Practical Considerations in Metastatic Melanoma - Episode 14
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Treatment strategies for patients with advanced melanoma continue to evolve, with several promising options emerging, including oncolytic virus therapy. At this point, there are over 50 oncolytic viruses under exploration, with the furthest along being talimogene laherparepvec (T-VEC), explains Robert H. I. Andtbacka, MD, CM.
In the phase III OPTiM study, treatment with T-VEC demonstrated a durable response rate of 16% compared with 2% with GM-CSF in patients with unresected stage IIIB/C and IV melanoma. The overall response rate (ORR) with T-VEC was 26% versus 5.7% with GM-CSF. The median OS was 23.3 months with T-VEC compared with 18.9 months for GM-CSF (HR = 0.787; 95% CI, 0.62-1.00; P = .051). Although not statistically significant, this was clinically meaningful, believes Andtbacka.
In a phase Ib study, the combination of ipilimumab and T-VEC demonstrated an ORR of 56%, with a complete response rate of 33%. The disease control rate was 72% overall. Additionally, T-VEC will be explored in combination with PD-1 inhibitors. This approach looks very promising in preclinical models, Merrick I. Ross, MD, notes. A phase I/II study is currently enrolling looking at the combination of T-VEC and the PD-1 inhibitor pembrolizumab in unresected patients with advanced melanoma (NCT02263508).
As the treatment of melanoma continues to change, further emphasis is needed on the importance of multidisciplinary care. For the majority of patients with melanoma, surgery remains the primary treatment, Andtbacka notes. Adding to this, Ross notes that no patient should start therapy based on the input of a single discipline. Optimal care should be based on input from surgeons, medical oncologists, radiation oncologists, and pathologists, the panel agrees.
As the field moves forward, emphasis should be placed on neoadjuvant trials, to better understand how novel therapies can be utilized, suggests Ross. Research needs to continue exploring the new agents in melanoma, in order to continue to improve outcomes, Jeffrey A. Sosman, MD, agrees. A cure for patients with metastatic melanoma could be found with further investigation, Sosman adds.
A greater dedication to finding predictive and prognostic biomarkers has arrived with the advent of new therapies, notes Omid Hamid, MD. These markers, which could be identified in the tumor itself or circulating in the blood, could help identify patients for treatment in the adjuvant setting.