Your Advanced Skin Cancer Care Team

This brings together experts from dermatology, surgical oncology, medical oncology, radiation oncology, pathology, and radiology, among other specialties, explains Naiara Abreu Fraga Braghiroli, MD, PhD, the chief of the Skin Cancer Clinic at Baptist Health Herbert Wertheim Cancer Institute in Miami.

“This collaborative approach is particularly important for patients with advanced or high-risk skin cancers,” she says. “Each specialist contributes a different perspective, allowing us to develop a comprehensive treatment plan that considers not only the cancer itself, but also the patient's overall health, quality of life, and individual needs.”

Who Belongs on Your Advanced Skin Cancer Care Team?

• Primary Care Physician (PCP) Your PCP is familiar with your health history, performs routine screenings, and may have been the one who first noticed the cancer during a routine skin check. As part of the multidisciplinary team, the PCP helps coordinate care and communication among specialists.

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• Dermatologist “Dermatologists and dermatopathologists are the physician experts in the diagnosis of skin cancer, and dermatologists are the experts in the treatment of the vast majority of common skin cancers,” says Daniel D. Bennett, MD, a professor of dermatology at the University of Wisconsin School of Medicine and Public Health in Madison. “However, for those unusually complex or advanced skin cancers, a multidisciplinary approach is very important.” Dermatologists perform biopsies and certain procedures to remove or treat localized skin cancers. For advanced skin cancer, a dermatologist will refer patients to specialists and continue to collaborate on care.

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• Mohs Surgeon Mohs micrographic surgery is a procedure that removes high-risk skin cancer while preserving healthy surrounding tissue. The tumor is removed in layers, with each layer examined under a microscope for the presence of cancer cells. This process continues until the cancer is gone.

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   Most Mohs surgeons are dermatologists who have completed training to perform this procedure.
• Surgical Oncologist The type of surgery required to remove the skin cancer depends on many factors, including its size and location and whether it has spread.

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   “A dermatologist or Mohs surgeon may be focused on removing the cancer from the skin, while a surgical oncologist might be involved if surgery is needed beyond the skin, such as a lymph node biopsy,” says Maral Kibarian Skelsey, MD, the director of the Mohs surgery unit and a clinical professor of dermatology at Georgetown University in Washington, DC.
• Medical Oncologist Drug therapy may be needed to treat advanced skin cancer. There are several different types of medications that are used, including immunotherapy, targeted therapy, or chemotherapy. A medical oncologist usually prescribes and oversees this treatment.

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• Radiation Oncologist Radiation therapy is widely used in cancer treatment and is administered by a radiation oncologist. In advanced skin cancer, it is sometimes used for tumors that may be difficult to remove surgically, or if you can’t have surgery. It can also be used alongside other therapies.

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• Radiologist A radiologist specializes in interpreting diagnostic imaging, including X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI), ultrasound, and positron emission tomography (PET) scans. Using these scans, radiologists can assess the size of the tumor, determine whether it has spread, and also guide surgery.

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• Pathologist While patients generally never meet the pathologist, they play an essential role in the multidisciplinary team. A pathologist examines tissue under a microscope to make a diagnosis. They help determine the stage of the cancer as well as guide treatment.

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• Plastic Surgeon Cancer surgery can sometimes require extensive tissue removal or leave heavy scarring. Reconstructive surgeons help repair or replace tissues damaged by cancer or its treatment. This includes restoring function as well as improving appearance.

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• Supportive Professionals The multidisciplinary team can also include support professionals such as oncology nurses, social workers, pharmacists, and rehabilitation specialists.

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How Your Care Team Collaborates: The Tumor Board

“Each person contributes to a different piece of the puzzle, and that collaboration is particularly important when a cancer has spread beyond the skin or requires multiple types of treatment,” says Dr. Skelsey.

How a Tumor Board Works

Tumor board meetings can vary, but they all follow the same basic protocol. During a typical meeting, several cases are evaluated.

“Each specialist provides insights based on their expertise, and we discuss the available treatment options, incorporating current medical evidence and clinical guidelines,” says Dr. Braghiroli.

For example, she says, “In a patient with locally advanced squamous cell carcinoma, we may discuss whether surgery is the best first step, which type of surgery, whether radiation therapy would be beneficial, or whether immunotherapy should be considered.”

The discussion can sometimes point to a treatment strategy that would not have been as apparent from the perspective of a single specialty.

It’s important to note that not every case needs to be presented before a tumor board. Many situations are straightforward, with clear guidelines that can be applied. “Programs give priority to new diagnoses, complex or unusual cases, disagreements between specialists, cancers that have come back, and cases where a trial might apply,” Bennett says.

Coordinating Communication Across Specialists

“One of the advantages of receiving care at a comprehensive cancer center is that specialists, with the assistance of a nurse navigator, can communicate directly and coordinate treatment decisions through established multidisciplinary pathways,” says Braghiroli.

If you aren’t being treated at a cancer center, you’ll need to identify who is the coordinator for your overall treatment plan. “Depending on the patient’s situation, that might be the dermatologist, oncologist, or another physician,” says Skelsey. “That person doesn’t necessarily make every treatment decision, but they can help make sure recommendations from different specialists are communicated and that everyone understands what the next steps are.”

Skelsey says it’s important for you to take an active role in keeping your healthcare team informed — and that includes providers who aren’t directly involved in your cancer treatment. “Other doctors need to understand whether the cancer diagnosis or its treatment could affect another medical condition or interact with medications they are prescribing,” she says.

She recommends that patients keep an organized record of their pathology reports, imaging results, medications, previous treatments, and the names and contact information of their specialists.

And while electronic health records have improved communication, it’s important not to assume that one doctor automatically knows what other doctors are doing. “Many electronic medical records are not linked across practices,” says Bennett. “Savvy patients can take advantage of patient portals to obtain copies of records from one practice in order to upload them to the patient portal of another practice.”