http://www.onclive.com/publications/targeted-therapies/2012/June-2012/Immunotherapy-in-Advanced-Melanoma/5

http://www.onclive.com/publications/targeted-therapies/2012/June-2012/Immunotherapy-in-Advanced-Melanoma/5

Immunotherapy in Advanced Melanoma – Page 5

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Increasing Options: Sequence of Therapy

With increasing options for treatment in melanoma, it becomes incumbent to understand the nuances associated with each therapy and aim to streamline an evidence-based approach to the metastatic patient. Immunotherapy offers the only chance for durable disease control and should preferably be the first-line therapy for the patient with advanced, unresectable melanoma in the absence of any obvious contraindication (eg, active autoimmune disease). Tumors from these patients should be tested for the BRAF^V600 gene mutation.

The following algorithm offers a reasonable approach in decision making:

1. For younger, fit patients without cardiopulmonary comorbidity, high-dose IL-2 remains an appropriate first choice, including patients whose tumors harbor the BRAF^V600 mutation.
2. Ipilimumab is also a reasonable option for those unfit for, or unwilling to get, high-dose IL-2, or whose disease progresses after IL-2 therapy.
3. Vemurafenib should be considered for patients with BRAF^V600 mutation with bulky, symptomatic disease at presentation, or those in whom immunotherapy is contraindicated or has failed (including toxic effects).
4. Cytotoxic chemotherapy can be used in patients with BRAF-wild type melanoma after failure of immunotherapy, or as a possible bridge to immunotherapy in case of symptomatic disease.
5. At any point in therapy, participation in a clinical trial is an accepted standard of care.