Challenges of Treating Recurrent Merkel Cell Carcinoma in the Rural US: A Case Report.

An 80-year-old White male individual presented with a rapidly growing lesion on his left forearm that had been increasing in size for the past 2 months. The patient resides in a northern rural state with limited access to dermatology care. The shave biopsy performed indicated Merkel cell carcinoma (MCC). The patient was referred to oncology and surgical oncology. The patient underwent a wide local excision, then adjuvant immunotherapy with pembrolizumab. The patient presented 2 years later with a rapidly growing lesion on the left forearm in the location of the prior surgical scar, and this was found to be recurrent MCC. Two months later, a new lesion developed approximately 7 cm from the most recent surgical incision; this was also found to be MCC. MCC is a rare form of skin cancer that is the most fatal, is more invasive than other types of skin cancer, and has a high rate of mortality. Diagnosis is confirmed by biopsy. Currently, no screening tests are in place regarding MCC or recurrent MCC. Treatment often involves wide local surgical excision and radiation therapy. Adjuvant immunotherapy and targeted therapies are promising treatment options and are continuing to evolve. Patients diagnosed with MCC in rural areas have been found to have decreased life expectancy compared to urban patients. Rural patients often encounter extraneous challenges involving travel, limited access to care, and financial hardship compared to urban patients. Treating rural patients can pose challenges to the clinician involving access to care barriers, nonadherence, patient inducement, and adhering to clinical guidelines to achieve the best outcome.