perform Mohs, but they've been exposed to it at some point. By using the high resolution dermal ultrasound with superficial radiotherapy, we're essentially applying the Mohs philosophy to radiation therapy. We're watching these things go away in real time. We're making sure our margins are correct, so we're able to precisely treat the tumor exactly as well as it needs to be treated. That, to me, is really what spoke to me once these newer techniques came out. I was really very excited. I had used superficial radiotherapy before, and one of the questions I got is, "How do you know you got it all?" I said, "Well, we're going to follow you up very closely." When I finally got an answer to that, it was truly a breath of fresh air.

I feel like I'm giving my patients the absolute highest tech, best quality care that is available in the world today, even though I'm in southern Alabama. From a dermatologist standpoint, having those options available, being able to utilize and different techniques depending on patient preferences, is really, really helpful to us as dermatologists. It continues to show that we are on the forefront of something that, not that long ago, was declared a public health emergency by the Surgeon General, and we are the ones that really should be in charge of this. This is how we continue to take charge and keep charging.

References

1. New study underscores efficacy of systematic ultrasound imaging in the treatment of nonmelanoma skin cancer with image-guided superficial radiation therapy. PR Newswire. Accessed September 3, 2024. https://www.prnewswire.com/news-releases/new-study-underscores-efficacy-of-systematic-ultrasound-imaging-in-the-treatment-of-nonmelanoma-skin-cancer-with-image-guided-superficial-radiation-therapy-302230530.html
2. Stricker JB, Hopkins J, Farberg AS, Harris PM. Understanding the importance of daily imaging in the treatment of non-melanoma skin cancer with image-guided superficial radiation therapy. Dermato. 2024; 4(3):86-96. https://doi.org/10.3390/dermato4030010