Selecting Therapy & Managing Patients With BRAF+ Melanoma

Source: OncLive, October 2019

Hussein A. Tawbi, MD, PhD: In the adjuvant treatment of melanoma, at this point, I wouldn’t say that we suffer from this, but we have a bit of an embarrassment of riches. Finally, we have several therapies that can actually improve our patients’ outcomes, and they are safe and tolerable. Again, just to go through the therapies, we have 2 single-agent anti–PD-1 [programmed cell death protein 1] antibodies, nivolumab and pembrolizumab, that have proven safe—about 15% grade 3/4 toxicity and highly effective, decreasing the risk of recurrence by about half, with a hazard ratio that is in the range of 0.5. And then we have targeted therapy, which is at this point dabrafenib and trametinib for patients who have a BRAF mutation. This decreases the risk of relapse by about half.

It should be noted that the 3 different studies that were done to approve each of the therapies were different. Pembrolizumab was compared with placebo, whereas nivolumab was compared with active therapy with ipilimumab. Dabrafenib and trametinib was also compared with placebo, but none of these 3 agents were compared head-to-head. All we can do at this point is get a general sense of how effective they are. As you heard me say, they all have about a 50% reduction in the risk of relapse.

Really, when we have to make a choice in the adjuvant setting, the first thing I always do is test for BRAF. I feel that’s an important consideration and an option that our patients should know about—whether they have it or not. I tend to insist on getting the BRAF result before we start immunotherapy, although I have patients who feel strongly about receiving immunotherapy. It’s clear that they don’t want to have targeted therapy, so I wouldn’t delay their therapy specifically for that. But generally speaking, to have a fuller conversation with your patients, I think knowing the BRAF result is very important.