Melanoma forces so many difficult questions -
What do I do now? Will I respond to the therapy I choose? Will I tolerate the therapy I am given? What happens if I develop side effects and have to stop therapy? What happens if I do okay on therapy and then stop? When should I stop?
Unfortunately, we have few definitive answers. But, there is this report on how patients did after stopping anti-PD-1 ~
Outcomes
of metastatic melanoma (MM) patients (pts) after discontinuation of
anti-Programmed-Death 1 (PD1) therapy without disease progression.
Schvartsman, Ma, Bassett, et al. ASCO 2018.
The
optimal duration of PD1 therapy for MM pts that do not progress
remains unknown. There is limited information available about
long-term outcomes of patients that discontinue treatment due to
toxicity.
Methods:Our institutional database was queried to identify stage IV or unresectable stage III MM pts that received single-agent anti-PD1 from January 1, 2012, to July 31, 2016, with at least 6 months of clinical follow-up. Pts that discontinued PD1 therapy for reasons other than progression were identified, including maximal clinical benefit (MCB) and toxicity. MCB was defined as either completion of two years or discontinuation per physician’s discretion. Data on demographics, tumor characteristics, treatment variables and outcomes were collected.
Results:From 580 MM pts treated with PD1, 41 pts discontinued treatment for MCB and 34 for intolerable toxicity (75 total). 56% of pts achieved a complete response (CR), 35% partial response (PR), and 9% stable disease (SD). Response rate was similar among patients discontinuing therapy due to MCB (93%) and toxicity (88%), but CR rates were higher in the MCB group (76% vs 32%). Median time on PD1 was 19.5 months in the MCB group and 6.5 months in the toxicity group; median time to response was 2.9 months, and median time to CR was 7.3 months. With median follow-up of 16 months after discontinuation, 89% were disease-free and 93% were alive; 6 patients died; no deaths were due to disease progression, and 3 were due to PD1 treatment complications. 8 pts progressed (3 in the MCB group, 5 in the toxicity group). 2 out of 3 in the MCB group were successfully rechallenged with PD1 (1 CR, 1 PR) and one had surgery and is still off therapy. One pt in the toxicity group was rechallenged, 2 are receiving ipilimumab, one had a single brain lesion resected (still off therapy) and one died of cardiac arrest while on T-VEC. No baseline factors were associated with relapse.
Conclusions:Anti-PD1 was safely discontinued in the majority of MM pts, and no deaths due to disease progression were seen. Further prospective validation of early discontinuation for MM pts achieving MCB is warranted to prevent unnecessary toxicity and financial costs.
Methods:Our institutional database was queried to identify stage IV or unresectable stage III MM pts that received single-agent anti-PD1 from January 1, 2012, to July 31, 2016, with at least 6 months of clinical follow-up. Pts that discontinued PD1 therapy for reasons other than progression were identified, including maximal clinical benefit (MCB) and toxicity. MCB was defined as either completion of two years or discontinuation per physician’s discretion. Data on demographics, tumor characteristics, treatment variables and outcomes were collected.
Results:From 580 MM pts treated with PD1, 41 pts discontinued treatment for MCB and 34 for intolerable toxicity (75 total). 56% of pts achieved a complete response (CR), 35% partial response (PR), and 9% stable disease (SD). Response rate was similar among patients discontinuing therapy due to MCB (93%) and toxicity (88%), but CR rates were higher in the MCB group (76% vs 32%). Median time on PD1 was 19.5 months in the MCB group and 6.5 months in the toxicity group; median time to response was 2.9 months, and median time to CR was 7.3 months. With median follow-up of 16 months after discontinuation, 89% were disease-free and 93% were alive; 6 patients died; no deaths were due to disease progression, and 3 were due to PD1 treatment complications. 8 pts progressed (3 in the MCB group, 5 in the toxicity group). 2 out of 3 in the MCB group were successfully rechallenged with PD1 (1 CR, 1 PR) and one had surgery and is still off therapy. One pt in the toxicity group was rechallenged, 2 are receiving ipilimumab, one had a single brain lesion resected (still off therapy) and one died of cardiac arrest while on T-VEC. No baseline factors were associated with relapse.
Conclusions:Anti-PD1 was safely discontinued in the majority of MM pts, and no deaths due to disease progression were seen. Further prospective validation of early discontinuation for MM pts achieving MCB is warranted to prevent unnecessary toxicity and financial costs.
So - 580 melanoma patients were given anti-PD-1. 41 patients stopped after 2 years or at doc's discretion (characterized as MCB in study [maximal clinical benefit]). 34 stopped due to side effects. I presume the rest of the peeps are still on treatment. Overall, 56% of patients had a complete response, 35% had a partial response, and 9% had stable disease. These responses were similar across the 2 groups with a response rate of 93% in the MCB group and 88% in the toxicity group. Complete responses were higher in the MCB group (76% vs 32%). Median time on drug = 19.5 months for MBC and 6.5 months for the toxicity group. Median time to response was about 3 months (this has been demonstrated repeatedly in studies looking at anti-PD-1). Median time to complete response was 7.3 months. At f/u 16 months after stopping anti-PD-1, 89% were disease free, 93% were alive, 6 had died (NONE due to disease progression), but three deaths were due to complications from anti-PD-1. 8 patients progressed (3 in the MCB group and 5 in the toxicity group). 2 of the MCB group were rechallenged and 1 gained a complete response and the other a partial.
Interesting info...but I think this report from ASCO last year...actually provides more data:
ASCO 2017: Outcomes after stopping immunotherapy in melanoma
And along these same lines there was this post at the end of last year: Durable responses to pembro. The 'C' word (CURE!!!!!!!!!!) used by melanoma researchers. And....HAPPY NEW YEAR!!!!
My Granny gave me a book titled something like, The School of Hard Knocks, when I graduated from high school. Bless her. She had no idea how hard The School of Melanoma World was going to be. But, I know part of my ability to deal with it is due to her...and I'd like to think I've done her proud. Hang in there ratties!!! - c
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