In separate live, virtual events, Hussein A. Tawbi, MD, PhD; and Allison Betof Warner, MD, PhD, discuss potential treatment options for a patient with BRAF mutation–negative melanoma.
Case Summary
Hussein A. Tawbi,
MD, PhD
Professor
Deputy Chair
Director, Personalized Cancer Therapy
Department of Melanoma Medical Oncology
Division of Cancer Medicine
The University of Texas
MD Anderson Cancer Center
Houston, TX
TAWBI:The decision-making here was reasonable and appropriate. Either of those regimens technically would be appropriate for this patient. I would probably say the patient’s high LDH is the biggest [factor]. I also recognize that as you start using a new combination more consistently…people’s perception of the combination changes as they became more familiar with it.
In the National Comprehensive Cancer Network [NCCN] guidelines, they list nivolumab and relatlimab-rmbw [Opdualag] as a preferred regimen.1 They only added category 1 recently. I was [surprised] at the NCCN not adding category 1 evidence from the get-go because the randomized, phase 2/3, blind, independent review study [RELATIVITY-047; NCT03470922] hit its primary end point.2
That to me made it a category 1 regimen, so I’m happy [the NCCN recognizes] this is category 1 evidence. In the NCCN guidelines, you can technically choose any of those combination regimens or single-agent PD-1 inhibitors; that’s the current recommendation.
The low-dose ipilimumab [Yervoy]/pembrolizumab [Keytruda] was mentioned there. I’d be very careful because there have never been randomized studies for low-dose ipilimumab/pembrolizumab, and there's only been 1 nonrandomized phase 2 trial.
Allison Betof Warner,
MD, PhD
Assistant Professor, Department of Medicine
Director, Melanoma Medical Oncology
Director, Solid Tumor Cellular Therapy
Codirector, Pigmented Lesion
and Melanoma Program
Stanford Cancer Center
Palo Alto, CA
WARNER: The way I think about this, when I talk about this with my patients, is we now have 3 options. We have single-agent PD-1 inhibitors, we have nivolumab/relatlimab, and then we have ipilimumab plus nivolumab [Opdivo]. I don’t give a ton of low-dose ipilimumab plus PD-1 anymore because we have nivolumab/relatlimab, but that’s also a fourth option.
There’s a spectrum of increased response rates, but that correlates exactly with an increased rate of toxicity. So I think treatment is highly dependent on what your patient can tolerate and is willing to tolerate. I think there are times [when] it’s the wrong decision to give combination—[for example], in frail patients, [very old patients], someone who has a history of autoimmune disease, those types of things. I do think if they have low disease burden in not a dangerous place in their body that it’s probably the wrong decision to give them full-dose ipilimumab/nivolumab. But could you be faulted for doing it? No, it just wouldn’t be my clinical decision in that situation.
REFERENCES:
NCCN. Clinical Practice Guidelines in Oncology. Melanoma: cutaneous, version 2.2023. Accessed June 19, 2023. https://bit.ly/3NivRJS
Tawbi HA, Schadendorf D, Lipson EJ, et al; RELATIVITY-047 Investigators. Relatlimab and nivolumab versus nivolumab in untreated advanced melanoma. N Engl J Med. 2022;386(1):24-34. doi:10.1056/NEJMoa2109970
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