Advanced BCC — SCE Dermatology MCQ

Correct answer: B — Cemiplimab (anti-PD-1 — NICE approved for advanced BCC after hedgehog inhibitor failure or intolerance)

The correct answer is B, Cemiplimab (anti-PD-1, licensed for advanced BCC after hedgehog inhibitor failure or intolerance). Cemiplimab is a fully human IgG4 monoclonal antibody against the PD-1 receptor: <cite index="0-6">Cemiplimab is a fully human immunoglobulin G4 monoclonal antibody that binds to the PD-1 receptor.</cite> By blocking PD-1/PD-L1 interaction it restores T-cell mediated tumour killing, exploiting the high UV-driven mutational burden of BCC that makes it immunogenic. Its licensed indication specifically covers <cite index="0-9">basal cell carcinoma in adults previously treated with a hedgehog pathway inhibitor</cite>, exactly matching this stem where the patient has progressed on vismodegib, a hedgehog pathway inhibitor. No other checkpoint inhibitor carries a licensed BCC indication in UK practice, making cemiplimab the only evidence-based next step once hedgehog inhibitor therapy fails. Why the other options are wrong: A. Ipilimumab: this is an anti-CTLA-4 antibody licensed for melanoma and renal cell carcinoma combinations, with no licensed indication or robust trial evidence in advanced BCC. E. Nivolumab: an anti-PD-1 agent, but its licensed indications are melanoma, lung, renal, head and neck and other cancers; it has no UK licence or established BCC-specific efficacy data. D. Pembrolizumab: also anti-PD-1 and effective in cutaneous SCC and melanoma, but it lacks a licensed indication or phase 2/3 evidence base specifically supporting use in hedgehog-inhibitor-refractory BCC. C. Atezolizumab: an anti-PD-L1 antibody used in lung, bladder and other solid tumours; it has no trial data or licence for advanced BCC. Key point: cemiplimab is the only checkpoint inhibitor with a licensed indication and trial evidence for advanced BCC after hedgehog pathway inhibitor (vismodegib or sonidegib) failure or intolerance.

Reference: MJA Insight/PMC review of cemiplimab licensed indications (mechanism and BCC-after-hedgehog-inhibitor indication consistent with the UK/EU Libtayo SmPC), 2022, https://pmc.ncbi.nlm.nih.gov/articles/PMC9427629/