The success of immunotherapy in neoadjuvant and adjuvant settings has rendered the traditional, sequential referral model (dermatologist to surgeon to oncologist) obsolete. Optimal care now demands an integrated, team-based discussion among all specialists *before* the first treatment decision is made to determine the best sequence and timing.

While neoadjuvant hedgehog inhibitors can successfully downstage locally advanced basal cell carcinoma (BCC) before surgery, the three-year recurrence rate is a surprisingly high 36%. This indicates that this strategy reduces surgical complexity but does not eliminate the high underlying risk, often necessitating further treatment.

T-cells have natural inhibitory signals, or "brakes" (like PD-1), to prevent over-activation. Some cancers exploit this. Checkpoint inhibitor drugs block these brakes, unleashing a patient's existing T-cells to attack cancer cells more aggressively. This approach has been miraculous for cancers like melanoma.

With 72% response rates to neoadjuvant immunotherapy, surgeons are shifting from immediate, aggressive surgery to a "wait-and-see" approach. Shrinking the tumor first can turn a morbid, disfiguring operation into a much simpler procedure, fundamentally changing the initial surgical evaluation for cutaneous squamous cell carcinoma (CSCC).

Standard cancer surgery often removes lymph nodes—the factories producing immune cells. Administering immunotherapy *before* this destructive process is critical. It arms the immune system while it is still intact and capable of mounting a powerful, targeted response against the tumor.

Contrary to the common assumption that metastatic disease is the primary cause of cancer-related death, a large international study on CSCC found that two-thirds of patients died from local-regional uncontrolled progression. This highlights the critical importance of effective local control strategies.

Experts argue that radiation therapy is often wrongly perceived as a salvage or adjuvant option. For many patients with early-stage basal or squamous cell carcinomas, it offers local control rates over 95%, comparable to surgery, and should be presented as a primary alternative, especially when cosmetic outcomes are a priority.

Patients receiving systemic immunotherapy for advanced skin cancer are still at high risk for developing new, low-risk primary skin cancers. Medical oncologists should not act as default dermatologists; ongoing co-management is crucial to identify and treat these new lesions while the patient is on systemic therapy.

Instead of a rigid, pre-defined treatment plan, clinicians are adopting a "response-determined" approach for cutaneous squamous cell carcinoma. A tumor initially deemed unresectable can become operable after just one or two doses of immunotherapy, requiring dynamic, ongoing collaboration between surgical and medical oncology teams to adjust the plan.