Sparing Melanoma Survivors From Overexposure to Surveillance Imaging

Immune checkpoint inhibitors are at the forefront of treatment options for melanoma, leading to durable disease control and long-term survivors. But as a result, these patients are at risk of developing side effects from frequent imaging surveillance. A study presented at the American Society of Clinical Oncology (ASCO) annual meeting looked at the risk of progression or death when reducing the frequency of imaging surveillance for durable progression-free survivors (i.e., patients with 2 years of no progression).

In this exclusive MedPage Today video, investigator Igor Puzanov, MD, from the Roswell Park Comprehensive Cancer Center in Buffalo, New York, explained the background to the study, and what physicians can take from the results.

Following is a transcript of his remarks:

So, I have been fortunate to be curing and treating people with melanoma since 2004. We, of course, went a long way together with our patients. When I started, melanoma was one of the top 10 killers in both males and females in the United States, with about 15,000 people dying every year. Now it’s 7,700. So according to American Cancer Society, melanoma is the one cancer tumor type in [the] solid tumor field, which [has] the best improvement in mortality, almost 50% improvement over the last 10 to 20 years. So that has been very satisfying.

We are now actually seeing more survivors which were exposed to some of the drugs we develop[ed] over the years, such as the checkpoint inhibitors, like nivolumab [Opdivo], like pembrolizumab [Keytruda], ipilimumab [Yervoy], and others. And that brings actually separate challenges. People live longer, but these drugs are not without toxicity. We recognized that, at our Society for Immunotherapy of Cancer very early, and put together a multidisciplinary team in 2016 and developed the first guidelines actually for patients treated with checkpoint inhibitor therapy.

And now we recognize the need to go one further, and that is to take care of patients who are survivors, long-term survivors. And we are working on white paper guidelines, because we are seeing these patients suffering more, let’s say from coronary artery disease, probably based on the chronic inflammatory response against cancer, [which] also may damage some of the organs. There are some other issues with the patients.

And as part of the effort to spare those patients the side effects, as well as the long-term sequelae, one of our best fellows, Dr. Lei Deng, led the team at Roswell to look at the question whether the care for the long-term survivors needs to contain so many exposures to potentially harmful x-rays, CT scans. And he analyzed the data from over 1,400 patients from multiple trials and asked the question, if after the 2 years of no progression — so somebody who may have had a response or even stable disease — but didn’t progress in 2 years, if we started doing scans every 6 or even 12 months instead of shorter like 3 months, which has been standard pretty much for many patients, are we in danger of missing some of the patients progressing? How many and what is the incremental benefit for all these scans, which of course are also costly to the healthcare system?

And the answer was in our poster yesterday, presented at the poster session for melanoma and skin cancers. And the answer is no. After 2 years of no progression, you can safely switch to either 6 months, or even 12 months, after the third year of scans for the long-term survivors with 1% or 2% of patients developing progression in those scans. But most of the mortality is not dictated by the scan. Most of the mortality, at the end of the day, is dictated by biology of the cancer.

And so the overexposure to the potentially harmful x-rays may not be necessary. So the next step will be to collaborate both with Dr. Thach-Giao [Truong] at Kaiser Permanente, as well as Dr. John Thompson at [Fred Hutchinson Cancer Center] in Seattle to try to confirm the data with the bigger dataset, and also to potentially calculate some of the pharmacoeconomic aspects of the trial.