The Doctor Is In:
Dr. Richard Joseph, MD
Dr. 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.
I am stage 3A and have been offered Opdivo to take in case there are stray melanoma cells. I also have been told I could watch and wait. What is the best approach?
This is a great question. In the clinical study evaluation nivolumab versus ipilimumab in the adjuvant setting, only patients with Stage IIIB, Stage IIIC, and Stage IV were included. Stage IIIA patients have such an excellent prognosis overall with an estimated 20% chance of recurrence. Given this relatively low chance of recurrence combined with possible long term toxicities of adjuvant nivolumab, I tend to steer patients with Stage IIIA melanoma towards observation rather than adjuvant nivolumab.
I’ve heard there are new vaccine therapies that are personalized to the individual. How soon will these be available? Are they in clinical trial?
There are multiple studies assessing the efficacy of vaccines that are individualized towards the patients. These approaches are not in the clinic and only available in clinical trials.
What about the new combinations of PD1 (keytruda and opdivo) that are in clinical trial? Are some more promising than others for stage 4?
There are dozens of trials combining anti-PD1 agents with a variety of other agents including other immunotherapies, targeted therapies, and radiation therapies. Given the early stage of most of these trials it’s too soon to categorize one combination as more promising over another combination.
I heard there is injectable therapy in combination with keytruda that was in trial and fast tracked called IMO? How is that looking as a promising therapy especially for intransit mets?
I believe the agent you are referring to is IMO-2125 which is an injectable form of a immune stimulatory agent that works through toll like receptors. In September 2017, investigators presented the phase 1 data of the first patients treated with IMO-2125 in combination ipilimumab. A total of 9 patients received the full dose of IMO-2125 along with ipilimumab. In these 9 patients, 4 of 9 (44%) patients responded. This response rate is higher than what we would typically expect from ipilimumab alone so this is a promising signal.
Which is better: opdivo and IPI combined or opdivo/or keytruda alone?
Another great question I’m often asked. It’s quite clear that the combination of opidivo and ipilimumab has slightly more increased efficacy but the combination comes with significant increase in toxicity when compared to single agent anti-PD1. In my practice, I first try to decide if a patient is able to tolerate the potential toxicity of the combination so I generally offer single agent PD1 to patients in poor physician condition from either their melanoma or significant other health problems.