The Doctor Is In…
Dr. Richard Joseph, MD
Richard Joseph, MD, is an assistant professor of medicine/oncology at Mayo Clinic. His Hematology/Oncology fellowship was completed at MD Anderson Cancer Center. He is a voting member of the NCCN (National Comprehensive Cancer Network. He belongs to Melanoma International’s Scientific Advisory Board and received MIF’s Doctor of the Year award for 2015.
» IPI MAINTENANCE
My husband recurred once on IPI (Yervoy) and now 2 years later has no evidence of disease (NED). Is there a maintenance dose or further information as to chart our future with IPI? He is still scanned every 4 months.
Dr. Joseph: “At present, there is no role for maintenance ipilimumab in patients who experience a complete or partial remission to ipilimumab. Fortunately, most patients who experience a partial or complete remission with ipilimumab will not require further therapy. In the minority of patients who do recur after having responding to ipilimumab, retreatment with ipilimumab has shown excellent activity. In summary, if the patient remains without evidence of disease, I would not recommend further therapy but continued surveillance. “
» IPI/OPDIVO COMBINATION
I heard that many centers are concerned about prescribing the iPI/Opdivo combo because of the intense nursing needed for toxicity. Will this make this combo approved but uncommon?
Dr. Joseph: “The combination of ipilimumab/nivolumab (Yervoy/Opdivo) has demonstrated remarkable activity in patients with metastatic melanoma. At present the combination is not approved by the FDA or endorsed by the NCCN, making it a challenge to prescribe since the combination may not be covered by insurance. I do foresee that the combination will be approved and once approved, I believe the combination will be more widely used. At present the regimen is readily available for patients willing to participate on expanded access protocol open at many centers as listed on clinicaltrials.gov. Certainly the toxicity of the regimen can be intense but very manageable with proper surveillance and patient education. The toxicity could limit the use of the combination in patients who are especially frail but otherwise it should be widely accepted.”
What are the best scans? Pet or CAT for following melanoma, either from NED or for tumor progression?
Dr. Joseph: “This is a great question and one I’m most frequently asked. There has never been a formal study comparing the utility of CAT versus PET scans in melanoma. In my practice, I normally use CAT scans and then if something is ambiguous, I might order a follow up PET scan.”
» MOHS SURGERY
What do you think about slow Mohs surgery for melanoma instead of the usual biopsy/removal?
Dr. Joseph: “Another great question where the data is rapidly evolving. The paradigm in all of oncology is to try and do less harm while still maintaining equivalent efficacy. At present, I wouldn’t recommend Mohs surgery to treat melanoma but I do believe this topic deserves more prospective studies.”
» TREATMENT SEQUENCE
What is the best order to take these new therapies, i.e. braf and immunotherapies?
Dr. Joseph: “If a patient with BRAF mutant melanoma progresses on ipilimumab and then on anti-PD1, then I would certainly recommend starting treatment with a combination of BRAF/MEK inhibitor or participation in a clinical trial. Tumors that are resistant to BRAF or BRAF/MEK inhibitors often rapidly progress, and retrospective data suggests that patients who progress on a BRAF inhibitor rarely if ever respond to ipilimumab (Sullivan et al. Cancer, 2013). Please keep in mind there are no prospective studies that definitely conclude the sequence of therapy matters.”