“The most striking take-home message from the NCCN guidelines update for melanoma may be the continued reference that clinical trial participation is still the recommended approach in essentially all lines of therapy,” Dr Luke said.
“Despite the explosion of new drugs for this disease, we as a community know little about the proper sequence or exact clinical circumstances for their use. Beyond this, combination therapies have already been identified in early phase studies that appear to be more efficacious and less toxic than currently available treatments.”
Many more therapeutic options for combating melanoma are possible thanks to the advent of targeted therapy. The updated NCCN guidelines stated that there are specific genetic alterations among distinct clinical subtypes. The authors reported that clinical subtypes of cutaneous melanoma include chronic sun damage (CSD)—marked by solar elastosis—and non-CSD. In addition, acral melanomas are found on the soles, palms, or subungual sites.
The updated guidelines cited an analysis of 102 primary melanomas, which showed that the non-CSD subtype was found to have the highest proportion of BRAF mutations (56%) compared with CSD and other subtypes. However, that was not the case with KIT aberrations, which were found to be the highest in CSD.
Jeffrey Weber, MD, PhD, deputy director at the Perlmutter Cancer Center at NYU Langone Medical Center in New York, said that today, clinicians have a greater number of tools to attack melanoma on different levels based on their specific genetic mutations. Therefore, clinicians must be aware of the latest recommended changes in melanoma care when managing patients with varying stages of disease and subtypes.
“The changes relate to new information available on the benefits of adjuvant therapy after surgery to prevent recurrence using ipilimumab, the checkpoint inhibitor, and biochemotherapy, and the use of a new so-called ‘oncolytic’ virus that can treat locoregional melanoma,” Dr Weber told Cancer Therapy Advisor.
“These guidelines are important as they impact the ability to have new therapy for patients with in-transit or locoregional melanoma, and they clearly delineate that there are treatments for adjuvant therapy of melanoma that add to the existing single choice of interferon alpha.”
Nikhil Khushalani, MD, medical oncologist at Moffitt Cancer Center in Tampa, FL, said it is important to note that the new guidelines update the new standard of care for stage III melanoma.
“The updated guidelines highlight the toxicity of [high-dose ipilimumab] and encourage the practitioner to weigh the risk of recurrence with the risk of toxicity of therapy in the decision-making process,” Dr Khushalani told Cancer Therapy Advisor.
He also stressed that the field of melanoma therapeutics has and continues to change rapidly, which is vital as the rates continue to increase unabated.
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“What was considered standard of care therapy in metastatic or unresectable melanoma yesterday is not so today,” he said. “So the updated NCCN guidelines help keep oncologists up to date on the latest evidence in a timely fashion. It is important for the practicing oncologist to review the numerous footnotes on each page as well, as this provides additional information of clinical value that is germane to daily practice.”
- Coit DG, Thompson JA, Algazi A, et al. Melanoma, Version 2.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2016;14:450-473.