Addressing what they consider an unmet need, a multidisciplinary group has issued new recommendations for treating patients receiving systemic therapies for cancer who are undergoing surgical resection of a concomitant dermatologic malignancy.

“Prior to this review, there was not a comprehensive framework [for adjusting systemic cancer therapy] tailored to dermatologic surgery,” explained the lead author of the guidance, Megan H. Trager, MD, MS.

Instead, “clinicians could draw on FDA prescribing information, reports of adverse events, and limited drug-specific literature, but this review synthesizes this information and includes expert opinions,” Trager, who is also a member of the Dermatology Service at the Memorial Sloan Kettering Cancer Center (MSKCC) in New York City, told Medscape Medical News.

The problem of weighing competing needs in patients with resectable dermatologic cancer and a concomitant solid tumor or hematologic malignancy has become more common in an era where highly targeted drugs and immunotherapies are extending survival. This is a group where more guidance is needed, the authors of the new recommendations said.

“As systemic cancer treatments increasingly influence bleeding, wound healing, and infection risk, multidisciplinary coordination of oncology and preoperative screening is essential,” wrote the team who collaborated in producing the guidance published in the Journal of the American Academy of Dermatology.

Many of the concerns regarding systemic cancer therapies are unique to dermatologic cancer resection relative to other types of surgery, said Trager. The data collected for this review “provide a basis of discussion for dermatologists and oncologists to collaborate and individualize therapy.”

What Is the Evidence of an Unmet Need?

The process of weighing risks of systemic cancer therapies in patients scheduled for a dermatologic surgery grew out of care already being offered at MSKCC, where “we routinely manage patients undergoing dermatologic surgery while on systemic cancer therapy,” said Trager. This was the basis for these recommendations, but the authors felt that there was a need to systematically review and formulize the strategies they had developed.

The recommendations were developed in a series of formal meetings, involving four Mohs micrographic surgeons and two medical oncologists, that were completed in early 2026.

For patients who are on drugs that inhibit VEGF, whether directly or by targeted blockade of VEGF receptors (VEGFRs), the newly released recommendations advise treatment interruption to avoid adverse effects on wound healing. Decisions should be individualized to the type of VEGF inhibitor and the patient’s circumstances, according to the recommendations.

For example, they recommend discontinuing monoclonal antibodies targeting VEGF up to 4 weeks before dermatologic surgery, but interruptions of 7-8 days are generally considered sufficient for therapies targeting VEGFRs, such as sunitinib or sorafenib. Resumption of drugs targeting VEGF depends on the depth of surgery and expected time to wound healing.

Are the Risks Drug- or Patient-Specific?

The important message is that the recommendations regarding the risks posed by VEGF inhibitors, which can include gastrointestinal perforation, bleeding, hypertension, and other adverse events in addition to delayed wound healing, are drug-specific. Not all patients share the same risk for adverse events, such as bleeding or meaningful increased blood pressure, the new guidance emphasized.

For example, the recommendation for cabozantinib, a VEGFR2 inhibitor, is to stop therapy at least 3 weeks prior to surgery because of its long half-life, but lenvatinib, a VEGFR1/3 inhibitor, should be stopped 1 week before surgery. Axitinib, another VEGFR1/3 inhibitor, can be stopped 24 hours prior to surgery.

While the risk for bleeding is generally increased following dermatologic surgery in patients on the Bruton tyrosine kinase inhibitors, ibrutinib and acalabrutinib, the relative risk in the individual patient depends on history of bleeding, extent of surgery, and site of surgery. This might enter into the discussion of whether to stop the systemic anticancer therapy, reduce dose, or consider other strategies when balancing the effort to provide sustained control of the nondermatologic cancer relative to the dermatologic malignancy.

Ultimately, a multidisciplinary team can decide to continue systemic drugs despite risk for bleeding or infection as long as markers of risk, such as cytopenias, are monitored regularly.

A similar recommendation was made for the BCL-2 inhibitor venetoclax.

The guidance also encourages drug interruption of MEK inhibitors because of the bleeding risk they pose. These drugs are best halted 2 days before surgery and then resumed when surgical wounds are healed, which might be as early as 7 days post-surgery, as per the guidance.

Are Risks Generally Shared Across Small-Molecule Inhibitors?

Targeted small-molecule inhibitors differ markedly for risks in patients undergoing dermatologic resection. For example, not all the drugs that inhibit the mitogen-activated protein kinase, such as dabrafenib, have been associated with impaired wound healing. Although resumption of trametinib, like MEK inhibitors, should be delayed for 7 days after surgery, dabrafenib can be resumed the following day, according to the recommendations.

In a collaborative discussion, continuation of systemic cancer therapies can be considered for many drug types, including histone deacetylase inhibitors and epidermal growth factor inhibitors, if patients’ preoperative complete blood counts, including adequate thrombocytes, suggest risk for bleeding is low. But blood counts should be monitored perioperatively, the authors noted.

A similar recommendation was made for epidermal growth factor inhibitors and immune checkpoint inhibitors. Again, the best decision might depend on an assessment of risk factors for wound healing and bleeding based on patient variables, according to the recommendations. These should be weighed against the risk of discontinuing cancer therapy.

How Comprehensive Are These Recommendations?

The guidelines contain far more details and provide recommendations for a broad array of cancer therapies, including T-cell receptor-engineered T-cell therapies, antibody-drug conjugates, bispecific T-cell engagers, JAK inhibitors, taxanes, alkylating agents, cell cycle inhibitors, and immunomodulatory therapies, such as lenalidomide.

Trager said that the need for these recommendations was driven primarily by the expanding array of options with novel mechanisms of action.

“The timeliness of this paper is closely connected to the expanding number and variety of systemic cancer therapies, immunotherapies, targeted therapies, cellular treatments, bispecific agents, and antibody-drug conjugates that improved survival and created a growing population of patients who remain on active therapy and develop skin cancers requiring surgery,” she explained.

“Each of these cancer therapies may affect bleeding, wound healing, infection risk, immune function, or blood counts differently,” Trager continued.

This paper will provide a foundation for guidelines with greater precision as more is learned about how best to manage treatments that may not be compatible, she predicted.

Other oncologists serving on the panel agreed that these recommendations address an important need.

“These guidelines highlight the importance of interdisciplinary discussion between medical oncologists and dermatologic surgeons as there are often opportunities for patients to safely undergo dermatologic surgeries while receiving active therapies for advanced malignancies,” said James Smithy, MD, one of the co-authors, who is also a medical oncologist and cellular therapist at MSKCC.

With the help of these recommendations, “close collaboration between these teams can identify the optimal timing of surgery, the role of potential dose holds, and opportunities for robust risk/benefit discussions with patients,” he added.

Trager reported no potential conflicts of interest. Smithy reported conflicts of interest with Bristol Myers Squibb, Daiichi Sankyo, Immatics, IO Biotech, Iovance, and Regeneron.

Ted Bosworth, a career medical writer based in New York City, has been covering advances in clinical medicine, including dermatology and oncology, for several decades.