Current Standard of Care for Melanoma: Insights from Dr. Sapna Patel
In discussion with Dr. Sapna Patel, Associate Professor, Director of the Uveal Melanoma, and Melanoma Fellowship Program Director at the MD Anderson Cancer Center we discuss how to treat Cutaneous Melanoma and important nuances from Community Oncology perspective.
Key Points:
- Management of Stage 0/IA melanoma - where management is mainly surgery
- Who is the most appropriate candidate for lymph node evaluation
- Stage IIB and beyond, discussing choice of observation, radiation or immunotherapy especially given recent promising results
- In patients with metastatic disease, how to manage BRAF positive vs. negative patient population
Hosts and Guests
- Rahul Gosain and Rohit Gosain introduce themselves as the Oncology Brothers.
- They welcome Dr. Sapna Patel from MD Anderson Cancer Center.
Discussion on Melanoma Staging and Treatment
Stage 0 and 1A Management:
- Surgery is the primary treatment; these patients are rarely seen by medical oncologists.
- Dr. Patel emphasizes the importance of physical examinations and not overusing radiographic surveillance.
Importance of Tumor Measurement:
- Dr. Patel explains melanoma is measured in millimeters, unlike other solid tumors.
- Wide local excision remains the standard treatment with histopathological assessment.
Stage 1B to 2A Management:
- Sentinel lymph node evaluation is crucial for this patient population.
- Current guidelines recommend sentinel lymph node biopsy, as stated by the MSLT-2 trial.
Stage 2B and 2C Considerations:
- Treatment options include observation, radiation, or immunotherapy.
- The keynote 716 study supports using adjuvant immunotherapy in stage 2B and 2C patients.
Immunotherapy and Recurrence Rates
Immunotherapy Benefits:
- Dr. Patel discusses the benefits of immunotherapy, including improved recurrence-free survival.
- Current evidence suggests that Stage 2B has a recurrence rate similar to stage 3B, warranting close surveillance.
Surveillance Strategies:
- Recommendations for scans vary; stage 2B patients may need scans 2-3 times a year.
- For stage 2C patients, quarterly surveillance is recommended due to higher recurrence risks.
Locally Advanced and Metastatic Melanoma
Approaching Stage 3B Patients:
- The discussion moves to the management of stage 3B melanoma, highlighting preoperative immunotherapy options based on SWAG 1801 results.
- Dr. Patel advises engaging surgeons early for potential preoperative PD-1 therapy.
Choosing Between Immunotherapy and Targeted Therapy:
- Discussion on choosing adjuvant immunotherapy versus targeted therapy for patients post-surgery.
- Dr. Patel emphasizes that treatment decisions should not solely rely on pathological response to neoadjuvant therapy.
Elevated LDH and Mutation Considerations
Frontline Metastatic Treatment:
- In cases with BRAF mutations, the use of neoadjuvant immunotherapy remains important.
- If LDH is elevated, Dr. Patel suggests considering BRAF inhibitors before switching to immunotherapy.
Dosing Considerations:
- The standard dose for ipilimumab is discussed, along with considerations for higher doses in specific cases.
Toxicity Management
- Managing Toxicities:
- Strategies for managing skin toxicity and pyrexia in patients on BRAF and MEK inhibitors are outlined.
- Emphasis on the need for careful toxicity management, including the use of antipyretics and topical treatments.
Conclusion
- Recap of Key Points:
- Dr. Patel summarizes the discussion on the treatment landscape for melanoma, emphasizing the importance of surgery, adjuvant immunotherapy, and the role of sentinel lymph node biopsy.
- The hosts thank Dr. Patel for her insights and encourage listeners to stay updated on the evolving treatment options for melanoma.
