STEP 6: Managing recurrent, residual or metastatic disease

Patients who present with recurrent, residual or metastatic disease should be managed by a multidisciplinary team and offered timely referral to appropriate physical, practical and emotional support.

Step 6 is concerned with managing recurrent or local residual and metastatic disease. The likelihood of recurrence depends on many factors usually related to the type of cancer, the stage of cancer at presentation and the effectiveness of treatment. Some cancers cannot be eradicated even with the best initial treatment. But controlling disease and disease-related symptoms is often possible, depending on the clinical situation.

Unlike most other types of cancer, there is a much lower risk that keratinocyte cancer will metastasise. It is estimated that BCC will spread to other parts of the body in less than 1/1,000 to 1/35,000 cases. Recurrences commonly occur in the mid-face (H-zone). The risk is slightly higher for SCC, which spreads to other parts of the body in about 4 per cent of cases.

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).

More information

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.

More information


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.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise at this time for patients:

  • assistance for dealing with emotional and psychological distress resulting from fear of death or dying, existential concerns, anticipatory grief, communicating wishes to loved ones, interpersonal problems and sexuality concerns
  • potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
  • cognitive changes as a result of treatment and disease progression such as altered memory, attention and concentration (a patient may appoint someone to make medical, financial and legal decisions on their behalf – a substitute decision-maker – before and in case they experience cognitive decline)
  • management of physical symptoms such as pain and paraesthesia
  • disfigurement and scarring from appearance-altering treatment (and possible need for a prosthetic), which may require referral to a specialist, plastic surgeon who offers reconstructive scar revisional procedures, psychologist, psychiatrist or social worker
  • possible wound complications following surgery requiring appropriate care by the practitioner who performed the surgery, the patient’s general practitioner, or a specialist plastic and reconstructive surgeon
  • lymphoedema, which may require referral to a trained lymphoedema practitioner
  • decline in mobility or functional status as a result of recurrent disease and treatments (referral to physiotherapy or occupational therapy may be required)
  • coping with hair loss and changes in physical appearance (refer to the Look Good, Feel Better program – see ’Resource List’)
  • appointing a substitute decision-maker and completing an advance care directive
  • financial issues as a result of disease recurrence such as gaining early access to superannuation and insurance
  • legal issues (completing a will, care of dependent children) and making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Rehabilitation may be required at any point of the metastatic care pathway, from preparing for treatment through to palliative care. Issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, achieving independence in daily tasks, returning to work and ongoing adjustment to cancer and its sequels.

Exercise is a safe and effective intervention that improves the physical and emotional health and wellbeing of cancer patients. Exercise should be embedded as part of standard practice in cancer care and be viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment.

The lead clinician should ensure there is adequate discussion with patients and carers about the diagnosis and recommended treatment, including treatment intent and possible outcomes, likely adverse effects and the supportive care options available.

More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.