Multidisciplinary Management of Advanced cSCC: A Medical Oncologist’s Perspective

Editors from AJMC® spoke with Martin Dietrich, MD, PhD, a medical oncologist at Cancer Care Centers of Brevard in Rockledge, Florida, and assistant professor of internal medicine at the University of Central Florida in Orlando, Florida, about multidisciplinary management of advanced cutaneous squamous cell carcinoma (cSCC).

AJMC: How would you describe your role in managing patients with advanced or metastatic squamous cell carcinoma (SCC)?

As a medical oncologist, my role focuses on managing patients with cutaneous malignancies that extend beyond surgical treatment alone, including locally advanced melanoma, SCCs, or basal cell carcinomas. I do have a predominant role in patients with metastatic diseases, although local interventions with surgery and radiation therapy may have a role there. In our practice, the more challenging presentations involving multiple specialties are locally advanced disease presentations that require coordinated care. In these cases, systemic therapy is rarely sufficient on its own. It must be integrated with dermatology, Mohs surgery, radiation, and other supportive specialties like ENT(ear, nose, and throat)/head and neck surgery, and plastic reconstruction surgery, among others. In this setting, I ultimately serve as a member of a multidisciplinary team for complex, locally advanced cutaneous squamous and basal cell carcinomas. Identifying the best path for optimal medical, functional, and cosmetic outcomes in accordance with the patient’s values and expectations is the focus of the multidisciplinary team.

AJMC: In your own words, how would you define high-risk, resectable cSCC?

High-risk cSCC is defined by a combination of clinical and pathological features that elevate the risk of recurrence or metastasis despite local intervention. There are many factors that need to be taken into account. Tumor size and location, particularly near critical anatomical structures, can complicate resection margins. Additional risk factors include large tumor size and poorly differentiated histology. High-grade tumors are particularly concerning due to their aggressive behavior and increased likelihood of recurrence and metastasis. Additional indicators that could also be observed are local regional spread into lymph nodes or perineural invasion, often evidenced by locoregional numbness and tingling. These high-risk features are often readily identifiable upon first clinical evaluation, but sometimes additional evaluation, including imaging, is required for full understanding of the disease. Factors such as prior treatments, including surgery or radiation, can further contribute to a tumor’s risk assessment. Together, we can confirm that these clinical and pathological characteristics form the basis for defining high-risk, resectable cSCC.

AJMC: What factors do you consider when determining the need for systemic therapy in these patients?

In the multidisciplinary management of cSCC, there are several aspirational treatment goals. When the idea is to provide the patient with a permanent solution to locally advanced disease with optimized functional and cosmetic outcomes, the options include medical treatments, surgery, and radiation therapy. Systemic therapy is often considered in combination with surgery or radiation to achieve durable control or potential cure. Beyond oncologic outcomes, we carefully weigh functional and cosmetic considerations, particularly since cSCC commonly arises in sun-exposed, visible areas near the eyes, ears, or face. Preserving function and minimizing disfigurement are critical to maintaining quality of life. Psychosocial impacts—including heightened risk of anxiety, depression, and even suicide—further underscore the importance of a comprehensive, patient-centered treatment approach. The arrival of highly effective systemic therapy options for basal and SCC of the skin should shift the goalpost in the direction of patient centricity and optimal medical oncology outcomes.

AJMC: Given the new and emerging systemic treatment options for patients with unresectable cSCC, what are some of the main considerations for deciding between these different therapeutic options?

In unresectable cSCC, systemic therapy selection depends on disease setting and patient-specific factors. For locally advanced cases receiving radiation, we may use radiosensitizing chemotherapy. However, with the advent of immunotherapy, cytotoxic chemotherapy has been largely deprioritized. Today, PD-1 inhibitors are the standard first-line treatment; they are used almost universally, except in patients with contraindications such as solid-organ transplants or autoimmune conditions for which traditional chemotherapy may still play a role along with radiation. We have seen some very interesting data with injectable oncolytic virus in cutaneous malignancies that enhance the local inflammatory effect and synergize well with standard checkpoint inhibitor therapy. A lot of work has also gone into making these therapies available to patients given solid-organ transplants, for whom the immunosuppression can lead to particularly aggressive nonmelanoma skin cancers.

AJMC: How do you monitor and manage immune-related adverse events in patients receiving checkpoint inhibitors?

PD-1 and PD-L1 checkpoint inhibitors are generally well tolerated, and their management protocols are well established in oncology practice. With broad indications and extensive clinical experience in many indications, we are well familiar with managing these agents in routine clinical practice. Patient and provider education is the foundation of safe delivery of these therapies, emphasizing the mechanism of action by activating the immune system against the present tumors. Unfortunately, this immune activation sometimes is misguided and turns against healthy tissue, an adverse effect that we have to monitor and intervene on, if necessary. We implement layered monitoring strategies, including symptom questionnaires, nurse triage during infusions, regular laboratory testing, and clinic visits. After a decade of experience with checkpoint inhibitors, we have developed confidence in their favorable risk-benefit profile.

AJMC: When referring to multidisciplinary collaboration in patients with cSCC, when do you typically become involved in a patient’s care, and what role does multidisciplinary collaboration play in cSCC management?

Ideally, we become involved with the multidisciplinary team at the time of initial diagnosis—medical, surgical, and radiation oncology working in concert. Surgical specialists may include dermatologic surgeons, Mohs surgeons, or head and neck surgeons, depending on tumor location. After reviewing a patient together, the best course of action can be decided. Early collaboration allows us to optimize oncologic, functional, and cosmetic outcomes and allows treatment sequencing optimization that can help prevent recurrence and local or distant treatment failure, which are substantially more difficult to treat. Unfortunately, in the real world, referrals are often sequential, so we see patients after initial surgery or radiation attempts, when the disease has progressed. This delays optimal care and limits systemic therapy effectiveness. Early integration of medical oncology into the treatment plan is critical for the best outcomes.

AJMC: How did you develop a multidisciplinary team, and how do you collaborate with dermatologists outside of your organization in managing cSCC?

Our multidisciplinary collaboration is often built on close, real-time communication rather than formal, scheduled meetings. Within our institution, we maintain open lines of communication among the multidisciplinary team, allowing for rapid, coordinated decision-making. However, other multidisciplinary team members can be involved via other means of communication. For cutaneous malignancies, sharing images and clinical impressions in real time enhances efficiency and supports timely care planning.

Most dermatologists we work with are in private practice, as we do not have in-house dermatology. We have built strong relationships with them through outreach and education, ensuring we are viewed as accessible partners. Our goal is not to replace surgery but to complement it, particularly by offering systemic therapy when appropriate to optimize surgical outcomes. Many referring dermatologists have my direct contact information, which helps foster a tightly connected, responsive care network.

AJMC: How do you ensure all the members of the care team are aligned on treatment goals and that the patient’s best interests remain at the center of their treatment plans?

Effective multidisciplinary care is dependent on intentional coordination. Before initiating any therapy, we consult with surgical and radiation colleagues to agree on the next best step and subsequent steps moving forward. That alignment is foundational. It prevents fragmented care and ensures decisions are made collaboratively with the patient’s best interest in mind. We often connect by phone in real time during patient visits, and we integrate clinical notes and photographs into the shared medical record so that all team members have a clear view of disease progression and treatment status. This approach fosters continuity, transparency, and a unified standard of care.

AJMC: What do you think are some of the most common communication gaps between dermatologists and medical oncologists? How does your organization address them?

Most communication gaps are logistical, but we have been workinghard on closing them. Often, they come down to barriers—lack of a direct phone number, email address, or fax number—which can delay collab­oration. To address this, we focus on building direct, personal lines of communication. We proactively reach out to dermatologists and their office staff, sharing contact information, reviewing complex cases together, and offering support as needed.

Our goal is to be a readily accessible resource that complements, rather than replaces, the care dermatologists provide. By making ourselves available and reducing friction in the referral and consultation process, we help ensure patients with complex or advanced cSCC are connected to the multidisciplinary care they need without unnecessary delays. Everyone is aligned in wanting the best outcome for the patient, and our job is to make that collaboration as seamless as possible.

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

Multidisciplinary collaboration has been pivotal in transforming outcomes for patients with locally advanced cSCC, particularly in anatomically challenging areas like the head and neck or pretibial region. Historically, these cases were managed with surgery or radiation alone, often resulting in high morbidity or incomplete resection. A prime example involves patients with bone-invasive, locally advanced head and neck cSCC. These cases were previously considered surgically unresectable or carried a high risk of poor cosmetic and functional outcomes. By introducing immunotherapy in the neoadjuvant setting, prior to definitive surgery, we have been able to downstage tumors, achieving margin-negative resections with better functional preservation and improved aesthetic results.

Immunotherapy in this context is not curative on its own, but it significantly enhances the effectiveness of surgery. We see response rates nearing 70% in the neoadjuvant setting, and this early tumor shrinkage often converts complex, high-risk surgeries into more straightforward procedures. Additionally, definitive surgery after immunotherapy allows for pathological confirmation of disease clearance, providing both clinicians and patients with a clearer treatment end point, something that can often be uncertain in immunotherapy-only strategies. This approach also avoids the complications seen when immunotherapy is delayed. For example, patients with cSCC in areas like the pretibial region who first receive radiation and later experience recurrence are significantly harder to treat surgically. Early integration of immunotherapy prevents these scenarios and improves outcomes across the board.

In summary, early and coordinated integration of immunotherapy with surgical planning has resulted in faster and more effective treatment, better surgical outcomes, and clearer treatment trajectories, demonstrating the value of real-time multidisciplinary collaboration.

AJMC: What best practices for multidisciplinary collaboration in cSCC have you implemented in your practice and institution?

There is no one-size-fits-all approach to multidisciplinary collab­oration, as institutional structures and geographic contexts vary widely. That said, a few best practices have consistently enhanced coordination and outcomes in our experience. First and foremost, ease of communication is critical. Dermatology is often practiced in community-based, private settings, making it essential to maintain open lines of communication both within and across institutions. Sharing direct contact information, cell phone numbers, and secure email addresses and using platforms compliant with the Health Insurance Portability and Accountability Act of 1996 can close many of the most common communication gaps.

Second, visual documentation has proven invaluable. While traditionally more common in dermatology, we have adopted the practice of photographing tumors at baseline and throughout treatment. These images are integrated into the electronic medical record and shared during interdisciplinary discussions, helping to align perspectives and track progress in real time. Another key principle is involving all relevant specialists before initiating treatment. Input from dermatologists, surgeons, radiation oncologists, and medical oncologists ensures that the patient receives a fully informed and optimized care plan. This also underscores to the patient the seriousness of advanced cSCC and the importance of a coordinated treatment strategy, especially when the disease has progressed beyond what they may have previously experienced.

Lastly, we have implemented structured processes to streamline evaluation. That includes standardized checklists to confirm necessary imaging and diagnostic steps, as well as ensuring all consultations are completed before key decisions are made. These practical and scalable steps, real-time communication, visual documentation, early multidisciplinary input, and standardized workflows have allowed us to improve coordination and deliver more effective, patient-centered care.

AJMC: Are there institutional barriers that make it challenging to implement seamless transitions of care between dermatology and oncology? And if so, how can these be addressed?

Yes, there are significant institutional barriers, particularly when patients are not already integrated into a multidisciplinary care team. In those cases, transitions between dermatology and oncology can be fragmented and delayed, especially when relying on standard referral pathways. For patients with locally advanced disease, timeliness is critical. These lesions often progress rapidly and require expedited evaluation. Standard referrals can create unnecessary delays. To address this, we’ve found that direct, provider-to-provider communication, what we refer to as a warm handoff, is essential. This not only accelerates access to care but also reassures the patient that a cohesive, collaborative care team is engaged. Warm handoffs improve administrative efficiency, shorten time to treatment, and enhance patient confidence. Encouraging these direct connections and minimizing siloed communication should be a key institutional priority to improve outcomes in advanced cSCC.

AJMC: How do you envision the role of medical oncologists evolving in the management of cSCC as therapies continue to advance?

The role of medical oncologists in managing cSCC is rapidly expanding and will become increasingly central as therapies evolve. Emerging modalities, such as injectable oncolytic viruses, are expected to enhance treatment options, particularly when integrated early with surgical and dermatologic care. Medical oncologists should no longer be viewed as a last resort. Instead, they must be involved early, often before any surgical intervention, to assess whether neoadjuvant immunotherapy could improve resectability and outcomes. Immunotherapy has demonstrated exceptional efficacy in cSCC, often converting unresectable tumors into candidates for curative surgery. In fact, few malignancies exhibit response rates to immunotherapy as high as those seen in cSCC and basal cell carcinoma. As such, the medical oncologist’s evolving role is not just in salvage settings, but as a key facilitator of definitive, one-time interventions like surgery or radiation, ensuring that patients receive the most effective, coordinated care from the outset. Early involvement in the plan of care can be critical.

AJMC: What outcomes do you hope to achieve in the future?

Our goal is to optimize oncologic, cosmetic, and functional outcomes for patients with cSCC while minimizing the need for disfiguring surgeries, complex reconstructions, or secondary interventions. Historically, patients have faced significant morbidity from initial treatments, such as skin flaps and extensive rehabilitation, but multidisciplinary coordination can prevent many of these challenges Immunotherapy plays a key role in improving surgical and radiation outcomes by shrinking tumors preoperatively and enabling more conservative, patient-centered resections. This approach not only enhances resectability but also leads to better quality-of-life outcomes.

Looking ahead, we aim to integrate novel strategies such as injectable immunotherapies, combination regimens, and topical agents like toll-like receptor modulators to further improve response rates and tailor care. Ultimately, our vision is to deliver coordinated, effective, and durable treatment that avoids overtreatment and maximizes patient benefit across all modalities.

AJMC: Do you have any closing thoughts on this topic that we should add?

This is an exciting and rapidly evolving field. Immunotherapy has already reshaped our treatment landscape in cSCC, offering new opportunities to improve outcomes. I am optimistic about the continued development of combination therapies and novel agents that will further enhance care. As these advances move from research to clinical practice, our focus remains on expanding access and refining strategies to benefit more patients. We have an immediate opportunity to bring the agents we already have to better use.