Dr. Sullivan on Considerations for Treatment in Metastatic Melanoma

Ryan J. Sullivan, MD
Published: Wednesday, Feb 27, 2019



Ryan J. Sullivan, MD, instructor of Medicine, Harvard Medical School, assistant in medicine, MGH Cancer Center, Massachusetts General Hospital, discusses considerations for initial treatment of patients with metastatic melanoma.

There are several different factors for physicians to take into consideration before deciding on a treatment strategy, Sullivan says. First and foremost, knowing the extensiveness of the spread of the disease is critical. Metastatic melanoma can range in severity from a subcutaneous nodule in a nonlife-threatening site to widespread metastatic disease where patients could have as little as days to live after diagnosis. Obviously, Sullivan notes, the approaches for these 2 cases would vastly differ. Not all cases of metastatic melanoma are the same, stresses Sullivan, and thus, a personalized treatment approach is needed.

Another important consideration is that the management of patients with brain metastases has changed in recent years. Currently, oncologists are more inclined to use the combination of ipilimumab (Yervoy) plus nivolumab (Opdivo) as opposed to single-agent immunotherapy or BRAF-targeted therapy. This shift in strategy is based on the results of 2 trials which showed a significant benefit with the ipilimumab/nivolumab combination in patients with brain metastases. However, it is important to note that the 2 trials enrolled patients with asymptomatic brain metastases—many patients in the real-world setting present with symptomatic brain metastases.

For patients with symptomatic disease, Sullivan says, physicians should try to reduce the symptoms with surgery or radiation, and occasionally, BRAF-targeted therapy, before moving forward with immunotherapy.
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Ryan J. Sullivan, MD, instructor of Medicine, Harvard Medical School, assistant in medicine, MGH Cancer Center, Massachusetts General Hospital, discusses considerations for initial treatment of patients with metastatic melanoma.

There are several different factors for physicians to take into consideration before deciding on a treatment strategy, Sullivan says. First and foremost, knowing the extensiveness of the spread of the disease is critical. Metastatic melanoma can range in severity from a subcutaneous nodule in a nonlife-threatening site to widespread metastatic disease where patients could have as little as days to live after diagnosis. Obviously, Sullivan notes, the approaches for these 2 cases would vastly differ. Not all cases of metastatic melanoma are the same, stresses Sullivan, and thus, a personalized treatment approach is needed.

Another important consideration is that the management of patients with brain metastases has changed in recent years. Currently, oncologists are more inclined to use the combination of ipilimumab (Yervoy) plus nivolumab (Opdivo) as opposed to single-agent immunotherapy or BRAF-targeted therapy. This shift in strategy is based on the results of 2 trials which showed a significant benefit with the ipilimumab/nivolumab combination in patients with brain metastases. However, it is important to note that the 2 trials enrolled patients with asymptomatic brain metastases—many patients in the real-world setting present with symptomatic brain metastases.

For patients with symptomatic disease, Sullivan says, physicians should try to reduce the symptoms with surgery or radiation, and occasionally, BRAF-targeted therapy, before moving forward with immunotherapy.

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