Clinical Scenario 2: Locally Advanced cSCC With CLL and Comorbidities

Dr. Singh presents Scenario 2: a 79-year-old woman with treatment-naïve CLL on active surveillance, type 2 diabetes (HbA1c 7.8%), mild CKD (creatinine 1.5), and a 4.2 cm cSCC of the left temple that has recurred after 2 prior surgical resections. Surgery is no longer feasible; radiation oncology has declined due to prior cumulative dose. ECOG PS 1. No distant metastases on imaging.

Dr. Park discusses how CLL adds complexity through inherent T cell dysfunction and impaired immune surveillance, similar in some ways to solid organ transplant patients. She evaluates whether the patient is on active CLL treatment (BTK inhibitors, BCL-2 inhibitors, or CD20 antibodies), all of which affect immune function. Despite these challenges, she does not consider CLL an absolute contraindication to immunotherapy, noting that cemiplimab's phase 4 registry data includes patients with hematologic malignancies. She counsels patients that responses may be less predictable and require closer monitoring, but immunotherapy remains a viable option when local therapies are exhausted.

Dr. Schoenfeld addresses goals-of-care conversations, underscoring the importance of understanding patient preferences from the outset, particularly whether they prioritize disease control or quality of life. He notes that with newer systemic options, the risk-benefit profile has improved markedly compared to prior local salvage attempts, and that patient-reported outcomes are increasingly central to treatment planning.