Understanding Your Nonsurgical Options for Advanced Nonmelanoma Skin Cancer

Surgery can be highly effective for treating skin cancer, including nonmelanoma skin cancer, but it’s not always the safest or most practical approach. Fortunately, surgery isn’t the only treatment available.

Advances in skin cancer care have given healthcare providers more ways to shrink tumors, manage cancer and help preserve your quality of life.

“Surgery is our first choice for many skin cancer tumors, but there are often times when additional or alternate treatments are recommended,” says head and neck oncologist Jessica Geiger, MD.

Dr. Geiger explains when surgery may not be the best option for advanced cutaneous squamous cell carcinoma or advanced basal cell carcinoma, and the nonsurgical strategies your care team may consider.

Why surgery may not be the first step

Surgery alone may be an option for removing skin cancers that are small and haven’t advanced to other parts of your body. But that’s not always the case when you’re living with advanced skin cancer. As cancer grows and spreads, surgery can become more complicated, and recovery can be more difficult.

“Advanced nonmelanoma skin cancers are often found on the head and neck,” Dr. Geiger says. “That’s some precious real estate, which can make surgery tricky.”

For example, surgery as a standalone treatment may not be the best choice if:

• The tumor is large, has ill-defined borders or is very close to critical structures, such as your eyes, ears or throat.
• The cancer has spread beyond the skin and is affecting lymph nodes or other parts of your body.
• Your age or other health concerns make surgery risky.
• Surgery compromises functional or cosmetic outcomes, like your vision or sense of smell.

“We approach treatment on a case-by-case basis,” she continues. “There can be a lot of factors that we weigh with people when we’re discussing their plans.”

Nonsurgical treatment options

When surgery isn’t an option — or if it’s not your best or only one — your team may recommend nonsurgical strategies. Depending on your health and the cancer, these strategies may be considered on their own or in combination with other treatments.

Dr. Geiger explains how these nonsurgical treatments work.

Radiation

Radiation therapy uses high-powered X-rays or radioactive medications to kill cancer cells and shrink tumors.

“Radiation is used as a treatment for a lot of types of cancer, and it can be very effective for advanced nonmelanoma skin cancer, too,” Dr. Geiger says.

Radiation may be used:

• Before surgery to make tumors smaller and easier to remove surgically
• After surgery to target any remaining cancer cells and lower your risk for recurrence
• On its own to destroy tumors altogether
• In combination with other treatments, like immunotherapy

Immunotherapy

Immunotherapy medications for skin cancer, called PD-1 inhibitors, essentially harness your own defense system to attack cancer cells. There are currently three immunotherapy medications approved for advanced skin cancer:

• Cemiplimab (Libtayo®) for advanced basal cell carcinoma and advanced cutaneous squamous cell carcinoma
• Pembrolizumab (Keytruda®) and Cosibelimab (Unloxcyt®) for advanced cutaneous squamous cell carcinoma

Immunotherapy may not work for everyone, but the results can be impressive.

“We’ve seen a great deal of people have long-term, complete responses to immunotherapy,” Dr. Geiger shares. In other words, there are times that immunotherapy can make your cancer undetectable.

Like radiation, immunotherapy may be a treatment on its own. It’s also sometimes used before surgery to shrink tumors and allow for a less intensive operation.

Hedgehog inhibitors

For some people with advanced basal cell carcinoma, oral medications known as hedgehog inhibitors may be used in addition to or instead of surgery. These targeted therapies go by the names vismodegib and sonidegib.

Hedgehog inhibitors turn off the signals that tell basal cell cancers to grow. That can help to gradually shrink tumors. But these medications aren’t always well-tolerated and can come with side effects, including:

• Muscle spasms and cramping
• Hair loss
• Changes in taste and loss of appetite, which may lead to profound weight loss and malnutrition

Chemotherapy

Chemotherapy isn’t often used these days for managing advanced cutaneous squamous cell carcinoma or advanced basal cell carcinoma.

“Chemotherapy hasn’t proven to be as effective as other treatments for advanced nonmelanoma skin cancer,” Dr. Geiger notes. “In cases where immunotherapy or other treatments aren’t available or haven’t been effective, chemotherapy may still be an option.”

Bottom line: Treatment is available

Finding out that surgery may not be right for you, at least for now, can bring a whirlwind of emotions. You may be glad to have other routes to consider. Or it may be disappointing to not have a clear path forward.

Nonsurgical options for advanced skin cancer can be highly effective at treating cancer. In some cases, they may even mean avoiding extensive surgery, recovery and reconstruction.

“The best treatment is really going to vary and depend on your needs and your goals,” Dr. Geiger reiterates. “We’re fortunate to have several ways to help you treat advanced skin cancer and help you live as healthy and full a life as possible.”