Patient Preference Plays Limited Role in Selection of Therapy for Melanoma

Evan J. Lipson, MD (MODERATOR)

Associate Professor of Oncology

Johns Hopkins Medicine

Baltimore, MD

DISCUSSION QUESTIONS

• How do you balance efficacy, safety, patient preferences, goals of therapy, and quality of life when recommending a first-line regimen in melanoma?​
• How does the availability of a novel immunotherapy target (anti-LAG3) change the landscape and decision-making process?

EVAN J. LIPSON, MD: Could you talk for about patient preference and how that plays into the recommendation you make?

AUGUSTO VILLEGAS, MD: If I think about the patients whom I have talked to, most of them have been young and fit, [and are mostly women]. I present the options; however, I still think that it’s hard to beat 7.5 years of data with melanoma [for ipilimumab (Yervoy) plus nivolumab (Opdivo)]. The other thing that worries me is that, besides BRAF [inhibitors], there is not a lot of salvage [therapy] with melanoma. You can do different things and even go all the way to interleukin-2, but there’s very little in my view that you can save [for later therapy].

[When I saw] the initial publication of the nivolumab/relatlimab [Opdualag], I was underwhelmed because we’ve been hearing about LAG-3 for quite some time and [hoped this regimen] was going to be superior [and a] substitute of ipilimumab/nivolumab, but it wasn’t. If 7 years later, we get the [overall survival] data, we [may] substitute it.

LIPSON: I agree with you. I don’t think it’s a substitute for ipilimumab/nivolumab.

VILLEGAS: What was your feeling when the publication came out? Were you excited or underwhelmed that LAG-3 was not the [treatment option you thought it might be]?

LIPSON: I was the one who presented the data first at the 2021 [American Society of Clinical Oncology Annual Meeting]. I’m a little bit biased, in terms of my excitement. We were pleased to see there was a pathway that could be blocked and was not as toxic as [the one targeted by] ipilimumab, but that was still giving an additional benefit to patients over and above anti–PD-1 monotherapy. I agree with what you said, that nivolumab/relatlimab does not take the place of ipilimumab/nivolumab, because the 2 were not compared head-to-head. I think what is true for a lot of us is that we’re not using much PD-1 monotherapy anymore, because that has been supplanted by nivolumab/relatlimab.

VILLEGAS: If you’re going to use a single agent…then I have no problems in picking nivolumab/relatlimab with very marginal additional toxicity, and clearly improved benefit. But I wasn’t doing single-agent immunotherapy to begin with. It’s the circumstances, [such as if] the patient didn’t walk in with the right characteristics. If I was thinking single agent, I might do nivolumab/relatlimab. If I’m thinking doublet immunotherapy, I’m still thinking ipilimumab/nivolumab.

JAY WANG, MD: I don’t have a lot of experience with nivolumab/relatlimab; [I have] more experience with ipilimumab/nivolumab. But patients usually don’t ask me in terms of what they prefer, they just say to give what I think is the best for them. I don’t think patient preference plays a role because they leave it up to the prescriber.

LIPSON: Yes, they rely on your judgment.

WANG: In younger patients and patients with central nervous system metastatic disease, I’ll stick with ipilimumab/nivolumab. In the older, frail patients, that’s where I pick nivolumab/relatlimab.

LIPSON: Dr Shanbhag, are you swayed by patient preference?

SATISH SHANBHAG, MD: I agree with what was said. I think patients do what we [recommend]. If you say ipilimumab/nivolumab is [tolerable], they will sign on. There will be very few patients who will say, “No, this is not right.” Most patients come to the table expecting you to give them an opinion, and they will mostly follow what you do. I don’t think it’s right to present patients with a buffet and say, “Pick what you want.” They don’t know what these regimens and their efficacy and toxicity is like. It’s our job to present to them our best interpretation of the data and make suggestions to guide them as to how to approach the disease. I feel like in somebody who’s frail [or older], when I’m worried about toxicity, I would go with nivolumab/relatlimab and if it’s somebody who’s young and fit, I think we should give them the benefit of doubt with ipilimumab/nivolumab.

LIPSON: Have there been any barriers to using either of the immunotherapy regimens [because] it’s not on your formulary, it’s not on your organization’s pathway, [or] getting pushback from insurance?

SUMIT SAWHNEY, MD: The barrier always is the cost to the patient. Insurance companies have gotten smarter; they don’t want to be the bad guys [by denying authorization]. [However], they dump [costs] on the patient. The patients can’t afford whatever the cost is; that’s what the major barrier is. If you’re not very well insured, trying to get support from foundations and everything is always a challenge. That’s the biggest barrier, [but] insurance companies are not saying no to [authorizing treatment] now.