[Krista Rubin]

Wow. Thanks for sharing Kathy. I had one woman who had such severe xerostomia, and likely Sjogrens syndrome from treatment. She was miserable. Lost almost 30 lbs as she could not eat, tongue was sore all the time, sho she had trouble drinking. I was worried about aspiration. A formal speech and swallow eval was helpful; she did not appear to be aspirating, and the SLP was able to provide some recommendations for food/beverage choices. All in all, she decided to end treatment due to misery. Luckily she experienced a dramatic regression of tumor (she had unresectable, bulky Stage III disease of the groin) within the 1st 6 months of treatment, therefore it was a little bit easier to support her decision to stop. It has been 18 months and she has not experienced recurrent disease (knock on wood). Unfortunately, she continues to have Sjogrens sx., but has adapted as best as she could.

For other patients, I have found dex mouthwash helpful, and I give a once weekly flucanazole to minimize risk of thrush.

Xerostomia is a big issue- most of the time, patients just deal with it; they hate it!

[Krista Rubin]

Hello-

I have a couple of patients right now receiving cemiplimab for met SCC. One is s/p renal transplant many many years ago, the other is not a transplant pt. Both pts are doing extremely well. One is having a fabulous response, with ongoing excellent renal function (better than when he started Rx in fact) and no sign of rejection thus far. The other has not yet been restaged, but is using much less opioid analgesia for related pain. That is a good sign. Too early to tell, but as we all gain more and more experience, it is great to share.

Krista

[Krista Rubin]

Hi Bri-
I have seen this a number of times. Maybe not the exact same, but similar. A few times with formal disgnosis of esophagitis, a few without. We treated for both (steroids for esophagitis and fluc for thrush ; unclear which was the chicken or the egg…or if one predisposes to the other. In all patients they respond very quickly to antifungal Rx. and A TEMPORARY hold of Rx.
I suspect that the inflammation is worse in pts receiving checkpoints just because the immune system is so primed and ready and therefore the slightest insult leads to significant inflammation.

Let us know how your patient does.

Krista

[Krista Rubin]

HI Lisa- we did have one patient if I recall correctly. I am pretty sure it was PD-1 monotherapy.
A short course of corticosteroids were effective, but they were not able to go back on Rx. for unrelated reasons.

[Krista Rubin]

Exciting news that encorafenib + binimetinib were FDA approved yesterday for metastatic melanoma with an identified BRAF v600E/K mutation. This combination has SIGNIFICANTLY less pyrexia than other regimens (notably D + T), and also has the added benefit if minimal photosensitivity over vemurafenib. For those patients intolerant of dabrafenib + trametinib due to pyrexia, they now have an opportunity to switch to enco/bini and hopefully, be able to stay on the meds.

One other advantage is both enco and bini can be taken with OR without food! That makes scheduling so much easier for patients.

[Krista Rubin]

You all make excellent points. I would suspect Guidelines will be soon include when when patients’ should have their tumor sent for molecular analysis. As a general role, we have been testing anyone with a Stage IIB or greater, knowing that the likelihood of relapse is high. The primary lesion is used. Having this information in our “pocket” in case….has saved time for those patients who have aggressive relapses. If not enough tissue is available or there is other concern for not proceeding with testing, we know that up front.

In an ideal world, having this knowledge expedites evaluation….but as we all know, we do not always live in an ideal world!

[Krista Rubin]

Kathy- Thanks for the info about CBD being a CYP inhibitor! Very important.
As more and more states legalize these products, this type of info sharing is incredibly helpful!

[Krista Rubin]

Agreed- Kathy, what an interesting post. I suspect we will be hearing/learning more and more about all sorts of alternative treatments for various irAEs. This is a wonderful example of how other disciplines are embracing these challenging patients and beginning to explore treatments to improve minimize toxicity and improve QOL. It is an exciting time; and personally, I love interacting with the various disciplines; the learning opportunities are incredible!

[Krista Rubin]

Our clinic has limited TVEC administrations to one day a week, so my fellow NP Riley does all of the administrations one day. Since I am not familiar with the ins and outs of treatment/management, the above information was very informative. And Suzanne, thanks for the superimportant reminder about managing those with AI.

[Krista Rubin]

I wonder if topical capsaicin cream would help. He could try it in focal areas (like feet) to see if it helped.

[Krista Rubin]

I wonder if topical capsaicin cream would help. He could try it in focal areas (like feet) to see if it helped.

[Krista Rubin]

We have been spoiled lately; in that so many treatment options for melanoma have become available in the recent years. We have not been disappointed by trial results in quite a while (thankfully). Perhaps this is a reminder to all of us that indeed, melanoma remains a difficult to treat malignancy.

[Krista Rubin]

In the time from my last reply to now….I too learned there will be no more “on the fly” peer-to-peers. It is a scheduled call.

One more thing…I have learned from speaking to many physician reviewers, the majority of the time, they are not oncologists! Often they are internists, or other specialty MDs, that just sit with guidelines in front of them- and that is how decisions are made. I understand the rationale by ensuring tests are indeed medically necessary and to be economically prudent, but as we all know….melanoma does not like to play by the rules, and often certain situations require certain specialty radiologic imaging. Decisions made by non-oncology physician providers are not always in the best interest of the patients (at least this is my experience…at times, now always).

[Krista Rubin]

Hi Lisa- I can honestly say I have not; I wonder if it is some sort of underlying neuromuscular issue. That type of pain is typically nerve related. I wonder if it hyperesthesia representing NM inflammation. Is there thought to trying gabapentin?

Please provide an update on your patient’s clinical course and work-up. I am curious…..

[Krista Rubin]

We are ordering less and less PET-CTs due to having to sell your 1st child to get insurance approve. However, in some cases, even for just CTs, I am finding more and more scan approvals require peer-to-peer discussions. These take up so much time, and must be done by APRNs or MDs.

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