[Suzanne McGettigan]

Such an interesting discussion.

Another factor that is influencing this group of patients is the results from the MSLT-II trial which demonstrated no increased benefit on overall survival for patients with microscopic disease undergoing completion lymph node dissection. From a practical standpoint, this potentially means that more patients will be classified as Stage IIIa now than previously. Therefore, it will continue to be a detailed conversation with patients about the role of adjuvant therapy in that setting.

[Suzanne McGettigan]

Hi Yael–
Such a great question. The immune related hepatitis can be particularly challenging to manage as Kathy all ready mentioned. It is also essential to check for dormant or undiagnosed viral hepatitis, which you have done.

Some patient’s liver enzymes will rebound quickly with corticosteroids, even oral, while others will require much longer courses of both corticosteroids and alternate immune modulatory therapies, such as mycophenylate.
Since your patient has all ready been started on mycopheylate, the other thing I want to point out in Kathy’s response is to make sure that the corticosteroid dose is continued–it may even have to be escalated. If at high dose corticosteroids, 2-4 mg/kg/day, and full dose mycophenylate, you are still not seeing improvement in the liver enzymes, then an alternate therapy may need to be considered.

please send any questions about this back as there is always someone monitoring this portal.
Suzanne

[Suzanne McGettigan]

Great comments Virginia and Kathy..

It is such an amazing time for melanoma therapies and cancer therapies in general. As many of these therapies receive approvals in multiple cancer types, it is essential to review the PI for specifics around the approvals as well as for nuances in toxicity profiles from one tumor type to another. For many of our colleagues who don’t specialize in a single tumor type, this is even more important.

[Suzanne McGettigan]

We have not incorporated the ipi/nivo flipped doses outside of a clinical trial. We are infusion nivo over 30 min as a single agent. There is some controversy and back and forth continuing with our pharmacy and the approved indications for the 30 min infusion time.

[Suzanne McGettigan]

Hi Lisa–
My practice would be very similar to Krista’s. It is hard to predict who will get a fever and who won’t, but it seems like most patients do, at some point. On one of the early trials, we had a patient who struggled with fevers/pyrexia for the first few months and then remained fever-free for almost two years. At that point, the fevers came back and recurred frequently.
We do have several patients who require low dose steroids daily to avoid the fevers. In that scenario, if a fever did recur, I would hold dabrafenib/trametinib as Krista mentioned, temporarily increase the steroids and then resume once afebrile for at least 24 hours.
These are really tough!

[Suzanne McGettigan]

Hi Lisa–
Thanks for the question. There are a variety of copay assistance programs available to patients with high copays from any of the immunotherapy agents. Eligibility requirements are sometimes different for each program, so it is important to check on that. The pharmaceutical companies all have copay and financial assistance programs for patients. Depending on an individual’s insurance, eligibility for these programs vary. There are also a variety of foundations that can provide copay and financial assistance to patients.

I typically find that completing the forms on the manufacturer’s websites can help get your patient connected to the right resources based on their insurance.

Hope that helps,
Suzanne

[Suzanne McGettigan]

Hi krista–
These side effects do have different implications in the adjuvant setting than in the metastatic setting. hold therapy is definitely a consideration.
it sounds like you have tried all of the conservative management strategies, but all of the things we would typically try for xerostomia from other anti-cancer therapies might be useful. It is important to ensure that patients are getting adequate hydration in general and also implementing strategies to keep their mucous membranes moist. Sugar-free gum and hard candy can occasionally be helpful in stimulating saliva production. Dry mouth can certainly be associated with dental complications, so making sure your patient is receiving regular dental care will be important.
There are numerous saliva substitutes available for patients currently–many are over the counter and a few are available by prescription. I won’t list all of the brand names here, but I do tend to have patients try one and quickly switch to another if they are not achieving good effect. I find the sprays easier to tolerate during daytime hours, saving the gels for the evening.
Acupuncture has been shown to have some benefit in radiation induced xerostomia, so also might be something to consider.
Hope that helps,
Suzanne

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