TREATING SQUAMOUS CELL SKIN CANCER:
TREATMENT OPTIONS

Once you have gone over the pathology report and staging information with your doctor, it’s time to plan the treatment strategy. This section discusses the different types of therapy that are available for squamous cell skin cancer and their advantages and disadvantages.*

 

Surface/Destructive Therapy

These treatments are applied directly to your skin to treat squamous cell skin cancer.

Curettage & Electrodessication (C & E)

In this procedure, the doctor scrapes the cancer from your skin (curettage). Then s/he applies heat to destroy any remaining cancer cells (electrodessication), which also stops any bleeding.

Advantages:

  • It’s quick, often completed in one office visit
  • It does not require stitches (or a follow-up appointment to remove them)
  • It’s a non-invasive option for people who don’t want or can’t tolerate a more-invasive procedure
  • For high-risk groups who have multiple squamous cell skin cancers, C & E allows rapid treatment of multiple cancers at the same time. It’s just important to check the pathology to make sure there are no high-risk features

Disadvantages:

  • It does not work well on areas that have hair
  • It may not heal as well as an excision, so it probably should not be used on an area where you are concerned about the appearance
  • If the tumor is deeper than expected, it may still need to be surgically removed
  • It is not as effective as surgery

Cryosurgery

This procedure involves applying a cold substance, such as liquid nitrogen, to the tumor and freezing it off. It may be considered for low-risk squamous cell skin cancer when more effective therapies are either not advised or impractical. It can also be considered in individuals with conditions that cause them to form large numbers of tumors.

Fact vs Fiction

Can’t I just use a topical medicine like Aldara®? It worked for my sister’s skin cancer.

DEBATABLE. Topical medications such as Aldara are used for actinic keratosis and basal cell carcinoma, but respected medical organizations do not agree on their use in squamous cell skin cancer. Aldara is not generally recommended for patients with squamous cell skin cancer, except in some in situ (non-invasive) cases. Similarly, topical 5-fluorouracil (5-FU), which is a type of chemotherapy, is not recommended as a treatment for squamous cell skin cancer.

Surgery

There are two general types of surgery for squamous cell skin cancer:

Wide Local Excision

A dermatologist (or specialized surgeon) cuts out the cancer and an area around the tumor. Removing an extra part of skin (a wide margin) assures that s/he got all the cancer. If there is a big enough margin of normal skin around the cancer cells, your treatment is complete. If not, your doctor may need to go back and take more.

Mohs Micrographic Surgery (MMS)

Mohs (rhymes with nose) surgery is recommended for squamous cell skin cancer that is likely to recur (come back) or is in an area where you don’t want to remove a lot of skin (such as the face, neck, or hand).

In Mohs (also called microscopic controlled excision) surgery, you are awake while the surgeon removes the smallest amount of tissue needed to treat the cancer.  Often this procedure can be done in the medical office but sometimes needs to be performed at a surgical center. It is done at a hospital only rarely, when surgery will be extensive.

The surgeon removes the skin cancer that can be seen. Then a thin layer of surrounding skin is cut away and examined under a microscope. If cancer cells are found in that additional layer, the process will be repeated until no cancer cells can be seen. The surgeon will then decide the best way to treat the wound.

Radiation Therapy

Radiation therapy is used if you can’t undergo surgery or if you really don’t want it. Radiation therapy can also be used in addition to surgery to help prevent the cancer from coming back (adjuvant therapy). Smaller and thinner tumors may respond well to this type of therapy. Finally, if the skin cancer has grown deep or spread, radiation therapy may help you feel more comfortable because it can control some of the symptoms associated with the cancer.

The different types of radiation therapy used to treat squamous cell skin cancer are:

  • Superficial radiation therapy: Radiation beams are sent just beneath the skin, treating only the tumor
  • External beam radiation therapy: High-energy beams of radiation are directed into the tumor in order to kill cancer cells, but no radioactive sources are placed inside your body
  • Brachytherapy: Radioactive implants are placed directly inside (or near) the cancer. Also called internal radiation, this therapy is also used to treat prostate cancer

Photodynamic therapy is a treatment that uses light-activated radiotherapy. Although this type of therapy is used for some basal cell carcinomas, it is not considered effective for squamous cell skin cancer. Similarly, laser therapy is also not considered effective for squamous cell skin cancer.

Key terms:

Adjuvant therapy: Additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back. For squamous cell skin cancer, the primary treatment is usually surgery.  Adjuvant therapy may include chemotherapy, radiation therapy, hormone therapy, targeted therapy, biological therapy, or immunotherapy.

Systemic Therapy

Systemic therapy is a therapy given throughout your body. There is currently only one drug approved by the U.S. Food and Drug Administration (FDA) for squamous cell skin cancer: cemiplimab.

Cemiplimab

Cemiplimab (Libtayo®) is an immunotherapy, a treatment that helps your immune system fight cancer. Cemiplimab is FDA approved for treatment of advanced squamous cell skin cancer, which includes locally advanced or unresectable (which means it can’t be removed with surgery) squamous cell skin cancer as well as squamous cell skin cancer that has metastasized (spread) to the lymph nodes or distant regions.  It is given in the vein (IV, intravenously) every three weeks, usually in a hospital or cancer center. Cemiplimab belongs to a class of drugs called programmed cell death protein 1 (PD-1) inhibitors. PD-1 inhibitors reactivate part of the immune system (the T-cell system) that has been suppressed by cancer cells. When this T-cell system is reactivated, it can then do its job and seek out and kill cancer cells.

In clinical trials, cemiplimab shrank tumors in about half the patients with squamous cell skin cancer. This shrinking lasted six months or longer in 61 percent of the patients who responded to cemiplimab. A few (about four percent) patients had their tumors disappear completely. Cemiplimab had side effects that are typically seen with PD-1 inhibitors, which are mostly related to the immune system being activated. These side effects included lung problems, intestinal problems, liver problems, hormonal issues, kidney problems, and skin issues such as rash, blistering, and sores in the mouth. For more information about these issues, see Dealing With the Side Effects of Therapy (Living With Squamous Cell Skin Cancer).

FDA approved in the advanced disease setting, cemiplimab is also being studied in clinical trials in the adjuvant setting (after surgery and radiation therapy) in patients with high-risk squamous cell skin cancer to keep the cancer from coming back.

Other Systemic Therapies Being Studied

A number of clinical trials are ongoing with investigational agents for squamous cell skin cancer. Other FDA-approved PD-1 inhibitors (as well as PD-L1 inhibitors that work on the same pathway), such as nivolumab, pembrolizumab, and avelumab, are being studied in squamous cell skin cancer. As mentioned previously, studies are also ongoing with targeted therapies (EGFR inhibitors) alone and in combination with chemotherapy agents.

More on Clinical Trials in Squamous Cell Skin Cancer

Clinical trials are research studies that test how well new medical approaches work.  They have an important place in your care as researchers strive to improve current cancer treatments and search for new and better ones. Clinical trials are essential for learning about cancer and how to prevent or cure it.

Our most-effective cancer treatments would not be available without the clinical trial process. Unfortunately, many people with cancer are unaware of the option for a clinical trial or are unsure about the value of participation.

Your goal is to find the best treatment available whenever you make a treatment decision.  While there may be a good standard of care for you—care that experts believe is appropriate for your specific diagnosis and treatment history—sometimes the current standard of care is not as effective as you and your healthcare team would like. Other times, the standard of care works for a time but then stops working.  In still other instances, there is no standard of care for your situation.  At these times, participation in a clinical trial may be the best option for you.

The best time to search for clinical trials is every time you are faced with a treatment decision.  

Skin Cancer Clinical Trial Matching Service

Register with EmergingMed so you know all your options and can make informed decisions about your care.  All information is kept in the strictest confidence.

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*Throughout these treatment sections, we make references to recommended treatment strategies. We consulted the American Academy of Dermatology (AAD) and the National Comprehensive Cancer Network (NCCN) guidelines on these topics. These professional groups are the foremost authorities on skin cancer management. To consult these guidelines, please see RESOURCES.

Mohs surgery image courtesy of Terese Winslow.