Some patients will have metastatic disease on initial presentation. Others may present with symptoms of recurrent disease after a previous cancer diagnosis. Access to the best available therapies, including clinical trials, as well as treatment overseen by a multidisciplinary team, are crucial to achieving the best outcomes for anyone with metastatic disease.

Signs and symptoms will depend on the type of cancer initially diagnosed and the location of metastatic disease. They may be discovered by the patient or by surveillance in the post-treatment period. Symptoms can often present as:

• new or changing skin lesions
• lumps or masses
• new/persistent symptoms.

These symptoms should be a trigger for further medical assessment.

The incidence of lymph node metastases from cutaneous SCC is low but may be considerably higher in the following scenarios:

• SCC occurring at sites of mucosal–squamous cell junctions, including the lip, anus and vulva
• immunosuppressed patients
• SCC occurring at sites of previous radiotherapy
• SCC arising in chronically inflamed/ulcerated areas.

Among patients who develop regional recurrence, specific tumour factors related to developing regional recurrence include the following:

• tumour size – SCCs larger than 20 mm are twice as likely to develop regional recurrence
• tumour site – SCCs located on the ear and lip have a higher rate of recurrence than SCCs in other sites
• tumour grade – poorly differentiated SCCs have double the recurrence rate of well-differentiated lesions
• tumour thickness – SCCs thicker than 4 mm recur three times more commonly than thinner lesions
• perineural invasion is the most serious predictor of regional recurrence, with up to 50 per cent developing regional recurrence (Cancer Council Australia Keratinocyte Cancers Guideline Working Party 2019).

Managing metastatic disease is complex and should therefore involve all the appropriate specialties in a multidisciplinary team including palliative care where appropriate. From the time of diagnosis, the team should offer patients appropriate psychosocial care, supportive care, advance care planning and symptom-related interventions as part of their routine care. The approach should be personalised to meet the patient’s individual needs, values and preferences. The full complement of supportive care measures as described throughout the optimal care pathway and in Appendices A and B, and in the special population groups section should be offered to assist patients and their families and carers to cope. These measures should be updated as the patient’s circumstances change.

Survivorship care should be considered and offered at an early stage. Many people live with advanced cancer for many months or years. As survival is improving in many patients, survivorship issues should be considered as part of routine care. Health professionals should therefore be ready to change and adapt treatment strategies according to disease status, prior treatment tolerance and toxicities and the patient’s quality of life, in addition to the patient’s priorities and life plans.

If there is an indication that a patient’s cancer has returned, care should be provided under the guidance of a treating specialist. Each patient should be evaluated to determine if referral to the original multidisciplinary team is necessary. Often referral back to the original multidisciplinary team will not be necessary unless there are obvious aspects of care involving different therapeutic and supportive care disciplines not otherwise accessible. The multidisciplinary team may include new members such as palliative care specialists.

Treatment will depend on the location, extent of recurrent or residual disease, previous management and the patient’s preferences.

The management for people with locally recurrent keratinocyte cancer is more urgent because patients have an increased risk of further regional recurrence and/or distant metastases. Treatment may include the following options.

In managing people with locally recurrent BCCs, treatment may include:

• surgical excision – excision of the lesion with the scar and any previously treated area is usually necessary
• radiation therapy – as primary treatment to a locally recurrent BCC or as adjuvant treatment after re-excision
• margin control surgery – for example, Mohs micrographic surgery (Cancer Council Australia Keratinocyte Cancers Guideline Working Party 2019).

In managing people with locally recurrent SCCs, treatment may include:

• surgical excision – excision of the lesion with the scar and any previously treated area is usually necessary
• radiation therapy – adjuvant radiation therapy following surgery should be considered for incompletely excised (residual) and locally recurrent SCCs, especially high-risk SCCs (e.g. rapidly growing tumours, recurrent disease, close margins [< 5 mm], perineural or lymphovascular invasion, in-transit metastases, and regional nodal involvement) (Cancer Council Australia Keratinocyte Cancers Guideline Working Party 2019).

In the management for people with nodal recurrent SCCs, treatment may include:

• surgery – this is the primary treatment for an SCC that has metastasised to the lymph nodes
• adjuvant radiation therapy – adjuvant radiation therapy following nodal surgery should be considered given high-risk disease following a complete excision (e.g. rapidly growing tumours, recurrent disease) (Cancer Council Australia Keratinocyte Cancers Guideline Working Party 2019)
• systemic therapy is available for a locally advanced or metastatic SCC and BCC that is not surgically resectable or suitable for radiation therapy – for metastatic SCCs, immunotherapy (e.g. checkpoint inhibitors), targeted therapy (e.g. epidermal growth factor inhibitors) and chemotherapy (as part of multimodal therapy or standalone therapy) are options that have demonstrated efficacy; for locally advanced or metastatic BCCs, targeted hedgehog inhibitor therapy (vismodegib and sonidegib) may be used for tumour suppression.

Some medications can predispose to keratinocyte cancer including immunosuppressives and photosensitizers such as voriconazole.

The potential goals of treatment should be discussed, respecting the patient’s cultural values. Wherever possible, written information should be provided.

Encourage early referral to clinical trials or accepting an invitation to participate in research.

Advance care planning is important for all patients with a cancer diagnosis but especially those with advanced disease. Patients should be encouraged to think and talk about their healthcare values and preferences with family or carers, appoint a substitute decision-maker and consider developing an advance care directive to convey their preferences for future health care in the event they become unable to communicate their wishes (AHMAC 2011).

Refer to section 4.3 ‘More information’ for links to resources.

Refer patients and carers to Advance Care Planning Australia or to the Advance Care Planning National Phone Advisory Service on 1300 208 582.

Early referral to palliative care can improve the quality of life for people with cancer and in some cases may be associated with survival benefits (Haines 2011; Temel et al. 2010; Zimmermann et al. 2014). The treatment team should emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers. Refer to section 4.3 for more detailed information.

The lead clinician should ensure timely and appropriate referral to palliative care services. Referral to palliative care services should be based on the patient’s need and potential for benefit, not prognosis.

Refer to the end of section 4.3 ‘Palliative care’ for links to resources.

The treatment team should support the patient to participate in research and clinical trials where available and appropriate.

For more information visit the Cancer Australia website.