With two effective new treatments for advanced melanoma, the question has become how to best use them and how to manage their toxicities. 

Vemurafenib (Zelboraf) and ipilimumab (Yervoy)¹ have different pharmacokinetics, which lend themselves to different patient types. Omid Hamid, MD, of The Angeles Clinic and Research Institute, Los Angeles, who discussed the two agents at the Best of ASCO meeting in Miami, Florida, said he uses vemurafenib first in patients who are symptomatic or have a high tumor burden.

“Response with ipilimumab may be delayed, but response can be rapid with vemurafenib,” he noted. Vemurafenib might reduce the tumor burden and set the patient up for a better response when switching to ipilimumab.

In patients with minimal symptoms and low tumor burden, ipilimumab might be preferred first-line. “The goal is durable benefit. Definitive progression should trigger a switch to vemurafenib,” Dr. Hamid said.

“Both agents require experience and commitment by the physician and patient in the management of the unique toxicities, which can be life-threatening,” he emphasized. “We are nowhere near the end of the road with these agents.” ■

Reference

1. Robert C, Thomas L, Bondarenko I, et al: Ipilimumab plus dacarbazine for previously untreated metastatic melanoma. N Engl J Med 364:2517-2526, 2011.