Patients with advanced basal cell carcinomas in treatment with sonic hedgehog inhibitors during the coronavirus disease 2019 (COVID-19) period: Management and adherence to treatment.

To the Editor: After the outbreak in China, the novel coronavirus (SARS-CoV-2) that causes corona virus disease 2019 (COVID-19) has now spread all over the world, raising concern in both physicians and patients. This novel coronavirus, in most cases, involves patients aged 30 to 80 years, showing higher morbidity and mortality in the elderly and in the population with comorbidities (diabetes, cardiovascular disease, cancer). Policies in place for infection control (safety measures, protection, screening, and teleconsultations) must be carried out to minimize the risk of infection. Until now, objective clinical data on COVID-19 in patients with advanced skin cancer receiving treatment with targeted therapy have not been reported, and there are no guidelines recommending the cessation of treatment because of potential infection risks in the community.

With this brief note, we want to report our experience regarding the treatment of patients with advanced basal cell carcinoma receiving treatment with the hedgehog pathway inhibitors sonidegib and vismodegib during the COVID-19 period, the preventive measures adopted, and patients' adherence to treatment. This analysis included patients with advanced basal cell carcinoma treated with sonidegib or vismodegib at 1 Italian referral center for skin cancer diagnosis and management.1, 2, 3 We reviewed a total of 37 patients (26 men and 11 women) with median age of 74.5 years. A total of 9 patients were receiving treatment with sonidegib, and the remaining 28 patients were receiving treatment with vismodegib. The median duration of treatment was 4.4 months (range, 1-18 months). All patients were responsive to treatment with partial (from 25% to 75%) and almost complete (>75%) remission of the skin cancer. Patients, or one of their family members, received a teleconsultation to organize therapeutic management to avoid treatment discontinuation, if unnecessary, and, above all, to adopt preventive measures, avoiding the risk of infection. Overall, 8 (88.9%) of the 9 patients receiving treatment with sonidegib decided to come to the outpatient clinic for the mandatory monthly drug prescription. In 1 of the 9 patients, treatment was interrupted for severe comorbidities. Regarding the group of the 28 patients treated with vismodegib, only 2 patients discontinued treatment for severe comorbidities. Overall, 19 (67.8%) patients did not come to the outpatient clinic and continued treatment with a modified treatment scheme based on dose adjustment (150 mg vismodegib twice a week) to prolong their treatment; 9 (32.1%) of the 28 patients decided to attend the outpatient clinic for the mandatory monthly drug prescription. Generally, patients showed complete adherence to treatment. The majority of them indicated that they were worried about the idea of interrupting hedgehog pathway inhibitor treatment despite the fact that they reported several adverse events, resulting in complete adherence to treatment. In 3 patients, considered to be at high risk for the presence of severe comorbidities, we favored discontinuation. Considering the risk of morbidity of COVID-19 infection, we do not have evidence to recommend preventively discontinuing these effective therapies. Dose adjustment to prolong treatment duration, when possible, could be an interesting strategy to adopt for this situation, and teleconsultation could be a useful way to take care of our patients.