Building Bridges in Skin Cancer Care: A Practical Approach to Multidisciplinary Management of cSCC

Editors from AJMC® spoke with Aaron S. Farberg, MD, founder and chief medical officer of Bare Dermatology in Dallas, Texas, about approaches to multidisciplinary management of cutaneous squamous cell carcinoma (cSCC).

AJMC: Briefly describe your approach to diagnosing and managing cSCC in your practice.

The second most common malignancy worldwide is cSCC. While melanoma is often considered the most dangerous skin cancer, cSCC accounts for more deaths due to its high incidence. Given its rising prevalence, early detection and management remain critical.

In clinical practice, patients often present with concerns about a lesion that has been bleeding, crusting, or changing in appearance. In many cases, their concerns are valid. If a lesion raises suspicion, I recommend a biopsy, a simple, quick procedure involving local anesthesia and tissue sampling for dermatopathologic evaluation. Some patients present for routine annual skin examinations, when we may identify asymptomatic lesions that they hadn’t noticed. This reinforces the importance of regular dermatologic evaluations, as nonmelanoma skin cancers, including cSCC, can sometimes be overlooked by patients.

Once a biopsy confirms cSCC, we discuss the next steps based on tumor characteristics. For early-stage lesions, excision is often curative. However, if the pathology report indicates high-risk features, such as deeper invasion or perineural involvement, further evaluation and multidisciplinary management may be necessary.

Patient communication is tailored to their experience with the disease. For first-time diagnoses, I ensure they understand the condition and treatment options. For those with prior cSCC, a brief discussion or a call from my staff often suffices. Our goal is timely intervention to prevent progression while minimizing morbidity.

AJMC: How do you define high-risk resectable cSCC?

From a surgical perspective, most tumors are technically resectable, but the key considerations are the morbidity and functional impact on the patient. Determining whether surgery is the best option requires balancing oncologic control and quality of life, making patient-centered decision-making essential.

High-risk cSCC is defined by a range of clinical and pathologic factors supported by data-driven guidelines. Staging systems such as the American Joint Committee on Cancer and Brigham and Women’s Hospital (BWH) criteria help stratify risk, but no single framework is comprehensive. For example, BWH considers tumor size, depth, perineural invasion, and subcutaneous fat involvement. However, they are not comprehensive. For instance, immunosuppression, a well-established high-risk factor, is not included in the BWH system, highlighting the need for a nuanced, individualized assessment.

Perineural invasion is a particularly concerning feature. While histologic evidence confirms risk, clinical signs, such as nerve-related symptoms elicited on examination, can indicate even more aggressive disease. Such cases warrant heightened vigilance.

Importantly, resectability is not solely about surgical feasibility, but also about appropriateness. Tumors involving functionally sensitive areas or critical structures, such as the eye, may require alternative treatments to preserve function and quality of life. In high-risk cases where surgery poses significant morbidity, multidisciplinary management that includes radiation, systemic therapy, or clinical trials should be considered.

AJMC: How do you determine when systemic therapies such as checkpoint inhibitors might be necessary for a patient with cSCC?

A comprehensive oncologic approach includes discussing all potential treatment options with patients. Open communication is essential to maintaining trust, as patients frequently seek external information and may question treatment decisions if options are not fully addressed.

For patients with locally advanced or metastatic cSCC, systemic therapy, particularly checkpoint inhibitors, should be considered. Immunotherapy plays a critical role when surgery or radiation alone is insufficient for disease control. Decision-making should be collaborative, akin to a multidisciplinary tumor board approach, ensuring that treatment aligns with disease severity, patient health status, and therapeutic goals.

AJMC: Who are the essential team members in your multi­disciplinary care program, and what roles do they play?

A broad, multidisciplinary team enhances the quality of care for patients with advanced cSCC by ensuring an individualized treatment approach. Key specialists include dermatologists and Mohs surgeons for diagnosis and localized surgical management, surgical and medical oncologists for systemic therapy and complex resections, and radiation oncologists for adjuvant or definitive radiotherapy. Genetics specialists may also play a role in assessing hereditary risk factors and treatment implications. Other surgical and medical subspecialists are consulted as needed based on tumor location and patient comorbidities.

Comprehensive, collaborative care is essential to optimizing outcomes, ensuring patients receive the most appropriate interventions at each stage of disease management.

AJMC: What key steps did you take to establish a multidisciplinary care program for managing cSCC in your practice? How did you develop a referral network for cSCC?

As the founder and chief medical officer of a large, multioffice dermatology practice with an affiliated residency program, I have prioritized building a strong multidisciplinary care model. I frequently mentor residents and colleagues on developing these networks, emphasizing the importance of proactive collaboration. Establishing relationships with specialists (eg, as medical oncologists, surgical oncologists, and radiation oncologists) before urgent cases arise ensures seamless coordination when complex patient needs emerge.

For new clinicians, integrating into a multidisciplinary network requires actively fostering connections with specialty colleagues. Many specialists already have established working relationships, so engaging with one often leads to broader integration within the community. While academic institutions offer built-in referral networks, private practitioners benefit from creating their own collaborative teams, allowing for efficient, high-quality patient care while maintaining continuity throughout treatment. By developing a well-connected multidisciplinary network, dermatology practices can optimize outcomes and streamline patient management.

AJMC: What challenges did you encounter trying to put together this network of multidisciplinary care? How did you address these challenges?

The biggest challenge in establishing a multidisciplinary care network is the significant investment of time, effort, and coordination—none of which is directly reimbursed by insurance. However, the driving force behind this effort is the commitment to delivering the highest quality patient care. Physicians enter clinical practice to provide the best possible treatment, and building strong collaborative networks is essential to that mission.

Developing these relationships requires dedication beyond routine clinical responsibilities, but the long-term benefits, both for patients and for the efficiency of care delivery, make it worthwhile. While it takes persistence, the goal is to create a system that ensures patients receive seamless, expert-driven care, just as we would want for our own family members.

AJMC: How do you ensure all members of the care team are aligned on treatment goals and patient management plans?

Ensuring alignment among the multidisciplinary care team starts with the dermatologist serving as the patient’s advocate. In cSCC, dermatologists often play a pivotal role as the diagnosing physician, performing biopsies and delivering the initial diagnosis. This establishes a critical foundation of trust, positioning them as key guides throughout the patient’s treatment journey.

Although dermatologists may not directly perform surgeries or administer radiation or systemic therapies, they act as the gateway to these interventions. Patients rely on their expertise for treatment recommendations and coordination, even as care transitions to medical or surgical oncologists. By actively participating in multidisciplinary discussions, dermatologists help ensure treatment plans align with both clinical best practices and individual patient goals. This advocacy fosters cohesive, patient-centered care, ultimately improving both outcomes and patient experience.

AJMC: In what scenarios do you typically refer patients with cSCC to a medical oncologist? How do you coordinate with medical oncologists to develop treatment plans for patients with cSCC?

When a patient with cSCC may require systemic therapy, I refer them to a medical oncologist for further evaluation. Before the referral, I provide the patient with a broad overview of potential treatment options, ensuring they are informed before their detailed discussion with the oncologist.

Because I have established strong professional relationships with my oncology colleagues, I can facilitate timely referrals. In many cases, I also have a direct conversation with the oncologist to discuss the patient’s history, goals, and my treatment considerations. After their oncology visit, I schedule a follow-up with the patient to review the discussion, assess the proposed treatment plan, and ensure alignment with their care goals. I continue to monitor their progress, maintaining ongoing communication with both the patient and the care team to optimize outcomes and patient experience.

AJMC: What specific workflows or protocols have you implemented to streamline referrals and transitions of care between dermatology and oncology?

An efficient referral and transition process for patients with cSCC starts with assembling a multidisciplinary team committed to rapid triage and care coordination. The key is identifying specialists—dermatologists, surgical oncologists, medical oncologists, radiation oncologists—and other subspecialists who prioritize timely evaluation and treatment initiation.

We have established a streamlined workflow in which urgent cases are considered priority add-ons, ensuring that patients receive timely, in-person evaluations. Follow-ups can be conducted virtually to minimize travel burdens, particularly for patients requiring multiple appointments. A centralized triage system facilitates this process by gathering medical history, pathology, and imaging up front, allowing the care team to review cases and make recommendations efficiently.

Strong collaboration with oncology groups is essential. In our practice, we’ve developed relationships with oncologists who can typically see patients within a week, allowing for quick treatment decisions and timely initiation of systemic therapy when needed. By optimizing triage, centralizing patient data, and fostering close coordination, we ensure that patients receive the highest quality care without unnecessary delays.

AJMC: How do you ensure the patients’ information gets quickly and efficiently shared with these various practices or physicians you work with?

Because our electronic medical record system is separate from the oncology group, we rely on a multimodal communication approach to ensure seamless information transfer. Patient records are sent via email and fax, but we also follow up with a same-day phone call to confirm receipt and verify that the patient has been scheduled with the appropriate oncology specialist. This redundancy ensures efficiency and minimizes delays, facilitating timely treatment initiation.

AJMC: Are there specific challenges you face in collaborating with medical oncologists, and how do you address them?

Many community dermatologists worry not about losing patients to oncology specialists, but rather that patients might fall through the cracks after referral. As physicians, we treat patients like family, and entrusting their care to another specialist requires a high level of trust. The concern is often logistical; patients may face transportation issues, scheduling conflicts, or unforeseen barriers that prevent them from attending critical oncology appointments.

While large academic centers can provide comprehensive, acute care, there is a risk that patients will transition all follow-up care to these institutions. While this may be appropriate in some cases, maintaining a strong referral network and proactive follow-up ensures that patients receive personalized, ongoing care within their local dermatology practice when appropriate.

AJMC: Can you share an example of a successful case in which multidisciplinary collaboration resulted in improved patient outcomes?

A recent case highlights the impact of multidisciplinary collaboration in managing high-risk cSCC. The patient was presented with locally advanced cSCC of the left cheek, which was successfully cleared through Mohs surgery. However, molecular testing revealed a high-risk 40–gene expression profile result, indicating a significantly elevated risk of metastasis.

An immediate referral was made to our multidisciplinary team and specialists quickly evaluated additional treatment options. The patient ultimately opted for adjuvant radiation therapy, while further discussions explored the potential role of sentinel node biopsy, serial imaging, and adjuvant immunotherapy, including cemiplimab. Given the high-risk status, a proactive surveillance plan with serial imaging was implemented, ensuring early intervention if metastasis occurs.

This entire process, from risk identification to treatment initiation, was completed within 1 week, demonstrating how efficient coordination across specialties ensures timely, personalized care and improves patient outcomes in high-risk cSCC.

AJMC: What outcomes or goals are you hoping to achieve in the future?

Our goal is to establish a center of excellence that delivers the highest standard of care, one we would trust for our own family members. We aim to provide cutting-edge treatments, including emerging and experimental therapies, while maintaining a conservative, evidence-based approach to ensure both safety and efficacy.

As medicine advances, we strive to stay at the forefront of innovation while adhering to the latest clinical data to optimize patient outcomes. In dermatology and cutaneous oncology, we see an opportunity for leadership in shaping advanced cancer treatment protocols. We encourage dermatologists to take an active role in driving progress in oncology care, ensuring that patients receive the most effective and forward-thinking treatment options available.

AJMC: What advice would you give to another organization looking to implement their own multidisciplinary program for cSCC management?

Managing advanced cSCC is one of the most impactful and rewarding roles in dermatology. While it requires additional effort, these patients remain a central focus of our specialty. Dermatologists should take a leading role in the diagnosis, treatment, and long-term management of cSCC, ensuring seamless coordination with multidisciplinary teams. Establishing efficient workflows, fostering strong collaborative relationships, and staying at the forefront of emerging therapies are key to building a successful and patient-centric cSCC management program.