Advances in the Treatment of Malignant Melanoma - Episode 3

Molecular Testing in Locally Advanced Melanoma

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Jeffrey S. Weber, MD, PhD: Along the same lines, let me turn to Adil, to go a little further with the issue of molecular testing. How important is BRAF testing that it helps you guide adjuvant or neoadjuvant therapy? Does it play a role? It sounds as if, for Jason, it doesn’t play a role for neoadjuvant. Will it play role for you when you try to decide about adjuvant therapy for patients?

Adil Daud, MD: It could potentially be an important tool for patients where you’re maybe worried about autoimmune adverse effects, or if you have an extremely bulky tumor—I just saw this patient last week, the tumor is so large that I have a hard time, and he’s already having nerve compression symptoms in his arm and isn’t grip strength. That may be 1, and actually, I did order BRAF testing on him. I’m going to see him tomorrow, so I’m considering the possibility of starting him on targeted therapy, but I rarely do that. For me, the BRAF testing is something to do in case your immunotherapy doesn’t work and you’re looking for a plan B. For us, we have this home-grown T-cell assay that we use, and we’ve published on it before. Basically, it measures exhausted T cells in the tumor microenvironment, and it’s run by Mike Rosenblum at UCSF Helen Diller Family Comprehensive Cancer Center. That’s the test. Although I’m a big fan of PD-L1 testing, if you’re trying to make decisions on an individual patient, it’s going to be hard to really slot a melanoma patient based on PD-L1 testing and do a neat box.

Jeffrey S. Weber, MD, PhD: Su, do you ever look at any other biomarkers? Do you ever assess tumor mutational burden or anything else on a routine basis, or is it all just a research tool?

Sunandana Chandra, MD: For our resectable patients, our priority at my institution is to try to get them on trial. We do have some adjuvant as well as some neoadjuvant trials that we try to prioritize for these patients. In terms of routine testing, besides what’s been mentioned, looking at tumor mutation burden, of course, is a certainly interesting research question. We often have that information in front of us as we’ve ordered next-generation sequencing, etc, but it doesn’t really inform my decision-making at that time.

I do think that, as more is learned about these neoadjuvant as well as adjuvant approaches, we’re probably going to have to fine-tune them a little more to be able to identify the patients who would benefit more compared with others, and that’s when these parameters will be probably more looked at and maybe acted upon a real-time basis that would actually be practice changing for our patients.

Transcript Edited for Clarity