After Your Melanoma Is 'Clear': Adjuvant Therapy?
Carla Rake clearly remembers repeatedly seeing a TV commercial that cautioned viewers not to ignore a mole that had changed shape or color or ‘looked funny.’ Carla, 46, of Glenside, Penn., thought, "Well, I have one on my stomach and maybe I should have it looked at."
It was one very smart move. In August 2013 she visited her dermatologist, whom she says had a great poker face that didn't reveal his hidden concern as he biopsied her mole and whisked it away to a pathologist. Then she heard the word melanoma for the first time when the sample was sent for a second pathology to a major academic medical center, resulting in a call to "come in right away."
In two weeks, a surgical oncologist performed two surgeries: one to remove the melanoma with a wide excision and also do a sentinel node biopsy and the second to remove lymph nodes where the cancer had metastasized. A few weeks later, Carla underwent removal or resection of all of her lymph nodes.
Managing adjuvant therapy with life
In December, Carla was offered adjuvant therapy, the only option then being interferon for her newly-diagnosed stage 3A melanoma. "For three weeks, five days a week, I went to the cancer center after work and sat for four hours, then I'd go home and be sick to my stomach for hours," she says. "The next day I went to work."
This trooper was supposed to continue to four weeks, and then treatment for a year, but she knew she couldn't miss work as an occupational therapy assistant, and her home state didn't offer short-term disability. Fate was thankfully on her side, as she was declared no evidence of disease or NED after her last interferon treatment.
Now she gets a skin check every six months, along with a CT scan. The 6-month mark is also when she sees her surgical oncologist and medical oncologist.
She also participates in a support group to sustain her current level of self-care, which includes managing lymphedema, or swelling that resulted from removal of her lymph nodes. She underwent a surgery to help correct that condition.
Carla gives back as a tireless advocate for melanoma awareness, and she received an award from the Melanoma Research Foundation in 2016.
What is adjuvant therapy?
"For melanoma patients that have a relatively high risk of recurrence, adjuvant therapy is usually recommended," says melanoma specialist Gary Doolittle, M.D., a professor of medicine at KU Medical Center at The University of Kansas, and medical director for the Midwest Cancer Alliance.
This determination is made after the melanoma — along with a wide margin of surrounding tissue — is excised or removed, "to be sure you've cleared everything out of where it started," Dr. Doolittle says. Then the surgeon "maps" to the closest lymph node bed, via an injection of blue die or radioisotope. The first node that lights up — known as the sentinel lymph node — is removed.
"If the melanoma has spread to the sentinel lymph node — or other lymph nodes — the patient is a candidate for adjuvant therapy," he says.
What to expect with adjuvant therapy
A patient at high risk may undergo immunotherapy, a form of adjuvant therapy, for a year, given intravenously by infusion every three to four weeks. Immunotherapy helps the immune system fight the body's cancer.
"Put simply, the hope is that if there are any little microscopic deposits of melanoma that have already 'escaped,' immunotherapy will stimulate the body's immune cells and go 'find' the melanoma and clear those cells," says Dr. Doolittle. Here he shares his experience with adjuvant therapy and the medications most commonly used.
Your immunotherapy options for melanoma
The two most frequently used lines of defense in this category are both anti-PD-1 products or programmed death receptor-1 products. This means they block the PD-1 pathway and also help make sure those resourceful cancer cells don't hide from detection.
One is currently widely used, and the other is going to be new to this application in the marketplace. The first is nivolumab or OPDIVO. Mainly utilized to treat lung cancer, this medication was approved for melanoma adjuvant therapy in the fall of 2017. A study in a September issue of The New England Journal of Medicine reported that nivolumab resulted in significantly longer recurrence-free survival and fewer adverse events than adjuvant therapy with ipilimumab or YERVOY.
In his 28th year of practicing medicine, Dr. Doolittle recalls when the only treatment available was interferon — as in Carla's case. "Side effects were definitely rough, and included fever, muscle aches, and fatigue that couldn't be improved by sleep," he says. "Now nivolumab is much better tolerated, and I would say many of my patients go through treatment without any side effects or symptoms at all."
He also wants to clarify why "side effects" occur. "It's not the drug, but the way it activates the body's immune cells as it 'goes after' melanoma. Unfortunately, when the immune system is stimulated, it can damage normal tissues, too. The most common side effects — if they occur — are skin rash, colitis, hepatitis, and endocrine gland dysfunction."
Dr. Doolittle says patients take the drug for a year, then stop it and go into surveillance mode.
New to the melanoma adjuvant therapy playing field, pembrolizumab or KEYTRUDA is expected to be approved for this use early in 2019, Dr. Doolittle says.
Dr. Doolittle shares his enthusiasm for advancements made since he's been treating melanoma. "Before these medications, it was much more about managing symptoms, but now we see patients go into remission, living much longer and much better. It's actually remarkable."
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