Management of Immune-Related Toxicities in Melanoma Has Improved Over Time

Evan J. Lipson, MD (MODERATOR)

Associate Professor of Oncology

Johns Hopkins Medicine

Baltimore, MD

DISCUSSION QUESTIONS

• Discuss your comfort level in managing immune-related adverse events (AEs) in the setting of metastatic melanoma. How has this changed over time? ​
• To what extent does ease/difficulty of managing potential toxicities factor into your recommendations?​

EVAN LIPSON, MD: There’s a different feel for some of the immunotherapies [IOs] now, and…we as a group may be better at managing some of the toxicity. I’m interested if anybody has opinions about that. Dr Sawhney, are we better at managing toxicity now than we were 5 years ago?

SUMIT SAWHNEY, MD: Definitely.I was giving ipilimumab [Yervoy] when it was 10 mg/kg and patients experienced horrendous toxicities. Things have changed over the last 10 years. But the oldest person I gave ipilimumab was aged 90, at 10 mg/kg with melanoma, and he’s still alive 10 years later. But we have gotten better. There are guidelines now on when to intervene. Infliximab [Remicade] has changed [how you are treated] if you get immune-mediated toxicities. We have definitely gotten better by using [IO] in different disease states.

LIPSON: I agree with you. Dr Yellu, does the difficulty of managing these toxicities factor into what you recommend for patients?

MAHENDER YELLU, MD: I’m comfortable using dual IO vs monotherapy. We have been using these treatments in pretty much in every cancer right now. Adding ipilimumab will increase the risk of toxicities, but I’m pretty comfortable managing them. Sometimes I prefer [either] monotherapy or dual immunotherapy based on the age and performance status.

LIPSON: Dr Nakka, has the ease or difficulty of managing toxicities changed your approach for patients?

SUSHMA NAKKA, MD: Yes, over the last 5 years, we got more comfortable dealing with AEs [and] how to manage AEs. [We also learned] how to channel, in terms of consults, whether it is pulmonary, or how to get a CT scan very quickly, and manage your pneumonitis and other AEs, including neurological AEs and endocrine AEs. Over the last 5 years, [we have improved] not only the comfort level of [oncologists], but the availability of other specialties, as well as their comfort level getting up to speed with us in terms of management of AEs.

LIPSON: I agree with you. I remember I was lecturing in North Carolina…I said when you have somebody where you suspect pneumonitis, you have to call your pulmonology colleagues and get a bronchoscopy. One of the audience members raised their hand and said, maybe at [Johns Hopkins Medicine], you can get a bronchoscopy that week, but here in South and North Carolina, it takes 3 months to get somebody into pulmonology.

NAKKA: That is very true in the community practice where I am at. But I will say in the last couple of years, we have channels where we have our pulmonologist available just to see our patients and they can get them in within 2 to 3 days. That is definitely an improvement.

EVAN LIPSON, MD: Yes, you [can] build your network. Dr Parikh, has that been your experience? Have you built a network of specialists where you can call and ask for help with a complicated endocrine AE?

JIGARKUMAR PARIKH, MD: Yes, I have. One thing that I’m still struggling in managing the toxicity is musculoskeletal toxicities. At least in my practice, that is still an issue where it’s very debilitating to the patient, and I don’t think it’s well managed. It’s hard to get a dermatology appointment in a week or so. Usually, I ended up putting patients on steroids, and it would work, but in the long-term management, I feel like that is one toxicity that has still been an issue in my practice.

LIPSON: I don’t think you’re alone in that. Some of the rheumatologic toxicities, arthritis in particular, have been challenging for us to manage. We are fortunate to have a go-to rheumatologist who has published a lot on this and has a lot of fancy tools [such as] interleukin-6, [etc]. But I hear what you are saying quite a bit as I lecture around the country. Some of the [complex] toxicities, like rheumatology and some of the endocrine AEs, are tricky.