Factors that Impact Treatment Selection for Melanoma

Anna C. Pavlick, DO, discusses factors that impact treatment selection for patients with melanoma.


Sunandana Chandra, MD, MS: Let’s switch gears and talk about unresectable metastatic melanoma next. Dr Pavlick, when a patient walks in your office with unresectable metastatic melanoma, what are the decisions that drive your selection of treatments to offer or discuss with the patient?

Anna C. Pavlick, DO: There are many. Obviously, looking at the patient first. What’s the patient’s performance status? What are the patient’s medical issues? Are they immunocompromised already? Are they physically fit? Then it’s taking a look at disease burden. How [many] tumors does a patient have? Is their LDH [lactate dehydrogenase] elevated to indicate that they have a more aggressive form of metastatic disease? Looking at the pathology to see if, in fact, these patients have a BRAF mutation.

Clearly, based on the DREAMseq trial, we would like to treat all of our metastatic patients up front with immunotherapy. Whether it be with single-agent anti–PD-1 therapy because we think that’s what patients would best tolerate, or whether it’s combination anti–CTLA-4 and anti–PD-1 therapy because their tumor burden is more. They may have small, asymptomatic brain metastases that we’re looking to treat as well. That all needs to be looked at. It’s also nice to know the mutational status because you have to look at every patient as their own control.

Although the DREAMseq trial clearly says patients would benefit from upfront immunotherapy as first-line treatment, there’s always that patient who will walk in your door [with] disease that is rampant and raging, and their performance status is so compromised, not because of their underlying medical issues, but because their disease is so aggressive or extensive that you just need to get it under control. Those are the patients where you’re going to say, “This is [what the data show], however, you are a patient I need to treat with a targeted agent right now because those targeted agents will work very quickly to get the disease under control.”

That’s when a lot of us question, do we just leave patients on targeted therapies if they’re doing well? Do we stop those targeted therapies and hope they don’t progress when we try to change them over to immunotherapy? Or are those the patients we should be treating with targeted therapy plus immunotherapy? Is that the triplet patient we should focus on? I think we don’t really know, but those are the things that go through my head when I see a patient the first time.

Transcript edited for clarity.

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