ASCO updates

Many of you will know that ASCO is the annual meeting of oncologists, pulling together some 30,000 doctors from around the world.  The meeting started this morning, and one of the 8:00 sessions was on sequencing treatment for metastatic melanoma.  Here are few highlights:

Many of you will know that ASCO is the annual meeting of oncologists, pulling together some 30,000 doctors from around the world.  The meeting started this morning, and one of the 8:00 sessions was on sequencing treatment for metastatic melanoma.  Here are few highlights:

–Mike Atkins talked about immunotherapy, both the use of IL-2 and Yervoy (ipi), and also the clinical trials with anti-PD1 and anti-PDL1.  These all show promise.   He talked about a small study comparing people who were given Yervoy first, then if they showed progression of disease were put on a Zelboraf, vs. people who were given Zelboraf first then Yervoy.  The group who were treated with immunotherapy first (Yervoy) did better than the people who were given targeted therapy (Zelboraf) first.

–Keith Flaherty then showed data about Zelboraf and other targeted therapies for people who have BRAF mutations.  This includes adding a MEK inhibitor, or using other pathway blockades to treat people who have stopped responding to Zelboraf.  He pointed out that treating with immunotherapy first carries some risks.  Some patients have tumors that are growing too rapidly to wait for an immune response, which can take 2 months or more.  And some data shows that during immunotherapy the cancer evolves into a more robust form that may be harder to treat with targeted therapy.

–Jeff Sosman then talked about patients who do not have the BRAF mutation.  BRAF mutation occurs in about 40% of melanoma patients.  Another 18% have NRAS mutations, and 1-3% have KIT mutations.  This leaves almost a third of patients who have no known driver mutations.  This group may benefit from some more broad based targeted therapy, most of which is still in early development.  Some may actually have known mutations, but not at the normal spot.  Most BRAF mutations occur at a place called V600e, but he has found a patient with a BRAF mutation at a much different location.  And, of course, immunotherapy remains an option for these patients.

The bottom line is that we still have much to learn.  The consensus seems to be that if a patient has the time to wait, immunotherapy may be the first line of attack, and for very healthy patients that may mean starting with IL2.  Still, a lot of disagreement in this approach.  This makes treatment decisions challenging for doctors and even more challenging for patients.

The good news is, we have a few things in place and several things in development that all have some impact and, in some cases, significant impact.

More to follow.

Tim–MRF