The American Cancer Society estimates that this year 76,380 new cases of melanoma will be diagnosed in the United States. Of those, about 10,130 people will not survive. However, with new generation immunotherapies released on the market, some stage IV melanoma patients will live longer as a result.
“Recent advances in the understanding of immunology and antitumor immune responses have led to the development of new immunotherapies, including vaccination approaches and monoclonal antibodies that inhibit immune checkpoint pathways,” states the U.S. National Library of Medicine.
Among the latter class of drugs are pembrolizumab (Keytruda) and nivolumab (Opdivo), both FDA approved. They represent the latest research in immunotherapy. Keytruda was once a second-line therapy but last December, it got a priority review as a first-line therapy. It now joins Yervoy as first-line therapies for treating melanoma.
Immunotherapy works by stimulating the body’s own immune system to target and kill cancer cells. Dr. Maynard Bronstein, a practicing oncologist with Grande Ronde Hospital has used a predecessor therapy, Yervoy, for a number of years in treating cancer, and he looks forward to the advantages that Keytruda offers too.
“We have not used Keytruda in this clinic yet,” said Bronstein. “The first monoclonal antibody that was approved for melanoma was called ipilimumab (Yervoy), and I have used that. I have a guy who has received Opdivo for lung cancer. We haven’t given those yet in this clinic, but I’m sure that we will soon.”
The new generation of immunotherapy drugs supercede previous modalities because they do more than delay the recurrence of melanoma. For a growing percentage of patients, they actually extend their lives after the treatment is finished.
“Immunotherapy is an idea that has been around for decades, and it’s finally coming around to fruition,” Bronstein said. “Normally we would expect our immune system to attack and kill cancer. So the thought is that anyone who has cancer is experiencing a failure of their immune system in recognizing the cancer. So what these drugs do, Yervoy, Keytruda and Opdivo, is that they all turn on the immune system to try to get the immune system to turn against the cancer. And they are getting good results.”
Historically melanoma has been a disease for which oncologists didn’t have good treatment, so this is a game changer.
“People who had been on Keytruda for melanoma, 40 percent of them are still alive four years later, which is really remarkable,” said Bronstein. “That’s where I think these immune checkpoint inhibitors, like Keytruda and Opdivo, are different. With traditional chemotherapies, the disease tends to come back when you stop treatment, but these, if they work, they tend to last a long time.”
When someone has stage IV melanoma, any extra years a patient gains from treatment is precious time they can spend with loved ones.
“With Y ervoy, the first drug to be approved, there was only a 15 percent response rate, which is pretty bad, but still the FDA approved the drug because for those 15 percent, the disease seemed to go in remission for a long time,” he said. “Now we see the same results with Keytruda in melanoma, but the difference is that it’s a 40-percent response rate, and patients are still living four years later.”
Patients are made aware that there will always be side effects with any treatment.
Back in the days of interferon in the 1990s, the side effects were very unpleasant and included flu-like symptoms, such as fatigue, fever, chills, nausea, vomiting, and headache; rashes; hair thinning; and depression. Because of the side effects and lack of a survival benefit, many doctors do not recommend using higher doses of interferon any longer.
The new generation immunotherapy drugs are often tolerated better, but they still have side effects.
“The side effects relate to the immune system attacking stuff you don’t want it to attack,” said Bronstein. “It can attack the most common places like in the gastrointestinal tract (stomach, esophagus, colon) and the skin and other organs. Some people have had a reaction in the lungs or the pituitary gland. Patients can get organ damage from these drugs.”
If it’s a mild side effect, sometimes the oncologist will recommend a break in treatment or the patient may receive a low dose of prednisone to help offset the side effects. But there are times when the side effects are severe and treatment must be abandoned.
The course of treatments vary, and they may go on longer than 6 months. With the older drugs, like Yervoy, a patient just gets four doses and then stops. With Keytruda for melanoma, a patient actually gets an infusion every three weeks, and the course is open ended, so treatments may continue longer at the discretion of the oncologist.
Immunotherapies are very expensive treatments. With Yervoy each treatment cost $40,000, Bronstein explained. After four treatments, a patient’s insurance will be billed $160,000. Keytruda could likewise cost $150,000 if used for a full year. Patients should check with their insurance provider for coverage information.