Managing Advanced Basal Cell Carcinoma: A Guide for the Dermatology Clinician.

Objective: Basal cell carcinoma (BCC) is the most common form of skin cancer. Advanced BCCs include locally advanced BCCs (laBCCs), primary or recurrent tumors that are not amenable to surgery or radiation therapy, and metastatic BCCs (mBCCs). The management of advanced BCC has been revolutionized in recent years by the development of hedgehog inhibitors (HHIs) and immunotherapies (ie, PD-1 inhibitors). We aim to review the current literature on therapeutic options and outline treatment strategies to optimize care for patients with advanced BCC. Methods: A comprehensive literature search was completed using the keywords "advanced basal cell carcinoma," "treatment," "hedgehog inhibitor," "vismodegib," "sonidegib," "PD1-inhibitor," and "cemiplimab." The authors reviewed all studies and included those which addressed the topic of the review. Results: Surgery or radiotherapy may not be an option for certain high-risk BCCs due to due to invasion into local tissue, location near anatomically sensitive areas, or metastasis. There is increasing evidence for the efficacy of HHIs, including vismodegib and sonidegib, as the first-line treatment for these advanced BCCs. Despite known efficacy, utility of HHIs can be limited by their adverse event profiles. If patients fail HHIs due to inefficacy or adverse effects, there is evidence for use of the PD-1 inhibitor cemiplimab. Limitations: This is a review article and is limited by the information available in the published literature. In addition, comparison between studies is limited as they utilized varying methodologies. Conclusion: Treatment of advanced BCCs can be complex and poses challenges for clinicians. HHIs are currently the first-line treatments for laBCC and mBCC, while cemiplimab can be used if patients do not respond to or are unable to tolerate HHIs, or for whom HHIs are not appropriate.