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Future Outlook: Treating Advanced Melanoma

Panelists: Jeffrey S. Weber, MD, PhD, Laura and Isaac Perlmutter Cancer Center; Robert Andtbacka, MD, CM, Huntsman Cancer Institute; Omid Hamid, MD, The Angeles Clinic and Research Institute ; Jason J. Luke, MD, FACP, University of Chicago; Michael A. Postow, MD, Memorial Sloan Kettering Cancer Center; Hussein Tawbi, MD, PhD, UT MD Anderson Cancer Center
Published: Thursday, Sep 20, 2018



Transcript: 

Jeffrey S. Weber, MD, PhD: This has been a very informative discussion. Before we end the discussion, I’d like to close with some thoughts from each of the panelists. Dr. Andtbacka?

Robert Andtbacka, MD, CM: From the earlier stage, from the surgical perspective, I think that melanoma surgery has changed quite a bit. We do less completion lymph node dissections now than we did previously. We have to be aware of that when we think about adjuvant therapy for our patients. We also have to be aware of that when we follow our patients. If we don’t do a completion lymph node dissection, we need to follow those patients with ultrasound. Additionally, forward thinking, we know that those patients who we don’t do a completion lymph node dissection on will be patients that will recur. Most of the time, those recurrences are locoregional. Then, we need to think about what we treat those patients with. These adjuvant treatments will also affect what will be available to those patients. I think it’s an evolving landscape.

It is really the next step. From a surgical perspective, these patients will potentially become candidates for neoadjuvant therapies. This really will serve the melanoma community well, because it will lead us to be able to assess biomarkers with those neoadjuvant studies and help us understand how to best treat these patients that may have been on other therapies and failed those, or recurred. This can help us determine how to best treat them.

Jeffrey S. Weber, MD, PhD: Dr. Hamid?

Omid Hamid, MD: What I found most intriguing is that what I hear from my surgical colleagues, as they talk about adjuvant and neoadjuvant therapy, also relates to what we are saying to our patients with metastatic disease. We have to do better. We have more options, and we need to understand how to present these options to our patients. We need to understand which patients are appropriate for the right therapies, which is biomarker. We have to understand when to stop therapies. There are some data there. We have to know how to deal with these toxicities that we’re now seeing with our combinations.

Jeffrey S. Weber, MD, PhD: Dr. Luke?

Jason J. Luke, MD, FACP: There are 2 points that I’ll make, that I hope are somewhat practical. The standard of care needs to be acknowledged, especially in the community. Adjuvant therapy, for stage 3 disease, even with the caveats that we discussed, is the standard of care. It should be offered to almost every patient with stage III disease. That really is a change from historical practice, where options were, perhaps, not so tolerable. That’s definitely something that has recently changed. Also, with so many questions surrounding what to do after adjuvant therapy failure, or in the second-line setting, clinical trial participation for melanoma is essential. We’ve made all of this progress, but we’ve hit these new questions that we don’t have answers for. The Cooperative Group trials—that is a great point. A lot of these trials are for refractory patients. But, even for referral of patients who are interested in novel therapeutics, there are a lot of interesting trials ongoing right now. Clinical trial accrual has definitely slowed because of the availability of a lot of useful drugs, and it really needs to continue to push forward.

Jeffrey S. Weber, MD, PhD: Dr. Postow?

Michael A. Postow, MD: I think we have a lot of reasons for optimism, but until we have 100% of patients cured, or under great control of their melanoma, we have more work to do. For all of the reasons that we’ve been speaking about, we look forward to seeing more patients in trials and to learning more. Figuring out how to afford these drugs is going to be a big issue, and we have to determine how to best give them—either together or in sequence. Hopefully we’ll have some clue so that we can move forward and help 100% of patients.

Jeffrey S. Weber, MD, PhD: Dr. Tawbi?

Hussein Tawbi, MD, PhD: Well, I will echo most of my colleagues, because they have tackled the very important points. We’re really fortunate that we have so many therapies that have proven efficacious. Now our job is going to be along 3 lines—to actually optimize the therapy that we have, in terms of better patient selection and management of toxicity; to take the therapies that we have and put them into new settings that we haven’t used them in yet, such as brain metastases and the neoadjuvant setting; and to try to find solutions for our patients who don’t have treatments right now, like the  PD-1 progressors that we discussed earlier, patients with leptomeningeal disease, and other really difficult situations that we really have to do better with.

Jeffrey S. Weber, MD, PhD: Great. Well, thank you all for your contributions to this discussion. On behalf of our panel, we thank you for joining us. We hope that you found this OncLive® Peer Exchange® to be useful and informative.

Transcript Edited for Clarity

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Transcript: 

Jeffrey S. Weber, MD, PhD: This has been a very informative discussion. Before we end the discussion, I’d like to close with some thoughts from each of the panelists. Dr. Andtbacka?

Robert Andtbacka, MD, CM: From the earlier stage, from the surgical perspective, I think that melanoma surgery has changed quite a bit. We do less completion lymph node dissections now than we did previously. We have to be aware of that when we think about adjuvant therapy for our patients. We also have to be aware of that when we follow our patients. If we don’t do a completion lymph node dissection, we need to follow those patients with ultrasound. Additionally, forward thinking, we know that those patients who we don’t do a completion lymph node dissection on will be patients that will recur. Most of the time, those recurrences are locoregional. Then, we need to think about what we treat those patients with. These adjuvant treatments will also affect what will be available to those patients. I think it’s an evolving landscape.

It is really the next step. From a surgical perspective, these patients will potentially become candidates for neoadjuvant therapies. This really will serve the melanoma community well, because it will lead us to be able to assess biomarkers with those neoadjuvant studies and help us understand how to best treat these patients that may have been on other therapies and failed those, or recurred. This can help us determine how to best treat them.

Jeffrey S. Weber, MD, PhD: Dr. Hamid?

Omid Hamid, MD: What I found most intriguing is that what I hear from my surgical colleagues, as they talk about adjuvant and neoadjuvant therapy, also relates to what we are saying to our patients with metastatic disease. We have to do better. We have more options, and we need to understand how to present these options to our patients. We need to understand which patients are appropriate for the right therapies, which is biomarker. We have to understand when to stop therapies. There are some data there. We have to know how to deal with these toxicities that we’re now seeing with our combinations.

Jeffrey S. Weber, MD, PhD: Dr. Luke?

Jason J. Luke, MD, FACP: There are 2 points that I’ll make, that I hope are somewhat practical. The standard of care needs to be acknowledged, especially in the community. Adjuvant therapy, for stage 3 disease, even with the caveats that we discussed, is the standard of care. It should be offered to almost every patient with stage III disease. That really is a change from historical practice, where options were, perhaps, not so tolerable. That’s definitely something that has recently changed. Also, with so many questions surrounding what to do after adjuvant therapy failure, or in the second-line setting, clinical trial participation for melanoma is essential. We’ve made all of this progress, but we’ve hit these new questions that we don’t have answers for. The Cooperative Group trials—that is a great point. A lot of these trials are for refractory patients. But, even for referral of patients who are interested in novel therapeutics, there are a lot of interesting trials ongoing right now. Clinical trial accrual has definitely slowed because of the availability of a lot of useful drugs, and it really needs to continue to push forward.

Jeffrey S. Weber, MD, PhD: Dr. Postow?

Michael A. Postow, MD: I think we have a lot of reasons for optimism, but until we have 100% of patients cured, or under great control of their melanoma, we have more work to do. For all of the reasons that we’ve been speaking about, we look forward to seeing more patients in trials and to learning more. Figuring out how to afford these drugs is going to be a big issue, and we have to determine how to best give them—either together or in sequence. Hopefully we’ll have some clue so that we can move forward and help 100% of patients.

Jeffrey S. Weber, MD, PhD: Dr. Tawbi?

Hussein Tawbi, MD, PhD: Well, I will echo most of my colleagues, because they have tackled the very important points. We’re really fortunate that we have so many therapies that have proven efficacious. Now our job is going to be along 3 lines—to actually optimize the therapy that we have, in terms of better patient selection and management of toxicity; to take the therapies that we have and put them into new settings that we haven’t used them in yet, such as brain metastases and the neoadjuvant setting; and to try to find solutions for our patients who don’t have treatments right now, like the  PD-1 progressors that we discussed earlier, patients with leptomeningeal disease, and other really difficult situations that we really have to do better with.

Jeffrey S. Weber, MD, PhD: Great. Well, thank you all for your contributions to this discussion. On behalf of our panel, we thank you for joining us. We hope that you found this OncLive® Peer Exchange® to be useful and informative.

Transcript Edited for Clarity
View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Medical Crossfire®: Evolving Roles for Targeted Melanoma Therapies: Assessing Rapid Progress in the Field and Looking Toward Future CombinationsFeb 28, 20191.5
Advances in™ Melanoma: Exploring BRAF/MEK in Adjuvant and Neoadjuvant SettingsSep 28, 20191.5
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