Non-rash dermatologic adverse events related to targeted therapies

Immune checkpoint inhibitors in metastatic melanoma therapy (Review)

An increase in the incidence of melanoma has been observed in recent decades, which poses a significant challenge due to its poor prognosis in the advanced and metastatic stages. Previously, chemotherapy and high doses of interleukin-2 were available treatments for melanoma; however, they offered limited survival benefits and were associated with severe toxicities. The treatment of metastatic melanoma has been transformed by new developments in immunotherapy. Immune checkpoint inhibitors (ICIs), monoclonal antibodies that target cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), programmed cell death protein 1 (PD-1) and its ligand, PDL-1, have emerged as promising therapeutic options. Commonly used ICIs, such as ipilimumab, nivolumab and pembrolizumab, have been found to be associated with an improved median overall survival, recurrence-free survival and response rates compared to traditional chemotherapies. Combination therapies involving different types of ICIs, such as anti-PD1 with anti-CTLA-4, have further enhanced the overall survival and response rates by targeting various phases of T-cell activation. Additionally, the development of novel biomarkers has facilitated the assessment of responses to ICI therapy, with tissue and serum-based prognostic and predictive biomarkers now available. The increased response observed with ICIs also provides potential for immune-related adverse effects on various organ systems. Further research is required to evaluate the efficacy and safety of various combinations of ICIs, while ongoing clinical trials explore the potential of newer ICIs. Concerns regarding the development of resistance to ICIs also warrant attention. The present review summarizes and discusses the advent of ICIs with a marked significant breakthrough in the treatment of metastatic melanoma, providing improved outcomes compared to traditional therapies.

Guideline-Recommended Symptom Management Strategies That Cross Over Two or More Cancer Symptoms

PROBLEM IDENTIFICATION

Patients with cancer experience multiple symptoms, but current practice is driven by guidelines that address single symptoms. Identifying symptom management strategies recommended across two or more symptoms could relieve multiple symptoms and reduce patient burden.

LITERATURE SEARCH

The Oncology Nursing Society, National Comprehensive Cancer Network, and American Society of Clinical Oncology websites were searched to identify management guidelines for 15 symptoms.

DATA EVALUATION

The authors extracted symptom management strategies and recommendations. Recommendations were synthesized by symptom across the guidelines, and recommended strategies were compared across symptoms.

SYNTHESIS

Among 32 guidelines reviewed, a total of 88 symptom management strategies (41 pharmacologic, 47 nonpharmacologic) were recommended across two or more symptoms.

IMPLICATIONS FOR PRACTICE

Findings support the potential for coordinated selection of symptom management strategies that cross over multiple symptoms in a patient. Investigators should test these symptom management strategies in the context of co-occurring symptoms and develop guidelines that address multiple symptoms.

Adverse Event Management in Patients with BRAF V600E-Mutant Non-Small Cell Lung Cancer Treated with Dabrafenib plus Trametinib

Therapies for advanced non-small cell lung cancer (NSCLC) continue to become more sophisticated. Chemotherapeutics are giving way to newer approaches such as immune checkpoint inhibitors and targeted therapies for greater efficacy and improved outcomes. Dabrafenib plus trametinib combination therapy was first approved for the treatment of metastatic melanoma harboring the BRAF V600-mutation in 2014. In 2017, the U.S. Food and Drug Administration approved the combination for patients with NSCLC with the same mutation based on an ≈ 65% response rate and median progression-free survival of 10-11 months. BRAF mutations are a high-frequency event in melanoma (≈ 50%), whereas the overall incidence in lung cancer is ≈ 2%, but similar in number, because of the high incidence of the disease. As a new approach in NSCLC treatment, dabrafenib plus trametinib has a unique toxicity profile that is likely unfamiliar to care providers in thoracic and general oncology who have not used the combination to treat patients with melanoma. Common adverse events such as pyrexia, fatigue, and nausea, as well as a range of less frequent cutaneous, ocular, and hemorrhagic events, can be observed during treatment with dabrafenib plus trametinib. Previous experience in metastatic melanoma revealed that these events can be effectively managed to improve patient quality of life and reduce unnecessary drug discontinuation. The aim of this review is to summarize treatment guidelines, along with key insights obtained from previous clinical-trial and real-world experience in patients with metastatic melanoma, to properly manage toxicities associated with dabrafenib plus trametinib for NSCLC. IMPLICATIONS FOR PRACTICE: The combination of dabrafenib plus trametinib has demonstrated substantial clinical activity in patients with BRAF V600E-mutant non-small cell lung cancer, leading to U.S. Food and Drug Administration approval. Although the combination has a manageable safety profile, many toxicities associated with the regimen may not be familiar to thoracic specialists or general oncologists. Extensive clinical experience with the combination in patients with metastatic melanoma has provided a wealth of strategies to identify and manage adverse events associated with dabrafenib plus trametinib. These can be used by medical oncologists to enhance early recognition of toxicities and facilitate effective management, thereby improving quality of treatment for patients.

Pruritus Associated with Targeted Anticancer Therapies and Their Management

Targeted anticancer therapies have significantly increased the survival of patients with a variety of malignancies, improving tolerability and treatment duration. The increased lifespan and the expanded use of targeted agents have led to a variety of treatment-related adverse events. Pruritus, a common dermatologic adverse event with various incidences ranging from 2.2% to 47% across different categories of targeted anticancer therapies, has been overlooked. This article reviews the incidence, accompanying skin conditions, possible pathomechanism, and proposed management algorithms of pruritus associated with targeted therapies, including immunotherapies.

MAPK Pathway-Targeted Therapies: Care and Management of Unique Toxicities in Patients With Advanced Melanoma

BACKGROUND

Agents targeting the MAPK pathway, including inhibitors of BRAF and MEK, have dramatically transformed the treatment landscape for patients with BRAF-mutant metastatic melanoma. Although generally well tolerated, targeted agents were associated with unique toxicities.
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OBJECTIVES

This article aims to provide nurses with an overview of the key toxicities and associated management strategies of the characteristic adverse event (AE) profile associated with agents targeting the MAPK pathway.
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METHODS

Data from clinical trials evaluating vemurafenib, dabrafenib, trametinib, and cobimetinib were reviewed and summarized along with research on management of AEs identified in clinical trials.
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FINDINGS

The key AEs associated with these agents included pyrexia and cutaneous toxicities. Other notable AEs included arthralgias, ocular toxicities, and cardiac events. Because these agents are administered until progressive disease or unacceptable toxicity, nurses should be aware of management strategies to optimize treatment outcomes.

Nivolumab in Resected and Unresectable Metastatic Melanoma: Characteristics of Immune-Related Adverse Events and Association with Outcomes

PURPOSE

Retrospective analysis of irAEs in melanoma patients treated with nivolumab.

EXPERIMENTAL DESIGN

Data were pooled from 148 patients (33 resected, 115 unresectable) treated with nivolumab plus peptide vaccine or nivolumab alone every 2 weeks for 12 weeks. Patients with stable disease or regression received an additional 12-week cycle, then nivolumab alone every 12 weeks for up to 2 additional years. Frequency, grade, and characteristics of immune-related adverse events (irAE) were analyzed. A 12-week landmark survival analysis using a multivariate time-dependent Cox proportional hazard model assessed difference in overall survival (OS) in the presence or absence of irAEs.

RESULTS

IrAEs of any grade were observed in 68.2% of patients (101 of 148). Grade III/IV irAEs were infrequent: 3 (2%) had grade III rash, 2 (1.35%) had asymptomatic grade III elevation in amylase/lipase, and 2 (1.35%) had grade III colitis. A statistically significant OS difference was noted among patients with any grade of irAE versus those without (P ≤ 0.001), and OS benefit was noted in patients who reported three or more irAE events (P ≤ 0.001). Subset analyses showed statistically significant OS differences with rash [P = 0.001; HR, 0.423; 95% confidence interval (CI), 0.243-0.735] and vitiligo (P = 0.012; HR, 0.184; 95% CI, 0.036-0.94). Rash and vitiligo also correlated with statistically significant OS differences in patients with metastatic disease (P = 0.004 and P = 0.028, respectively). No significant survival differences were seen with other irAEs (endocrinopathies, colitis, or pneumonitis).

CONCLUSIONS

Cutaneous irAEs are associated with improved survival in melanoma patients treated with nivolumab, and clinical benefit should be validated in larger prospective analyses.