Management of Patients with BRAF-Mutated Melanoma

Source: OncLive, September 2019

My personal approach to sequencing treatments in BRAF-mutant patients is to look at all the different factors that are involved. What we know today, based on an analysis that was published combining the COMBI-d and COMBI-v patient, is that if your LDH [lactate dehydrogenase] is normal and you have limited sites of disease, you can have extremely prolonged responses lasting up to 5 years. That’s 1 important factor to consider. The other factor to consider is that immune therapy can also work well for patients who are BRAF-mutant, just as it can work for patients who are not BRAF-mutant. It can work for either group of patients. The question is, what do you do first, and what do you do second?

There are some pros and cons to consider. I think with the BRAF inhibitors, and BRAF and MEK inhibitor combinations, you are talking about a simple oral treatment that you can take with you with limited need for physician visits. With immunotherapy, when you start immunotherapy, you have to consider the possibility of either combination or a single-agent immunotherapy, and in 1 to 2½% of cases they can be severe or life-threatening immune-related adverse events. And some of these include things like type 1 diabetes, neurological adverse effects, and cardiac adverse effects, which can be life-threatening and which are not reversible. I think that’s just a personal preference.

But on the advantage side, on the pro side for immunotherapy, once you’ve had a response, once you’ve had a complete response, you can stop treatment and then just follow patients. You’re not on an active treatment every single day, as you are with a BRAF inhibitor. So that could be an advantage. That’s something that immunotherapy offers us.