New Metastatic Melanoma Therapies Create Hope for Patients, Key Role for Oncology Nurses

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The incidence of melanoma, the deadliest of all skin cancers, is quickly rising, and the disease is responsible for more than 8000 deaths each year.

Not surprisingly, melanoma nurse practitioner Rajni Kannan is passionate about helping her patients at NYU’s Cancer Institute to fight this devastating disease.

That’s why Kannan, BS, MS, RN, ANP-BC, is excited about the remarkable developments she’s seen in the treatment of metastatic melanoma over the last 5 years—including last year’s FDA approval of two new agents, ipilimumab and vemurafenib.

At the same time, Kannan is determined to reduce the number of patients she sees at the Manhattan facility based at the Langone Medical Center by being an advocate for increased awareness of the dangers of tanning, she told attendees during a presentation at NCONN 2012.

The incidence of melanoma, the deadliest of all skin cancers, is quickly rising, and the disease is responsible for more than 8000 deaths each year, Kannan said, adding that the average survival for melanoma patients with metastatic disease is 7 months, and that 50% of these patients will develop brain metastases. Kannan reminded audience members that exposure to ultraviolet (UV) radiation is a major risk factor for skin cancer, and that the World Health Organization has declared UV-emitting tanning devices carcinogenic.

In discussing ipilimumab (Yervoy), Kannan described the mechanism of the immunotherapy as “amazing.” The treatment is given intravenously every 3 weeks for a total of four doses, and Kannan explained that “patients have had a hard time understanding that they get four doses, and that’s all they get” before returning for tumor evaluations after 12 and 24 weeks and then every 3 months thereafter. Kannan noted that nurses have an important role to play in explaining to worried patients that “this is enough.”

The other new agent, vemurafenib (Zelboraf), is a targeted therapy approved for patients with unresectable or metastatic melanoma who test positive for the BRAF V600E mutation—approximately 40% of melanoma patients, according to Kannan. Testing for BRAF mutational status, she said, must be conducted at a site of metastatic disease, presenting another important role for oncology nurses and navigators: to help patients with earlier-stage cancers understand why they can’t be tested. Moreover, she said, “if you give this drug to patients who don’t have the mutation, you can actually accelerate the disease.”

“Eighty percent of patients respond to vemurafenib, but the question is, for how long?” Kannan noted. In some patients, disease quickly returns, while others do extremely well. “We need to determine why some patients have a sustained response,” she said.

These two agents offer new hope for metastatic melanoma patients, but both have complex side-effect profiles. Nurses are important in this regard, too, Kannan said, since they can share their expertise about the drugs with patients, who often “don’t communicate well about their side effects.”

National Comprehensive Cancer Center guidelines recommend clinical trials as first-line therapy for metastatic melanoma patients, and a number of new agents are under investigation for treatment of the disease, Kannan reported. PD-1, an immune checkpoint inhibitor, is about to go into phase III testing. Researchers are also looking at MEK inhibitors, vaccines, and combination therapies.

This is an area where nurse navigators also can make a huge difference, she said, by helping patients locate not only the right trials for their diseases, but also studies that will accept their health insurance plans. Kannan stays abreast of virtually all relevant clinical trials underway at NYU and elsewhere. “It’s not about us,” she said. “We’ll send patients anywhere to get the care they need.”

Kannan is currently writing a grant application to establish a melanoma survivorship program at NYU. “Survivorship is now a reality in melanoma,” she said, “but we don’t have the magic medicine yet.”

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