In this discussion, Prof Jean-François Beaurain, a medical oncologist at Cliniques Universitaires Saint-Luc, Brussels, and Dr Winan Van Houdt, a surgical oncologist at the Netherlands Cancer Institute, shed light on the evolving landscape of treatment options and the practical considerations for squamous cell carcinoma (SCC) patients.
Prof Beaurain emphasised the relatively common occurrence of SCC, often amenable to curative resection through surgical means. However, the challenges arise in cases of locally advanced disease, characterized by large, painful, ulcerating, or bleeding tumors, making surgical resection arduous. Both experts expressed their satisfaction with the emergence of upfront treatments like cemiplimab or anti-PD1 therapies when indicated, as they tend to yield favourable responses. This, in turn, makes subsequent surgery more manageable, and in some instances, it may even be omitted, although this decision remains subject to debate.
Both experts underscored the compelling data on neoadjuvant cemiplimab in advanced or metastatic settings, expressing enthusiasm for its use. However, a challenge arises in identifying the boundary between resectable and non-resectable tumours, particularly in patients who receive immunosuppressive therapies, primarily graft patients with SCC’s more aggressive forms. The decision may hinge on the balance between the feasibility of surgical intervention and the extent of morbidity inflicted upon the patient. For cases involving patients with suppressed immune systems, the discussion extends to evaluating the risks of administering cemiplimab and the potential consequences of forgoing the treatment. In life-threatening situations, the inclination is often to accept the risks involved.
Prof Baurain delved into the one-year follow-up data from a phase 2 study presented at ESMO, focusing on neoadjuvant cemiplimab in cutaneous SCC. Previous findings had demonstrated a remarkable pCR of 51% with neoadjuvant cemiplimab. The one-year follow-up showed an impressive 89% event-free survival rate with the cemiplimab regimen. Of the 40 patients achieving a pCR, the event-free survival was 94.9% with no disease recurrence, and notably, 60% of these patients did not receive any adjuvant treatment. One patient had adjuvant radiotherapy, and 12 received adjuvant cemiplimab.
Dr Van Houdt expressed his admiration for these compelling results, advocating using neoadjuvant treatments to avoid complex surgical interventions whenever possible. Similar favourable outcomes were noted in the MATISSE trial, which utilised a neoadjuvant nivolumab-ipilimumab approach, yielding durable complete remissions while obviating the need for debilitating curative surgery. This paradigm shift highlights the significance of the neoadjuvant approach in patients with advanced or metastatic SCC. The discussion then revolves around the necessity of adjuvant treatments, including the debated role of radiotherapy. The experts also emphasised the importance of planning for cases where patients do not respond to neoadjuvant therapy or experience disease progression, ensuring that the option of curative surgery remains viable within the given timeframe.
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