Please review this new treatment plan

Hi Rob,

Sorry Adriana's tumors did not respond like you hoped, but your treatment plan sounds fine enough.  My only thoughts are that I've not seen Merck or insurance companies allow patients to take Keytruda for free or with insurance as payment ever since it was FDA approved as a second line drug, to be used AFTER  the patient has failed ipi and then, if BRAF positive, BRAFi as well.  Absolutely insane, but there you have it.  But…I hope your doc wins.  If not, BRAFi next makes sense.  Here is a mish-mash of data I have put up about BRAF inhibitors.  Some of it I'm sure you are already well versed on, but there are some articles that address doing BRAF inhibitors purposefully to knock down the tumor burden and then jump quickly, before the tumors become unresponsive, to ipi in the case of the article noted….as well as how much better folks respond AND with fewer side effects, to combination BRAF/MEK…as well as how patients can indeed RE-respond to BRAFi after having had them previously.

General BRAFi info:  http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/02/braf-inhibitors-for-melanoma-dabrafenib.html

Discussion of re-response:  http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2013/01/better-ways-to-use-braf-inhibitors-for.html

Some of the latest BRAFi articles:  http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/09/all-things-brafilatest-articles.html

Hope that helps and I wish you both my best.  Celeste

Hi Rob,

Sorry Adriana's tumors did not respond like you hoped, but your treatment plan sounds fine enough.  My only thoughts are that I've not seen Merck or insurance companies allow patients to take Keytruda for free or with insurance as payment ever since it was FDA approved as a second line drug, to be used AFTER  the patient has failed ipi and then, if BRAF positive, BRAFi as well.  Absolutely insane, but there you have it.  But…I hope your doc wins.  If not, BRAFi next makes sense.  Here is a mish-mash of data I have put up about BRAF inhibitors.  Some of it I'm sure you are already well versed on, but there are some articles that address doing BRAF inhibitors purposefully to knock down the tumor burden and then jump quickly, before the tumors become unresponsive, to ipi in the case of the article noted….as well as how much better folks respond AND with fewer side effects, to combination BRAF/MEK…as well as how patients can indeed RE-respond to BRAFi after having had them previously.

General BRAFi info:  http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/02/braf-inhibitors-for-melanoma-dabrafenib.html

Discussion of re-response:  http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2013/01/better-ways-to-use-braf-inhibitors-for.html

Some of the latest BRAFi articles:  http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/09/all-things-brafilatest-articles.html

Hope that helps and I wish you both my best.  Celeste

Hi Rob,

Sorry Adriana's tumors did not respond like you hoped, but your treatment plan sounds fine enough.  My only thoughts are that I've not seen Merck or insurance companies allow patients to take Keytruda for free or with insurance as payment ever since it was FDA approved as a second line drug, to be used AFTER  the patient has failed ipi and then, if BRAF positive, BRAFi as well.  Absolutely insane, but there you have it.  But…I hope your doc wins.  If not, BRAFi next makes sense.  Here is a mish-mash of data I have put up about BRAF inhibitors.  Some of it I'm sure you are already well versed on, but there are some articles that address doing BRAF inhibitors purposefully to knock down the tumor burden and then jump quickly, before the tumors become unresponsive, to ipi in the case of the article noted….as well as how much better folks respond AND with fewer side effects, to combination BRAF/MEK…as well as how patients can indeed RE-respond to BRAFi after having had them previously.

General BRAFi info:  http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/02/braf-inhibitors-for-melanoma-dabrafenib.html

Discussion of re-response:  http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2013/01/better-ways-to-use-braf-inhibitors-for.html

Some of the latest BRAFi articles:  http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/09/all-things-brafilatest-articles.html

Hope that helps and I wish you both my best.  Celeste

I am sorry to hear about Adriana’s situation. I am sitting in a science meeting at the annual meeting of the Society for Melanoma Research. A number of sessions this morning addressed this issue.

The problem is that no one knows the answer. Studies suggest that BRAF/MEK inhibition encourages an immune response. Some believe this recommends using that approach with immunotherapy such as Keytruda, or at least giving Keytruda shortly after BRAF/MEK. Also a major factor in long term response to BRAF is low tumor burden.

On the other hand, the best numbers of any trial have been in combining IPI with anti-PD1.

I don’t know how much this helps. I don’t see any reason to prevent either approach. Which one to take is up tobyou (and Adriana).

I am sorry to hear about Adriana’s situation. I am sitting in a science meeting at the annual meeting of the Society for Melanoma Research. A number of sessions this morning addressed this issue.

The problem is that no one knows the answer. Studies suggest that BRAF/MEK inhibition encourages an immune response. Some believe this recommends using that approach with immunotherapy such as Keytruda, or at least giving Keytruda shortly after BRAF/MEK. Also a major factor in long term response to BRAF is low tumor burden.

On the other hand, the best numbers of any trial have been in combining IPI with anti-PD1.

I don’t know how much this helps. I don’t see any reason to prevent either approach. Which one to take is up tobyou (and Adriana).

I am sorry to hear about Adriana’s situation. I am sitting in a science meeting at the annual meeting of the Society for Melanoma Research. A number of sessions this morning addressed this issue.

The problem is that no one knows the answer. Studies suggest that BRAF/MEK inhibition encourages an immune response. Some believe this recommends using that approach with immunotherapy such as Keytruda, or at least giving Keytruda shortly after BRAF/MEK. Also a major factor in long term response to BRAF is low tumor burden.

On the other hand, the best numbers of any trial have been in combining IPI with anti-PD1.

I don’t know how much this helps. I don’t see any reason to prevent either approach. Which one to take is up tobyou (and Adriana).

I am sorry to hear about Adriana’s situation. I am sitting in a science meeting at the annual meeting of the Society for Melanoma Research. A number of sessions this morning addressed this issue.

The problem is that no one knows the answer. Studies suggest that BRAF/MEK inhibition encourages an immune response. Some believe this recommends using that approach with immunotherapy such as Keytruda, or at least giving Keytruda shortly after BRAF/MEK. Also a major factor in long term response to BRAF is low tumor burden.

On the other hand, the best numbers of any trial have been in combining IPI with anti-PD1.

I don’t know how much this helps. I don’t see any reason to prevent either approach. Which one to take is up tobyou (and Adriana).

I am sorry to hear about Adriana’s situation. I am sitting in a science meeting at the annual meeting of the Society for Melanoma Research. A number of sessions this morning addressed this issue.

The problem is that no one knows the answer. Studies suggest that BRAF/MEK inhibition encourages an immune response. Some believe this recommends using that approach with immunotherapy such as Keytruda, or at least giving Keytruda shortly after BRAF/MEK. Also a major factor in long term response to BRAF is low tumor burden.

On the other hand, the best numbers of any trial have been in combining IPI with anti-PD1.

I don’t know how much this helps. I don’t see any reason to prevent either approach. Which one to take is up tobyou (and Adriana).

I am sorry to hear about Adriana’s situation. I am sitting in a science meeting at the annual meeting of the Society for Melanoma Research. A number of sessions this morning addressed this issue.

The problem is that no one knows the answer. Studies suggest that BRAF/MEK inhibition encourages an immune response. Some believe this recommends using that approach with immunotherapy such as Keytruda, or at least giving Keytruda shortly after BRAF/MEK. Also a major factor in long term response to BRAF is low tumor burden.

On the other hand, the best numbers of any trial have been in combining IPI with anti-PD1.

I don’t know how much this helps. I don’t see any reason to prevent either approach. Which one to take is up tobyou (and Adriana).

Quick update.

I was able to discuss Adriana's situation with to world-class melanoma doctors. Of course they don't have the full information or her medical records, but in concept they agree with the move to Keytruda and the idea of holding back on BRAF/MEK for use if necessary later.

Hope this helps.

Tim–MRF

Quick update.

I was able to discuss Adriana's situation with to world-class melanoma doctors. Of course they don't have the full information or her medical records, but in concept they agree with the move to Keytruda and the idea of holding back on BRAF/MEK for use if necessary later.

Hope this helps.

Tim–MRF

Quick update.

I was able to discuss Adriana's situation with to world-class melanoma doctors. Of course they don't have the full information or her medical records, but in concept they agree with the move to Keytruda and the idea of holding back on BRAF/MEK for use if necessary later.

Hope this helps.

Tim–MRF

Rob,

Agreed with all that's been posted here, I think it's a good plan.  I've yet to need BRAF/MEK or anti-PD-1, but have done ipi (among other immunotherapies, surgeries, radiation, etc.) — however, I try to keep on top of the latest in order to have "plan B" (or "C" or "D") should the need arise, so it's something I discuss regularly with my doctors.

In a short time we've gone from few options for advanced melanoma to multiple new approaches, and within those treatments, competition (Zelboraf vs. Tafinlar, Keytruda vs. Opdivo, etc.), which is great, but it also creates an extra layer of complexity for us patients.  Instead of just basing treatment decisions on what's medically best, we now also have to navigate additional regulatory and insurance rules about what we can use and when.

It sounds like that's what your doctor is trying to do (navigating both the medical and regulatory), but the plan souns good.  I just saw a new study comparing the Tafinlar/Mekinist combination to Zelboraf alone and the combination appears to be more effective.  Additionally, they aren't mutually exclusive, i.e. how someone responds (or doesn't) to one doesn't necessarily indicate how someone will respond to the other.  Since Adriana is BRAF-positive, she needs to try a BRAF inhibitor (and ipi — I know you know this already) before moving on to Keytruda, so Zelboraf now and if it works for a time, great.  If not, move on to Keytruda, leaving another good option, the Tafinlar/Mekinist combination available as yet another option.

Joe

Rob,

Agreed with all that's been posted here, I think it's a good plan.  I've yet to need BRAF/MEK or anti-PD-1, but have done ipi (among other immunotherapies, surgeries, radiation, etc.) — however, I try to keep on top of the latest in order to have "plan B" (or "C" or "D") should the need arise, so it's something I discuss regularly with my doctors.

In a short time we've gone from few options for advanced melanoma to multiple new approaches, and within those treatments, competition (Zelboraf vs. Tafinlar, Keytruda vs. Opdivo, etc.), which is great, but it also creates an extra layer of complexity for us patients.  Instead of just basing treatment decisions on what's medically best, we now also have to navigate additional regulatory and insurance rules about what we can use and when.

It sounds like that's what your doctor is trying to do (navigating both the medical and regulatory), but the plan souns good.  I just saw a new study comparing the Tafinlar/Mekinist combination to Zelboraf alone and the combination appears to be more effective.  Additionally, they aren't mutually exclusive, i.e. how someone responds (or doesn't) to one doesn't necessarily indicate how someone will respond to the other.  Since Adriana is BRAF-positive, she needs to try a BRAF inhibitor (and ipi — I know you know this already) before moving on to Keytruda, so Zelboraf now and if it works for a time, great.  If not, move on to Keytruda, leaving another good option, the Tafinlar/Mekinist combination available as yet another option.

Joe

Rob,

Agreed with all that's been posted here, I think it's a good plan.  I've yet to need BRAF/MEK or anti-PD-1, but have done ipi (among other immunotherapies, surgeries, radiation, etc.) — however, I try to keep on top of the latest in order to have "plan B" (or "C" or "D") should the need arise, so it's something I discuss regularly with my doctors.

In a short time we've gone from few options for advanced melanoma to multiple new approaches, and within those treatments, competition (Zelboraf vs. Tafinlar, Keytruda vs. Opdivo, etc.), which is great, but it also creates an extra layer of complexity for us patients.  Instead of just basing treatment decisions on what's medically best, we now also have to navigate additional regulatory and insurance rules about what we can use and when.

It sounds like that's what your doctor is trying to do (navigating both the medical and regulatory), but the plan souns good.  I just saw a new study comparing the Tafinlar/Mekinist combination to Zelboraf alone and the combination appears to be more effective.  Additionally, they aren't mutually exclusive, i.e. how someone responds (or doesn't) to one doesn't necessarily indicate how someone will respond to the other.  Since Adriana is BRAF-positive, she needs to try a BRAF inhibitor (and ipi — I know you know this already) before moving on to Keytruda, so Zelboraf now and if it works for a time, great.  If not, move on to Keytruda, leaving another good option, the Tafinlar/Mekinist combination available as yet another option.

Joe