Joseph Stilwill, MD, medical oncologist, Sarah Cannon Research Institute, discusses exciting findings in melanoma from the 2018 ASCO Annual Meeting.

The external validation of the eighth edition of the American Joint Committee on Cancer Staging System is noteworthy, says Stilwill. Additionally, studies in the adjuvant setting confirmed that complete lymph node dissection is most likely not necessary for most patients with sentinel lymph node-positive disease.

Looking at the patient’s tumor burden and sentinel lymph node is of value, explains Stilwill. When patients with stage IIIA disease were stratified by tumor burden, physicians could see that patients with tumors of 1 mm or less showed substantially better prognosis.

That will affect how physicians practice. Moving forward, patients with low tumor burden in their sentinel lymph nodes will have to be considered for adjuvant therapy. Additionally, adjuvant therapy may be something physicians want to consider in patients with a higher tumor burden.

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Dr. Stilwill on Findings from the 2018 ASCO Annual Meeting in Melanoma

Joseph Stilwill, MD, medical oncologist, Sarah Cannon Research Institute, discusses optimal sequencing in melanoma.

A lot of the decision is based on toxicity, says Stilwill. In patients with autoimmune conditions and 

-positive disease, physicians certainly want to think about BRAF and MEK inhibition as initial therapy. For patients who have a more borderline performance status, therapy with an anti—PD-1 inhibitor alone makes sense. It is also likely better tolerated, notes Stilwill. All things being equal, it is an interesting decision to have to make between the 2 therapies, he adds.

In June 2018, the FDA approved the combination of the BRAF inhibitor encorafenib (Braftovi) and the MEK inhibitor binimetinib (Mektovi) for patients with BRAF-mutant unresectable or metastatic melanoma. Also in June, the FDA accepted a supplemental biologics license application for the use of adjuvant pembrolizumab (Keytruda) for patients with resected, high-risk stage III melanoma.

When physicians look at the stage IV setting, long-term data show that the responses to immunotherapy tend to be slightly more durable. In that case, Stilwill recommends single-agent immunotherapy as initial therapy.

Dr. Stilwill on Optimal Sequencing in Melanoma

Joseph Stilwill, MD, medical oncologist, Sarah Cannon Research Institute, discusses adjuvant advances in the treatment of patients with melanoma.

The most exciting advances in treating patients with melanoma have been in the adjuvant setting, says Stilwill. This includes patients with 

-positive melanoma as well as the overall population. BRAF and MEK inhibition in addition to anti—PD-1 therapy have shown significant benefit in the adjuvant setting. These therapeutic advances are not only more efficacious than previous agents, but are less toxic than prior adjuvant therapies.

Updates from the 2018 ASCO Annual Meeting confirmed what physicians knew to be true in practice. Stilwill says that completion lymph node dissection is most likely not necessary for most patients with sentinel lymph node positive disease. Additionally, updates from the 2018 ASCO Annual Meeting showed that the 8th edition of the American Joint Committee on Cancer Staging System holds up to external validation, says Stilwill.

Joseph Stilwill, MD

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Dr. Stilwill on Findings from the 2018 ASCO Annual Meeting in Melanoma

Dr. Stilwill on Optimal Sequencing in Melanoma

Dr. Stilwill on Adjuvant Advances in Melanoma