Factors that Impact Treatment Selection for Melanoma

Source: Onclive, May 2023

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.