Treatment

If you have a wide surgical excision, the surgeon who removes the cancer may be able to close the area by bringing the edges around the wound together. If the area is too large or the cancer went too deep for this approach, our reconstructive surgeons offer more options. One is closing the wound with neighboring skin that is turned into place (local tissue rearrangement). Others involve using skin from another part of your body (skin grafting) or using skin plus other tissue from another body area (free-flap reconstruction). Learn more about reconstructive surgery.

Depending on the size and location of your tumor, your team may recommend removing your cancer with a method called Mohs micrographic surgery. This method helps maintain your function and appearance in sensitive areas, like your face. The surgeon removes one thin layer of tissue at a time. During surgery, each layer is looked at with a microscope to see if the surgeon needs to remove another layer in order to get all of the tumor.

Our skin cancer surgery team includes experts in surgical oncology, reconstruction and head and neck surgery. This team specializes in the treatment of MCC. You can feel confident knowing that the surgeons who care for you are best suited for your specific diagnosis.

Although surgery can be effective, the rate of local recurrence (cancer coming back in the same place) is very high in people who have surgery as their only type of treatment. When the removed tissue is examined under a microscope, the margins (edges) may be free of cancer, suggesting that the surgeon got it all. But because of the way MCC spreads, cancer cells are often left behind in neighboring tissue.
 

To kill remaining cancer cells, surgery is often followed by external-beam radiation therapy to the tumor site and possibly to the lymph nodes in the same region of the body. MCC is very sensitive to radiation therapy.

There is evidence that in some people radiation alone may be a viable treatment option. This option makes the most sense for people who would need extensive surgery or those who cannot have surgery for medical reasons.

If you have more advanced MCC that has spread to nearby lymph nodes but not to other parts of your body (stage III), you are likely to have surgery to remove the cancer followed by radiation to the main site as well as the regional lymph nodes.

If your cancer has spread to distant parts of your body (stage IV), you are likely to need systemic therapy. Until recently, the standard systemic option was chemotherapy, which would shrink many tumors but provide only about three months of cancer control. Many recent clinical trials have led to a major shift toward treatments designed to stimulate your own immune system to fight your disease. 

The most promising emerging option for MCC is a class of drugs called immune checkpoint inhibitors (ICIs).

In March 2017, the U.S. Food and Drug Administration approved the first treatment for metastatic MCC: the ICI avelumab (Bavencio). Fred Hutch was one of the leading sites for a clinical trial testing this medicine. 

In the study, avelumab was used to treat 88 patients who had metastatic MCC that had come back despite at least one round of chemotherapy. Twenty-eight of those patients’ tumors shrank or disappeared in response to avelumab. Among patients who initially responded to the medicine, over 80% had responses lasting more than a year.

Many patients not only did well, without evidence of active cancer, but also had very good quality of life while receiving this therapy.

Another ICI, pembrolizumab (Keytruda), has also shown promise. The National Comprehensive Cancer Network (NCCN), which publishes treatment guidelines based on expert opinion, added pembrolizumab to its list of MCC treatment options in 2017 after research showed it shrunk many patients’ tumors and provided long-lasting results. NCCN has also listed the ICIs avelumab and nivolumab (Opdivo) as preferred treatments over chemotherpay for metastatic MCC.

Other ICIs, including ipilimumab (Yervoy), are being studied in clinical trials for people with advanced MCC. In addition, several other immunotherapy approaches are being investigated, including intra-tumoral injections and infusion of immune cells (T-cells or Natural Killer cells). Initial results suggest a promising future for immunotherapies in treating MCC.

Learn More About Immunotherapy

In general, chemotherapy is reserved for late stages of MCC, when immune therapies are not an option. For people who do not have problems with their immune system (no autoimmune disease and no major immunosuppressive medications), doctors typically recommend first trying an immune-stimulating therapy (such as an immune checkpoint inhibitor) before using chemotherapy.