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SCCs more deadly in the immunosuppressed

Not only are immunosuppressed people at increased risk of developing skin cancer, new research shows the skin cancer they get is more likely to be aggressive and multifocal.

According to the retrospective study of a cohort of almost 800 patients who had been treated for cutaneous SCC of the head and neck at a US tertiary cancer care centre, immunosuppression was found to be independently associated with a worse outcome.

In fact, when compared to similar SCC patients who were not immunosuppressed, those whose immune system was compromised were almost two and a half times more likely to die from the cancer, even after adjusting for such factors as age and history of skin cancer.

The study found five-year disease-specific survival was 68.2% in the group with immunosuppression compared with 84.1% in the non-immunosuppressed patient group.

We already know immunosuppression increases the risk of cutaneous SCC with previous research showing a compromised immune system being associated with a 65- to 100-fold increased risk. What this study adds is evidence of the association between immunosuppression and poor outcome in the patients who develop this type of skin cancer.

“Cutaneous SCC [of the head and neck] in patients with immunosuppression is associated with poor outcomes and aggressive behaviour when compared with the immunocompetent population,” the study authors said in JAMA OtolaryngologyHead and Neck Surgery.

And if you are thinking that we could simply monitor immunosuppressed patients for skin cancer more closely, enabling earlier detection and treatment and thereby improve survival outcomes, the study findings suggest this won’t help.

When the researchers looked at the stage of the SCC at presentation, there was no significant difference in the T category between the two groups, and most patients had no nodal disease at presentation.

“Overall American Joint Committee on Cancer stage distribution was similar between the two groups at presentation,” they said.

In addition there was no difference in the selection of treatment between patients who were immunosuppressed and those who weren’t, with the majority undergoing surgery, more than half being treated with post-operative radiotherapy and a minority treated with chemotherapy.

All these findings suggest we can’t necessarily make a difference by intervening any earlier than we already do, or escalating the treatments we already have. So what is the answer?

“Because of the poor disease control demonstrated in patients with [cutaneous SCC of the head and neck] and immunosuppression, a need for novel treatment strategies remains,” the study authors said.

Basically we need better targeted treatments.

Unfortunately most clinical trials exclude patients who are immunosuppressed, but there has been some evidence that some of the biologics can be effective in the neoadjuvant setting. There is also support for the use of checkpoint inhibitors in the management of aggressive cutaneous SCC.

While these options appear promising, the study authors suggest that as a first step we should be highlighting the fact that this is a specific high-risk group, which needs specific research.

“Although surgery remains the mainstay treatment in these patients, these findings suggest that an improved understanding of adjuvant treatment options in these high-risk patients is required to improve their disease outcomes,” they concluded.

Reference

Tam S, Yao CMK, Amit M, Gajera M, Luo X, Treistman R, et al. Association of Immunosuppression With Outcomes of Patients With Cutaneous Squamous Cell Carcinoma of the Head and Neck.JAMA Otolaryngol Head Neck Surg. 2019 Dec 5. DOI: 10.1001/jamaoto.2019.3571 [Epub ahead of print]