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New guide helps clinicians navigate immunotherapy revolution in Merkel cell carcinoma

‘Real-world’ review accompanies new clinical care guidelines in rare skin cancer
A histological image of a Merkel cell carcinoma tumor (light blue) surrounded by T cells (red and green) and other immune cells (purple). The cells were from a patient with immunotherapy-responsive MCC. Image by Dr. Rob Pierce, Dr. Jean Campbell and Kimberly Smythe / Fred Hutch

Fred Hutchinson Cancer Research Center researchers have published a new guide to help clinicians navigate a recent revolution in care for advanced Merkel cell carcinoma, a rare and deadly skin cancer. The guide was published this month in the Journal of the National Comprehensive Cancer Network, and it accompanies the network’s new clinical practice guidelines for Merkel cell carcinoma that was published in the same issue of the journal.

A series of clinical trials have made immunotherapy drugs known as checkpoint inhibitors the preferred choice for treating many patients with advanced Merkel cell carcinoma, or MCC, explained Dr. Kelly Paulson, a senior hematology/oncology fellow at Fred Hutch who wrote the new guide with Fred Hutch and University of Washington MCC expert Dr. Shailender Bhatia.

“About half of patients treated with immunotherapies get nice, long-term responses, and this is changing the way we manage Merkel cell carcinoma. When faced with a patient with metastatic Merkel cell, we no longer turn to chemotherapy — it’s the wrong choice in many cases,” Paulson said.

With its comprehensive review of current evidence, Paulson said the “real-world guide” provides a practical FAQ for clinicians who are learning how to use immunotherapy appropriately to treat patients with this cancer.

Paulson and Bhatia provide evidence-based answers for questions like: Does immunotherapy typically work quickly enough for patients with fast-growing tumors? (Yes.) Do patients usually need chemotherapy first? (No.) And: How should we treat patients who are not medically eligible for immunotherapy? (It’s complicated, and there are no good answers yet.)

In addition to discussing the evidence for using checkpoint inhibitors in metastatic MCC, the guide puts special focus on three particular groups of patients: geriatric patients, people with immunotherapy-resistant metastatic MCC, and those with localized MCC that is likely to recur after surgery. Other topics include the cancer’s presentation, incidence, historical survival rates, and its two distinct causal pathways (mutation-inducing UV radiation and viral infection), both of which make the cancer visible to immune cells and therefore a good candidate for immunotherapy.

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Susan Keown is an associate editor at Fred Hutchinson Cancer Research Center. She has written about health and research topics for a variety of research institutions, including the National Institutes of Health and the Centers for Disease Control and Prevention. Reach her at or on Twitter @sejkeown.

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Last Modified, September 21, 2021