Different medical specialists use different staging methods for cutaneous squamous cell carcinoma  – this may affect the treatment approach and outcomes

Cutaneous squamous cell carcinoma (CSCC) is the second most common types of skin cancer. CSCC is diagnosed at a rate of 15-35 per 100,000 people and is expected to increase 2-4 % per year. Fortunately, it is cancer that develops slowly and is associated with an excellent prognosis. Only about 2-4% of the tumors metastasize, leading to death in 1.5% to 2% of the cases. It means that early identification, staging, monitoring, and management can significantly help prevent CSCC-related mortality. However, when it comes to staging the CSCC, there is an issue that different specialists use different staging methods. The two most common staging methods used are Brigham and Women’s Hospital tumor staging system (BWH) and American Joint Committee on Cancer (AJCC). These staging methods share many traits. Nonetheless, they differ a bit. It means that even staging methods may influence the disease outcomes.

A new survey among the various medical specialists was done to determine if the difference in diagnostic and staging approaches between the different specialists exists or not? If it exists, what are these differences, and what could be the possible significance of these differences? The study mainly focused on finding the difference in approach to the CSCC between dermatologists and other cancer specialists. The study was conducted by Dr. Vishal Patel and colleagues from the Department of Dermatology, George Washington School of Medicine and Health Sciences, where the researchers sent 25 questions survey to 337 physicians. Out of them, 156 completed the survey; among them, 89 were dermatologists, and 67 were other cancer specialists (OCS). Radiation oncologists, Mohs surgeons, and head and neck surgeons were classified as OCS.

The researchers found both similarities and differences in staging approaches. They noticed that dermatologists always used the BWH staging method, and they used AJCC only as a supporting tool. Whereas OCS always used AJCC as the primary way to stage CSCC. Respondents considered BWH T2b and AJCC T3 as high-risk CSCCs.

There were some areas of consensus between the dermatologists and OCS like they gave equal importance to the depth of invasion (DI), perineural invasion (PNI), poor histological differentiation (HD), and immunosuppression. However, there were also areas of significant differences. Dermatologists were more likely to consider tumor diameter as a high-risk factor compared to OCS. Dermatologists described tumors with a diameter greater than 2 cm, moderate differentiation, poor differentiation, spindle cell, infiltration, and desmoplasia, unlike OCS. When it comes to OCS, they paid greater attention to PNI, while dermatologists only considered PNI if a larger nerve (equal to or above 1 mm diameter) was affected. Although both the dermatologists and OCS considered immunosuppression a vital component and regarded patients with solid organ transplants as high-risk individuals, OCS were more likely to consider other factors like stem cell transplant and chronic systemic diseases.

Additionally, most clinical respondents reported not using staging systems to decide on management approaches like radiological imaging, sentinel lymph node biopsy (SLNB), post-operative radiation therapy (PORT), or other treatment in high-risk CSCC patients. Nonetheless, most respondents agreed that BWT T2b or AJCC T3 stages were reason to consider radiological imaging, SLNB, PORT, and increased patient follow-up.

So, what this study found is that there is a lack of consensus among various doctors and specialists, with each using different staging methods. Moreover, there is also a lack of a universally accepted treatment approach based on the risk assessment. Although there are many areas of agreement between the different specialists, significant differences remain. Hence establishing a single harmonized way of assessing high-risk patients and developing a consensus on the disease management strategy that various specialists accept is the need of the day. It would further help improve CSCC outcomes.