Another Update from ASCO

Understanding the Rapidly Changing World of Melanoma Management

With the approval of pegylated interferon, ipilimumab, and vemurafenib, the management of melanoma has seen more development in the past year than it had for decades.
Research to establish the optimal dosing, scheduling, and sequencing of therapies and to identify the patients most likely to benefit from these agents has just begun.
With the heterogeneity of patients and presentations in melanoma and conclusive evidence lacking for the optimal treatment of many patients, there is controversy among U.S. oncologists and within the global oncology community.
The Clinical Problems in Oncology Session "Chasing Melanoma: Management Issues from Primary Tumor to In Transit Disease" is intended to provide the latest data on the management of melanoma and expert opinions on the best options for treatment from an international faculty in a highly interactive setting. The ticketed session will be held today, 4:45 PM-6:00 PM, E451b.
"Our goal for this session is to put these new developments in the treatment of advanced melanoma into the context of managing a patient from initial diagnosis to adjuvant care to relapse to in-transit disease," said Session Chair Vernon K. Sondak, MD, chair of the Department of Cutaneous Oncology and director of surgical education at the H. Lee Moffitt Cancer Center & Research Institute.
Using a case study to guide the presentations through each stage of care, the session will give everyone involved in the management of a patient with melanoma—dermatologists, surgical oncologists, and medical oncologists— a better sense of how each stage fits together in the overall care of a patient, Dr. Sondak said in an interview with ASCO Daily News.
"The new medications are approved for advanced cases—node-positive or distant metastatic disease—so the medical oncologists are using or will be using these new agents," he said. "It is important for the dermatologists and surgeons who are diagnosing melanoma and treating it at its earliest stages to understand where these treatments will be used and how they will change the treatment of their patients."

International Perspective

"It is important for the dermatologists and surgeons who are diagnosing melanoma and treating it at its earliest stages to understand where these treatments will be used and how they will change the treatment of their patients."
— Vernon K. Sondak, MD
The lack of definitive comparative data in many aspects of melanoma management leaves ample room to debate treatment decisions. Adding to the discussion are the differences in approaches to care between the United States, Europe, and other countries. This will be explored by the session’s international faculty, which includes Leslie Fecher, MD, of the Indiana University Simon Cancer Center; Claus Garbe, MD, of the University of Tübingen, Germany; and John F. Thompson, MBBS, BSc, MD, of the Melanoma Institute Australia at Royal Prince Alfred Hospital.
"Rather than presenting data from a clinical trial, we are going to start with a patient, all of these treatment options, and a lot of data ... but none of it from comparative head-to-head trials to give a definitive answer," Dr. Sondak said. "We will share views about how Australia, Europe, and the United States are approaching these decisions."
The session is designed to have a very informal structure to foster active participation and questions from the audience.
"The intent of this format is to be case-focused and open, with each of the faculty members contributing and commenting on the knowledge to date and practice in their respective arenas for all of the issues," said Dr. Fecher. "The session will also involve a significant amount of interaction between the audience and panel members," Dr. Fecher said.

Cancer Journey

Evaluation of the sentinel node remains the essential starting point in the patient’s management, as the determination of node-positive or node-negative status will dictate care, Dr. Sondak said. Node status also indicates how likely a patient is to develop metastatic disease, where the use of ipilimumab and vemurafenib is indicated. Both of these agents are, or will be, under investigation in resected, nodepositive melanoma, which could alter the standard course of treatment.
"This is really a transitional time in the management of melanoma," Dr. Sondak said. "We do not know what the data will tell us, but we can provide an update on what the thinking is and where the research is heading, as well as discuss where we stand right now to ensure that everyone is on the same page."
Although interferon has been widely adopted in the adjuvant setting, there are still a number of questions remaining about its cost and toxicity, as well as disagreement about the optimal dose and schedule. There is also uncertainty about its benefits, which patient populations should receive it, and for how long.
"There are significant toxicities associated with the use of interferon, and there is controversy over whether there is suffi cient benefit to justify administration of this agent for a year or, depending on the formulation and dose, several years," Dr. Fecher said.
Dr. Fecher explained that peglyated interferon received U.S. Food and Drug Administration approval based on the European Organisation for Research and Treatment of Cancer 18991 phase III study, which demonstrated a statistically significant improvement in relapse-free survival compared with observation in patients with resected melanoma with nodal involvement. High- and low-dose interferon will be discussed.
Another area that will be covered is isolated limb perfusion and limb infusion, which are highly specialized procedures to treat patients with in-transit melanoma. Performed in limited melanoma centers by trained surgeons, these techniques are not available in general surgical practices, but Dr. Fecher explained that it is critical for oncologists to understand what these procedures entail, as well as which patients should be referred for consideration and when.
Although the approval of the new agents in melanoma attracted a great deal of attention, there has been consistent improvement in all aspects of melanoma care, said Dr. Sondak, from improved understanding of the biology of melanoma and of the immune system, to better diagnostic approaches to identify patients earlier and refined surgical techniques.
"These are not sudden or headline-making advances," he said. "But there has been steady development, and we are now at a point where we all need to take a look at one another and at our patients and fi gure out how everything fits together."

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