How can we manage my father's metastatic SCC?

Question

Hi doctor,

My dad is 48 and was diagnosed with squamous cell carcinoma on the right side of his mouth about six years ago. He had surgery and then did weekly chemotherapy and radiation. He was cancer-free for a while, but about five years ago, they found something in his chest, biopsied it, and it was the same cancer.

He had chest surgery that same month. Since then, he has been on Pembrolizumab (Keytruda) and is doing fine with it. His recent PET scan looked clear, but now they have found something in his right collarbone area. They biopsied it, and it came back as metastatic squamous cell cancer. He has been having shoulder pain. We are trying to understand what this means and where things go from here.

Thanks.

Answer 1

Hi,

Welcome to icliniq.com.

I can understand your concern.

The collarbone biopsy came back as metastatic squamous cell cancer, and that fits with the shoulder pain he has been having. There is now an actual measurable disease, so the case for moving forward with treatment is clear.

The working assumption is that this is spread from the original head and neck cancer. His tobacco history does keep a second lung primary in play, and comparing the genetic sequencing from the original oral tumor to the lung specimen could help settle that. For treatment at this time, it may not change much; both scenarios point toward a similar approach.

His PD-L1 (programmed death-ligand 1) score is elevated, so immunotherapy should be active for him. I would lean toward Pembrolizumab (Keytruda) plus chemotherapy rather than immunotherapy alone, given how aggressively this has behaved. If it turns out to be a new lung primary, the plan would be platinum-based chemotherapy followed by Atezolizumab (Tecentriq). Since no EGFR (estimated glomerular filtration rate) mutation was found, targeted therapy is not in the picture.

Radiation to the collarbone could help with the pain there. The timing question his team needs to work through is whether to radiate that spot now or start systemic treatment first and keep it as a marker to track response. Starting drug therapy, getting the pain under control with medications, and adding radiation later if needed is one way to go. A clinical trial is also an option, especially given the current interest in treating minimal residual disease with immunotherapy. Has he had a thoracic oncologist involved yet?

I hope this information will help you.

Thanks.