Dr. Stilwill on Optimal Sequencing 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 BRAF-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.