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Wong MK, Burgess M, Chandra S, Schadendorf D, Silk A, Olszanski AJ, Grob JJ, Jang S, Grewal JS, Lewis KD, Fecher L, Rabinowits G, Lebbe C, Martin-Liberal J, Di Giacomo AM, Friedlander P, Brohl AS, Croft B, McGreivy JS, Rothbaum WP, Hanna GJ, Kelly CM. Navtemadlin (KRT-232) in combination with avelumab for patients with anti-PD-1/L1 treatment-naïve TP53 Merkel cell carcinoma (MCC). J Invest Dermatol 2022. [DOI: 10.1016/j.jid.2022.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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2
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Bakouny Z, Grover P, Labaki C, Awosika J, Gulati S, Hsu CY, Bilen M, Eton O, Fecher L, Hwang C, Khan H, McKay R, Ruiz E, Weissmann L, Thompson M, Shah D, Warner J, Shyr Y, Choueiri T, Wise-Draper T. 502P Association of immunotherapy and immunosuppression with severe COVID-19 disease in patients with cancer. Ann Oncol 2022. [PMCID: PMC9472565 DOI: 10.1016/j.annonc.2022.07.630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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3
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Schneider BJ, Naidoo J, Santomasso BD, Lacchetti C, Adkins S, Anadkat M, Atkins MB, Brassil KJ, Caterino JM, Chau I, Davies MJ, Ernstoff MS, Fecher L, Ghosh M, Jaiyesimi I, Mammen JS, Naing A, Nastoupil LJ, Phillips T, Porter LD, Reichner CA, Seigel C, Song JM, Spira A, Suarez-Almazor M, Swami U, Thompson JA, Vikas P, Wang Y, Weber JS, Funchain P, Bollin K. Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update. J Clin Oncol 2021; 39:4073-4126. [PMID: 34724392 DOI: 10.1200/jco.21.01440] [Citation(s) in RCA: 488] [Impact Index Per Article: 162.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with immune checkpoint inhibitor (ICPi) therapy. METHODS A multidisciplinary panel of medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to update the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 through 2021. RESULTS A total of 175 studies met the eligibility criteria of the systematic review and were pertinent to the development of the recommendations. Because of the paucity of high-quality evidence, recommendations are based on expert consensus. RECOMMENDATIONS Recommendations for specific organ system-based toxicity diagnosis and management are presented. While management varies according to the organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, except for some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert ≤ grade 1. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids. Corticosteroids should be tapered over the course of at least 4-6 weeks. Some refractory cases may require other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, except for endocrinopathies that have been controlled by hormone replacement. Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
| | - Jarushka Naidoo
- Beaumont Hospital, Dublin, Ireland.,Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | | | | | | | | | | | | | - Ian Chau
- Royal Marsden Hospital and Institute of Cancer Research, London & Surrey, Sutton, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Umang Swami
- Huntsman Cancer Institute-University of Utah, Salt Lake City, UT
| | - John A Thompson
- Seattle Cancer Care Alliance, University of Washington/Fred Hutchinson, Seattle, WA
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Santomasso BD, Nastoupil LJ, Adkins S, Lacchetti C, Schneider BJ, Anadkat M, Atkins MB, Brassil KJ, Caterino JM, Chau I, Davies MJ, Ernstoff MS, Fecher L, Funchain P, Jaiyesimi I, Mammen JS, Naidoo J, Naing A, Phillips T, Porter LD, Reichner CA, Seigel C, Song JM, Spira A, Suarez-Almazor M, Swami U, Thompson JA, Vikas P, Wang Y, Weber JS, Bollin K, Ghosh M. Management of Immune-Related Adverse Events in Patients Treated With Chimeric Antigen Receptor T-Cell Therapy: ASCO Guideline. J Clin Oncol 2021; 39:3978-3992. [PMID: 34724386 DOI: 10.1200/jco.21.01992] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with chimeric antigen receptor (CAR) T-cell therapy. METHODS A multidisciplinary panel of medical oncology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to develop the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 to 2021. RESULTS The systematic review identified 35 eligible publications. Because of the paucity of high-quality evidence, recommendations are based on expert consensus. RECOMMENDATIONS The multidisciplinary team issued recommendations to aid in the recognition, workup, evaluation, and management of the most common CAR T-cell-related toxicities, including cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, B-cell aplasia, cytopenias, and infections. Management of short-term toxicities associated with CAR T cells begins with supportive care for most patients, but may require pharmacologic interventions for those without adequate response. Management of patients with prolonged or severe CAR T-cell-associated cytokine release syndrome includes treatment with tocilizumab with or without a corticosteroid. On the basis of the potential for rapid decline, patients with moderate to severe immune effector cell-associated neurotoxicity syndrome should be managed with corticosteroids and supportive care.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ian Chau
- Royal Marsden Hospital and Institute of Cancer Research, London and Surrey, United Kingdom
| | | | | | | | | | | | | | - Jarushka Naidoo
- Beaumont Hospital, Dublin, Ireland and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | | | | | | | | | | | | | | | - Umang Swami
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - John A Thompson
- Seattle Cancer Care Alliance, University of Washington/Fred Hutchinson, Seattle, WA
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5
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Mandala M, Larkin J, Ascierto PA, Del Vecchio M, Gogas H, Cowey CL, Arance A, Dalle S, Schenker M, Grob JJ, Chiarion-Sileni V, Marquez I, Butler MO, Di Giacomo AM, Lutzky J, De La Cruz-Merino L, Atkinson V, Arenberger P, Hill A, Fecher L, Millward M, Khushalani NI, de Pril V, Lobo M, Weber J. Adjuvant nivolumab for stage III/IV melanoma: evaluation of safety outcomes and association with recurrence-free survival. J Immunother Cancer 2021; 9:jitc-2021-003188. [PMID: 34452930 PMCID: PMC8404438 DOI: 10.1136/jitc-2021-003188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Several therapeutic options are now available in the adjuvant melanoma setting, mandating an understanding of their benefit‒risk profiles in order to make informed treatment decisions. Herein we characterize adjuvant nivolumab select (immune-related) treatment-related adverse events (TRAEs) and evaluate possible associations between safety and recurrence-free survival (RFS) in the phase III CheckMate 238 trial. METHODS Patients with resected stage IIIB-C or IV melanoma received nivolumab 3 mg/kg every 2 weeks (n=452) or ipilimumab 10 mg/kg every 3 weeks for four doses and then every 12 weeks (n=453) for up to 1 year or until disease recurrence, unacceptable toxicity, or consent withdrawal. First-occurrence and all-occurrence select TRAEs were analyzed within discrete time intervals: from 0 to 3 months of treatment, from >3-12 months of treatment, and from the last dose (regardless of early or per-protocol treatment discontinuation) to 100 days after the last dose. Possible associations between select TRAEs and RFS were investigated post randomization in 3-month landmark analyses and in Cox model analyses (including a time-varying covariate of select TRAE), within and between treatment groups. RESULTS From the first nivolumab dose to 100 days after the last dose, first-occurrence select TRAEs were reported in 67.7% (306/452) of patients. First-occurrence select TRAEs were reported most frequently from 0 to 3 months (48.0%), during which the most common were pruritus (15.5%) and diarrhea (15.3%). Most select TRAEs resolved within 6 months. There was no clear association between the occurrence (or not) of select TRAEs and RFS by landmark analysis or by Cox model analysis within treatment arms or comparing nivolumab to the ipilimumab comparator arm. CONCLUSION Results of this safety analysis of nivolumab in adjuvant melanoma were consistent with its established safety profile. In the discrete time intervals evaluated, most first-occurrence TRAEs occurred early during treatment and resolved. No association between RFS and select TRAEs was evident. TRIAL REGISTRATION NUMBER NCT02388906.
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Affiliation(s)
- Mario Mandala
- Unit of Medical Oncology, University of Perugia, Perugia, Italy
| | | | | | - Michele Del Vecchio
- Unit of Melanoma Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Helen Gogas
- First Department of Medicine, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - C Lance Cowey
- Texas Oncology Baylor Charles A Sammons Cancer Center, Dallas, Texas, USA
| | - Ana Arance
- Hospital Clínic de Barcelona, Barcelona, Spain
| | | | | | | | | | - Ivan Marquez
- General University Hospital Gregorio Marañón, CIBERONC, Madrid, Spain
| | - Marcus O Butler
- Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | | | - Jose Lutzky
- Oncology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Luis De La Cruz-Merino
- Clinical Oncology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain.,Department of Medicine, Universidad de Sevilla, Sevilla, Spain
| | - Victoria Atkinson
- Gallipoli Medical Research Foundation and University of Queensland, Brisbane, Queensland, Australia
| | | | - Andrew Hill
- Tasman Oncology Research Ltd, Southport, Queensland, Australia
| | - Leslie Fecher
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Millward
- Sir Charles Gairdner Hospital, University of Western Australia, Perth, Western Australia, Australia
| | - Nikhil I Khushalani
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Maurice Lobo
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Jeffrey Weber
- Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
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Dans M, Kutner JS, Agarwal R, Baker JN, Bauman JR, Beck AC, Campbell TC, Carey EC, Case AA, Dalal S, Doberman DJ, Epstein AS, Fecher L, Jones J, Kapo J, Lee RT, Loggers ET, McCammon S, Mitchell W, Ogunseitan AB, Portman DG, Ramchandran K, Sutton L, Temel J, Teply ML, Terauchi SY, Thomas J, Walling AM, Zachariah F, Bergman MA, Ogba N, Campbell M. NCCN Guidelines® Insights: Palliative Care, Version 2.2021. J Natl Compr Canc Netw 2021; 19:780-788. [PMID: 34340208 DOI: 10.6004/jnccn.2021.0033] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Palliative care has evolved to be an integral part of comprehensive cancer care with the goal of early intervention to improve quality of life and patient outcomes. The NCCN Guidelines for Palliative Care provide recommendations to help the primary oncology team promote the best quality of life possible throughout the illness trajectory for each patient with cancer. The NCCN Palliative Care Panel meets annually to evaluate and update recommendations based on panel members' clinical expertise and emerging scientific data. These NCCN Guidelines Insights summarize the panel's recent discussions and highlights updates on the importance of fostering adaptive coping strategies for patients and families, and on the role of pharmacologic and nonpharmacologic interventions to optimize symptom management.
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Affiliation(s)
- Maria Dans
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - Justin N Baker
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - Anna C Beck
- Huntsman Cancer Institute at the University of Utah
| | | | | | - Amy A Case
- Roswell Park Comprehensive Cancer Center
| | | | | | | | | | - Joshua Jones
- Abramson Cancer Center at the University of Pennsylvania
| | | | - Richard T Lee
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
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7
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Waninger JJ, Ma VT, Journey S, Skvarce J, Chopra Z, Tezel A, Bryant AK, Mayo C, Sun Y, Sankar K, Ramnath N, Lao C, Sussman JB, Fecher L, Alva A, Green MD. Validation of the American Joint Committee on Cancer Eighth Edition Staging of Patients With Metastatic Cutaneous Melanoma Treated With Immune Checkpoint Inhibitors. JAMA Netw Open 2021; 4:e210980. [PMID: 33687443 PMCID: PMC7944385 DOI: 10.1001/jamanetworkopen.2021.0980] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Immune checkpoint inhibitors (ICIs) have transformed the survival of patients with metastatic melanoma. Patient prognosis is reflected by the American Joint Committee on Cancer (AJCC) staging system; however, it is unknown whether the metastatic (M) stage categories for cutaneous melanoma remain informative of prognosis in patients who have received ICIs. OBJECTIVES To evaluate the outcomes of patients with metastatic cutaneous melanoma based on the M stage category from the AJCC eighth edition and to determine whether these designations continue to inform the prognosis of patients who have received ICIs. DESIGN, SETTING, AND PARTICIPANTS This cohort study included patients with metastatic cutaneous melanoma who were treated between August 2006 and August 2019 at the University of Michigan. The estimated median follow-up time was 35.5 months. Patient data were collected via the electronic medical record system. Critical findings were externally validated in a multicenter nationwide cohort of patients treated within the Veterans Affairs health care system. Data analysis was conducted from February 2020 to January 2021. EXPOSURES All patients were treated with dual-agent concurrent ipilimumab and nivolumab followed by maintenance nivolumab or single-agent ipilimumab, nivolumab, or pembrolizumab therapy. Patients were staged using the AJCC eighth edition. MAIN OUTCOMES AND MEASURES Univariable and multivariable analyses were used to assess the prognostic value of predefined clinicopathologic baseline factors on survival. RESULTS In a discovery cohort of 357 patients (mean [SD] age, 62.6 [14.2] years; 254 [71.1%] men) with metastatic cutaneous melanoma treated with ICIs, the M category in the AJCC eighth edition showed limited prognostic stratification by both univariable and multivariable analyses. The presence of liver metastases and elevated levels of serum lactate dehydrogenase (LDH) offered superior prognostic separation compared with the M category (liver metastases: hazard ratio, 2.22; 95% CI, 1.48-3.33; P < .001; elevated serum LDH: hazard ratio, 1.73; 95% CI, 1.16-2.58; P = .007). An updated staging system based on these factors was externally validated in a cohort of 652 patients (mean [SD] age, 67.9 [11.6] years; 630 [96.6%] men), with patients without liver metastases or elevated LDH levels having the longest survival (median overall survival, 30.7 months). CONCLUSIONS AND RELEVANCE This study found that the AJCC eighth edition M category was poorly reflective of prognosis in patients receiving ICIs. Future staging systems could consider emphasizing the presence of liver metastases and elevated LDH levels. Additional studies are needed to confirm the importance of these and other prognostic biomarkers.
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Affiliation(s)
- Jessica J. Waninger
- University of Michigan Medical School, University of Michigan, Ann Arbor
- Department of Cellular and Molecular Biology, University of Michigan, Ann Arbor
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor
| | - Vincent T. Ma
- Division of Hematology Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Sara Journey
- University of Michigan Medical School, University of Michigan, Ann Arbor
| | - Jeremy Skvarce
- University of Michigan Medical School, University of Michigan, Ann Arbor
| | - Zoey Chopra
- University of Michigan Medical School, University of Michigan, Ann Arbor
| | - Alangoya Tezel
- University of Michigan Medical School, University of Michigan, Ann Arbor
| | - Alex K. Bryant
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Charles Mayo
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Yilun Sun
- Department of Radiation Oncology, University of Michigan, Ann Arbor
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Kamya Sankar
- Rogel Cancer Center, University of Michigan, Ann Arbor
| | - Nithya Ramnath
- Rogel Cancer Center, University of Michigan, Ann Arbor
- Department of Hematology Oncology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Christopher Lao
- Division of Hematology Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
- Rogel Cancer Center, University of Michigan, Ann Arbor
| | - Jeremy B. Sussman
- Department of Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Leslie Fecher
- Division of Hematology Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
- Rogel Cancer Center, University of Michigan, Ann Arbor
| | - Ajjai Alva
- Division of Hematology Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
- Department of Hematology Oncology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Michael D. Green
- Department of Radiation Oncology, University of Michigan, Ann Arbor
- Rogel Cancer Center, University of Michigan, Ann Arbor
- Department of Radiation Oncology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
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8
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Tsung I, Dolan R, Lao CD, Fecher L, Riggenbach K, Yeboah-Korang A, Fontana RJ. Liver injury is most commonly due to hepatic metastases rather than drug hepatotoxicity during pembrolizumab immunotherapy. Aliment Pharmacol Ther 2019; 50:800-808. [PMID: 31309615 DOI: 10.1111/apt.15413] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/29/2019] [Accepted: 06/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pembrolizumab immunotherapy has been associated with hepatotoxicity in 1%-10% of oncology patients treated in clinical trials. AIM To describe the incidence, phenotypes and outcomes of liver injury in a large cohort of solid organ tumour patients receiving pembrolizumab METHODS: Liver injury was defined by serum alanine aminotransferase, alkaline phosphatase, and/or total bilirubin levels exceeding threshold values. The likelihood of drug-induced liver injury was adjudicated by expert opinion. RESULTS Seventy (14.3%) of the 491 pembrolizumab-treated patients developed liver injury at a median of 62 days (6-478) and 71.4% had a cholestatic injury profile at onset. The median age, gender and tumour types of liver injury patients were similar to those without, but hepatic metastases (53% vs 21%, P < 0.01) and prior systemic and liver-directed therapy (71% vs 53%, P < 0.01) were more commonly observed in liver injury patients. During follow-up, liver injury patients were less likely to experience tumour remission (10% vs 40.4%) and had higher mortality (67.1% vs 33.7%). Only 20 (28.6%) liver injury cases were adjudicated as probable drug-induced hepatotoxicity; these patients were significantly more likely to present with an hepatocellular/mixed injury pattern (65% vs 12%), to receive corticosteroids (55% vs 12%) and had lower mortality (45% vs 76%) during follow-up. CONCLUSIONS Oncology patients treated with pembrolizumab who develop liver injury experience poorer outcomes during follow-up. The low incidence of confirmed drug hepatotoxicity highlights the need for thorough medical evaluation before initiating corticosteroids to optimise patient care.
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Affiliation(s)
- Irene Tsung
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Russell Dolan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Christopher D Lao
- Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Leslie Fecher
- Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kane Riggenbach
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Amoah Yeboah-Korang
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
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9
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Pavlick AC, Fecher L, Ascierto PA, Sullivan RJ. Frontline Therapy for BRAF-Mutated Metastatic Melanoma: How Do You Choose, and Is There One Correct Answer? Am Soc Clin Oncol Educ Book 2019; 39:564-571. [PMID: 31099689 DOI: 10.1200/edbk_243071] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Genetic analysis of melanoma has allowed us to identify a population of patients who have more aggressive disease and harbor the driver mutation BRAF. This mutation is found in approximately 50% of metastatic disease and provides a target for focused therapies to control this disease. These responses are usually brisk; however, they lack the durability of immunotherapy. Frontline therapy for patients with BRAF-mutated melanoma is not as straightforward as prescribing BRAF/MEK inhibitors. Prior trials of combination immunotherapy demonstrate similar responses and durability of responses in patients with BRAF wild-type as well as BRAF-mutated disease. Decisions about immunotherapy, targeted therapy, or the combination of immunotherapy with targeted therapy require an oncologist to evaluate multiple factors to select which treatment option is best for the patient. Trials for metastatic melanoma have included biomarkers as secondary endpoints and aim to identify some way to predict a response, or lack thereof, to therapy. Here, we discuss the utility and reliability of biomarkers in determining therapy for patients with BRAF-mutated metastatic melanoma and discuss combination immunotherapy with targeted therapy versus sequential immunotherapy/targeted therapy as well as which regimen should be implemented as initial therapy.
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Affiliation(s)
- Anna C Pavlick
- 1 New York University Perlmutter Cancer Center, New York, NY
| | - Leslie Fecher
- 2 University of Michigan Rogel Cancer Center, Ann Arbor, MI
| | - Paolo A Ascierto
- 3 From the Instituto Nazionale Tumori, Instituto di Ricovero e Cura a Carrattere Scientifico, Fondazione G. Pascale, Naples, Italy
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10
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Sullivan RJ, Atkins MB, Kirkwood JM, Agarwala SS, Clark JI, Ernstoff MS, Fecher L, Gajewski TF, Gastman B, Lawson DH, Lutzky J, McDermott DF, Margolin KA, Mehnert JM, Pavlick AC, Richards JM, Rubin KM, Sharfman W, Silverstein S, Slingluff CL, Sondak VK, Tarhini AA, Thompson JA, Urba WJ, White RL, Whitman ED, Hodi FS, Kaufman HL. An update on the Society for Immunotherapy of Cancer consensus statement on tumor immunotherapy for the treatment of cutaneous melanoma: version 2.0. J Immunother Cancer 2018; 6:44. [PMID: 29848375 PMCID: PMC5977556 DOI: 10.1186/s40425-018-0362-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/17/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cancer immunotherapy has been firmly established as a standard of care for patients with advanced and metastatic melanoma. Therapeutic outcomes in clinical trials have resulted in the approval of 11 new drugs and/or combination regimens for patients with melanoma. However, prospective data to support evidence-based clinical decisions with respect to the optimal schedule and sequencing of immunotherapy and targeted agents, how best to manage emerging toxicities and when to stop treatment are not yet available. METHODS To address this knowledge gap, the Society for Immunotherapy of Cancer (SITC) Melanoma Task Force developed a process for consensus recommendations for physicians treating patients with melanoma integrating evidence-based data, where available, with best expert consensus opinion. The initial consensus statement was published in 2013, and version 2.0 of this report is an update based on a recent meeting of the Task Force and extensive subsequent discussions on new agents, contemporary peer-reviewed literature and emerging clinical data. The Academy of Medicine (formerly Institute of Medicine) clinical practice guidelines were used as a basis for consensus development with an updated literature search for important studies published between 1992 and 2017 and supplemented, as appropriate, by recommendations from Task Force participants. RESULTS The Task Force considered patients with stage II-IV melanoma and here provide consensus recommendations for how they would incorporate the many immunotherapy options into clinical pathways for patients with cutaneous melanoma. CONCLUSION These clinical guidleines provide physicians and healthcare providers with consensus recommendations for managing melanoma patients electing treatment with tumor immunotherapy.
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Affiliation(s)
- Ryan J. Sullivan
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
| | | | | | - Sanjiv S. Agarwala
- St. Luke’s Cancer Center and Temple University, Center Valley, PA 18034 USA
| | | | | | | | | | | | | | - Jose Lutzky
- Mt. Sinai Medical Center, Miami Beach, FL 33140 USA
| | | | | | | | - Anna C. Pavlick
- New York University Cancer Institute, New York, NY 10016 USA
| | | | - Krista M. Rubin
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
| | - William Sharfman
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD 21231 USA
| | | | | | - Vernon K. Sondak
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612 USA
| | | | | | - Walter J. Urba
- Earle A. Chiles Research Institute, Providence Cancer Center, Portland, OR 97213 USA
| | | | | | | | - Howard L. Kaufman
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
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11
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Abstract
BACKGROUND Immune check point inhibitors (ICIs) have emerged as a new therapeutic paradigm for a variety of malignancies including metastatic melanoma. As the use of ICIs expand, immune-mediated adverse events are becoming a common occurrence. CASE PRESENTATION We describe the first reported patient with small vessel vasculitis, manifested by digital ischemia, following treatment with high dose Ipilimumab for resected stage IIIB/C melanoma. This patient received high dose steroids, five-day intravenous (IV) Epoprostenol protocol, botulinum toxin injections, and Rituximab 375 mg/m2 weekly for four cycles. With this treatment regimen, the digital ischemia did not progress proximally, but she did require multiple distal digit amputations about six months after the onset of her symptoms. CONCLUSIONS Prompt identification and management of immune related adverse events (IRAEs) are critical to optimal patient management. This patient's vasculitis did not reverse, but was likely halted and stabilized with multiple immunosuppressive medications.
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Affiliation(s)
- Amrita Padda
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Floor 3, Reception A, 1500 E Medical Center Drive, SPC 5342, Ann Arbor, MI 48109 USA
| | - Elena Schiopu
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Floor 3, Reception A, 1500 E Medical Center Drive, SPC 5342, Ann Arbor, MI 48109 USA
| | - Justin Sovich
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Vincent Ma
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Ajjai Alva
- Division of Hematology Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Leslie Fecher
- Division of Hematology Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
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Weber JS, Gibney G, Sullivan RJ, Sosman JA, Slingluff CL, Lawrence DP, Logan TF, Schuchter LM, Nair S, Fecher L, Buchbinder EI, Berghorn E, Ruisi M, Kong G, Jiang J, Horak C, Hodi FS. Sequential administration of nivolumab and ipilimumab with a planned switch in patients with advanced melanoma (CheckMate 064): an open-label, randomised, phase 2 trial. Lancet Oncol 2016; 17:943-955. [PMID: 27269740 DOI: 10.1016/s1470-2045(16)30126-7] [Citation(s) in RCA: 251] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 04/28/2016] [Accepted: 04/29/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Concurrent administration of the immune checkpoint inhibitors nivolumab and ipilimumab has shown greater efficacy than either agent alone in patients with advanced melanoma, albeit with more high-grade adverse events. We assessed whether sequential administration of nivolumab followed by ipilimumab, or the reverse sequence, could improve safety without compromising efficacy. METHODS We did this randomised, open-label, phase 2 study at nine academic medical centres in the USA. Eligible patients (aged ≥18 years) with unresectable stage III or IV melanoma (treatment-naive or who had progressed after no more than one previous systemic therapy, with an Eastern Cooperative Oncology Group performance status of 0 or 1) were randomly assigned (1:1) to induction with intravenous nivolumab 3 mg/kg every 2 weeks for six doses followed by a planned switch to intravenous ipilimumab 3 mg/kg every 3 weeks for four doses, or the reverse sequence. Randomisation was done by an independent interactive voice response system with a permuted block schedule (block size four) without stratification factors. After induction, both groups received intravenous nivolumab 3 mg/kg every 2 weeks until progression or unacceptable toxicity. The primary endpoint was treatment-related grade 3-5 adverse events until the end of the induction period (week 25), analysed in the as-treated population. Secondary endpoints were the proportion of patients who achieved a response at week 25 and disease progression at weeks 13 and 25. Overall survival was a prespecified exploratory endpoint. This study is registered with ClinicalTrials.gov, number NCT01783938, and is ongoing but no longer enrolling patients. FINDINGS Between April 30, 2013, and July 21, 2014, 140 patients were enrolled and randomly assigned to nivolumab followed by ipilimumab (n=70) or to the reverse sequence of ipilimumab followed by nivolumab (n=70), of whom 68 and 70 patients, respectively, received at least one dose of study drug and were included in the analyses. The frequencies of treatment-related grade 3-5 adverse events up to week 25 were similar in the nivolumab followed by ipilimumab group (34 [50%; 95% CI 37·6-62·4] of 68 patients) and in the ipilimumab followed by nivolumab group (30 [43%; 31·1-55·3] of 70 patients). The most common treatment-related grade 3-4 adverse events during the whole study period were colitis (ten [15%]) in the nivolumab followed by ipilimumab group vs 14 [20%] in the reverse sequence group), increased lipase (ten [15%] vs 12 [17%]), and diarrhoea (eight [12%] vs five [7%]). No treatment-related deaths occurred. The proportion of patients with a response at week 25 was higher with nivolumab followed by ipilimumab than with the reverse sequence (28 [41%; 95% CI 29·4-53·8] vs 14 [20%; 11·4-31·3]). Progression was reported in 26 (38%; 95% CI 26·7-50·8) patients in the nivolumab followed by ipilimumab group and 43 (61%; 49·0-72·8) patients in the reverse sequence group at week 13 and in 26 (38%; 26·7-50·8) and 42 (60%; 47·6-71·5) patients at week 25, respectively. After a median follow-up of 19·8 months (IQR 12·8-25·7), median overall survival was not reached in the nivolumab followed by ipilimumab group (95% CI 23·7-not reached), whereas over a median follow-up of 14·7 months (IQR 5·6-23·9) in the ipilimumab followed by nivolumab group, median overall survival was 16·9 months (95% CI 9·2-26·5; HR 0·48 [95% CI 0·29-0·80]). A higher proportion of patients in the nivolumab followed by ipilimumab group achieved 12-month overall survival than in the ipilimumab followed by nivolumab group (76%; 95% CI 64-85 vs 54%; 42-65). INTERPRETATION Nivolumab followed by ipilimumab appears to be a more clinically beneficial option compared with the reverse sequence, albeit with a higher frequency of adverse events. FUNDING Bristol-Myers Squibb.
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Affiliation(s)
- Jeffrey S Weber
- New York University Langone Medical Center, New York, NY, USA; H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Geoff Gibney
- H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | | | | | | | | | | | | | - Suresh Nair
- Lehigh Valley Health Network, Allentown, PA, USA
| | - Leslie Fecher
- Indiana University Simon Cancer Center, Indianapolis, IN, USA; University of Michigan, Ann Arbor, MI, USA
| | | | | | - Mary Ruisi
- Bristol-Myers Squibb, Princeton, NJ, USA
| | | | - Joel Jiang
- Bristol-Myers Squibb, Princeton, NJ, USA
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Hodi F, Gibney G, Sullivan R, Sosman J, Slingluff C, Lawrence D, Logan T, Schuchter L, Nair S, Fecher L, Buchbinder E, Ruisi M, Kong G, Horak C, Weber J. 23LBA An open-label, randomized, phase 2 study of nivolumab (NIVO) given sequentially with ipilimumab (IPI) in patients with advanced melanoma (CheckMate 064). Eur J Cancer 2015. [DOI: 10.1016/s0959-8049(16)31943-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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