Real World Health Care Blog

Cutting-Edge Melanoma Treatment at Rutgers Cancer Institute of New Jersey

This week, Real World Health Care continues our series on melanoma by interviewing two colleagues from the Rutgers Cancer Institute of New Jersey, a National Cancer Institute-designated Comprehensive Cancer Center.

Sharad Goyal, MD, is Associate Professor and Director of Clinical and Translational Research in the department of Radiation Oncology. He treats patients with brain tumors, melanoma and skin cancers, providing comprehensive cancer evaluation and the latest treatment planning technology to “map” tumors. He designs radiation treatments with pinpoint accuracy, ensuring that tumors get the most effective dose while healthy tissues and organs are spared.

Ann W. Silk, MD, is a medical oncologist who cares for patients with melanoma, and other skin cancers. She also leads clinical trials focused on combination treatment with immunotherapy and viral therapy for melanoma and other cancers.

Drs. Goyal and Silk discuss their work as part of a multidisciplinary team that translates research of investigational treatments and directly applies them to patient therapies.

Managing Multiple Melanoma Brain Metastases

Real World Health Care: How is treatment advancing for patients with multiple brain metastases (MBM) from melanoma?

Sharad Goyal; Faculty and Staff, Rutgers – Robert Wood Johnson Medical School, New Brunswick, NJ. 05/01/2014 Photo by Steve Hockstein/HarvardStudio.com

Sharad Goyal: The treatment of brain metastases from melanoma is controversial and includes surgical resection, stereotactic radiosurgery (SRS) and whole brain radiation (WBRT). Several new classes of agents have revolutionized the treatment of metastatic melanoma, allowing for subsets of patients to have long-term survival. Given this, management of MBM from melanoma is continually evolving.

As patients are living longer due to more effective systemic therapy, surveillance and management of intracranial disease is increasingly important. At this time, the standard of management for patients with MBM from melanoma includes SRS, WBRT, or a combination of both.

In addition, emerging data supports the notion that SRS, in combination with targeted therapies or immune therapy, may reduce the need for whole brain radiation. Prospective studies are required to fully evaluate the efficacy of these novel regimens in combination with radiation therapy. Given the advances in systemic therapy of melanoma, it is critical that oncologists treating these patients be aware of new treatment paradigms to optimize the outcomes for all patients with metastatic melanoma.

RWHC: Are there ways to treat melanoma in order to avoid or lessen the chances of brain metastases? Does early initial detection of melanoma help?

SG: Early detection of melanoma will always help reduce the chance a patient develops brain metastases. There is usually a fairly lengthy period when the tumor expands beneath the top layer of skin but doesn’t go any deeper. This allows time for screening, early detection, treatment, and a full recovery if the tumor is discovered before it spreads.

After a patient is diagnosed with melanoma, the use of certain anticancer treatments that are given after a cancer is surgically removed, such as interferon alfa and ipilimumab, will allow for an improvement in overall survival in patients with stage III or IV melanoma. In addition, the use of anti-PD-1 checkpoint inhibitors prolongs overall survival in patients with stage IV melanoma. Currently, many studies are underway investigating the optimal anticancer treatment in patients with Stage III melanoma.

Promising Therapies

RWHC: What are the most promising therapies on the horizon for metastatic melanoma?

Ann W. Silk, MD, Rutgers Cancer Institute of New Jersey

Ann Silk: Melanoma is the “posterchild” for breakthrough immunotherapies. At Rutgers CINJ, we are testing novel combinations of new agents coupled with immunotherapies. Those novel agents help to “prime” tumors so immunotherapies work better. One example of this is combining an immune checkpoint inhibitor pembrolizumab with intra-tumoral injections of talimogene laherperepvec, which is a live herpesvirus that infects cancer cells, replicates within them, and lyses the cancer cell, thus killing the cell. We’re also seeing promising early results in trials that combine intra-tumoral injections of coxsackievirus with injections of pembrolizumab, with response rate of 60%, which we reported at this year’s American Association of Cancer Research Annual Meeting. We have just recently opened a study in which we will combine IL-2 cytokine therapy with pembrolizumab, a combination of two drugs that have already demonstrated good activity in metastatic melanoma.  They are each FDA-approved as single-agents, but we are studying them as a combination therapy. The goal of these studies is to build on the success of immunotherapies to increase response rates, particularly complete response rates.

Access to Clinical Trials

RWHC: What are some of the biggest challenges facing researchers studying metastatic melanoma?

AS: Access to clinical trials is a challenge, from a patient or participant status. Running clinical trials requires vast resources and numerous support personnel, so they tend to be concentrated at large medical centers. As a result, only about five percent of the patient population has access to these trials. I think that number should be closer to 80 percent. Trials aren’t only important for the patients receiving the treatment; the knowledge we gain also helps future patients.

Treating Melanoma

RWHC: What are the biggest challenges facing clinicians treating patients with metastatic melanoma?

SG: One of the most challenging types of cancer to treat is melanoma and the most challenging area it can spread to is the brain. With the advancements being made in cancer treatment, the odds of survival for many of these patients are changing dramatically.

In recent years, our understanding of cancer biology has progressed substantially and this has led to the development of targeted therapies and immunotherapies. These novel therapies have prolonged survival in a disease which previously had a dismal outcome. As patients are living longer due to more effective systemic therapy, surveillance and management of intracranial disease is of increasing importance.

AS: There are many standard therapies approved to treat melanoma, and as indicated earlier, there’s lots of research activity in this area as well. Patients benefit from the wealth of approved therapies on the market. But while about 30-40 percent of patients will respond very well to these therapies, the majority still struggle and succumb to their disease. Patients who don’t respond to the first line of treatment must move on to a second line of treatment. Once those treatment options are exhausted, the only course of action is to try and get the patient enrolled in an investigational therapy trial. In many cases, the patient would benefit from earlier involvement in clinical trials.

Early and Current Inspirations

RWHC: What initially interested you in researching melanoma and treating people with the disease? What continues to inspire you?

AS: I became interested in the interplay between cancer and the immune system in my first job as a data manager at the Dana-Farber Cancer Institute, where I managed one of the first clinical trials of ipilumumab, which was later FDA approved with the distinction of being the first drug that prolonged survival in melanoma. I was inspired by researchers who were on the forefront of personalizing medicine by using the immune system to attack cancer cells. Ever since then, in both my research and clinical practice, I haven’t found any better ally in the fight against cancer than retraining the immune system to attack cancer cells.

SG: Throughout my career, I have been inspired by the cancer patients I treat.  The relationships that I have developed with patients and their families are unlike those in almost any other medical specialty. Once a patient has a diagnosis of cancer, I am able to see the patient and his or her family members on a regular basis and develop a long-lasting relationship with them.

Fighting Melanoma with Immunotherapy

For this week’s post in our series on melanoma melanoma, Real World Health Care interviewed Kelly M. McMasters, MD, PhD. Dr. McMasters serves as the director of the Multidisciplinary Melanoma Clinic at the University of Louisville’s James Graham Brown Cancer Center. Here, he works with colleagues to identify the most … (read full article)

Harnessing the Immune System to Treat Melanoma

Real World Health Care continues our series on melanoma with a discussion with Howard Kaufman, MD, FACS, surgical oncologist at Rutgers Cancer Institute of New Jersey. Dr. Kaufman’s clinical and research work focuses on using the immune system to fight cancer. He also runs a scientific laboratory focusing on oncolytic … (read full article)

Profiling Melanoma to Predict Immune Therapy Success

May is Melanoma awareness month, and our series on melanoma continues with a discussion with Dr. Douglas B. Johnson of the Vanderbilt-Ingram Cancer Center. Dr. Johnson leads Vanderbilt’s melanoma clinical and research program, overseeing clinical trials, patient care and translational research. His research interests focus on developing new immune and … (read full article)

Accelerating Melanoma Research

It’s Melanoma Awareness Month and this week, Real World Health Care is pleased to shine a light on The Society for Melanoma Research. We spoke with the Society’s President, Keith Flaherty, MD. In addition to his role with SMR, Dr. Flaherty serves as director of the Henri & Belinda Termeer … (read full article)

Categories: General, Melanoma

Skin Cancer Awareness and Prevention Efforts in Focus at American Academy of Dermatology

This week, Real World Health Care continues our recognition of May’s Melanoma and Skin Cancer Awareness Month by highlighting the work of the American Academy of Dermatology. We spoke with the AAD’s new President, Henry W. Lim, MD, about the organization’s mission and some of the challenges and opportunities associated … (read full article)

Categories: General, Melanoma

The Mechanics of Melanoma

May is Melanoma Awareness Month. This article originally appeared in the Biotech Primer WEEKLY. For more on the science behind the headlines, subscribe.  Melanoma 101  Melanoma accounts for less than one percent of skin cancer cases, yet accounts for the vast majority of skin cancer deaths (skincancer.org). If detected early … (read full article)

Categories: General, Melanoma

New Real World Health Care Series: Melanoma Research and Treatment

“Have you heard from mom and dad recently?” My sister’s question caught me off-guard.  Without realizing it, I hadn’t actually heard from my parents in a while.  She had already asked my brother the same question and he reported not hearing from them lately either.  With no imminent trips back … (read full article)

Categories: General, Melanoma

APS Calls for Pain Management Funding

Real World Health Care concludes its series on pain management with an interview with David Williams, PhD, president of the American Pain Society (APS). Dr. Williams is Professor of Anesthesiology, Medicine (Rheumatology), Psychiatry and Psychology at the University of Michigan, where he also serves as the Associate Director of the … (read full article)

Challenges in Pain Management for MS Patients

This week, Real World Health Care interviews Theodore R. (Ted) Brown, MD, MPH, about pain management in patients with Multiple Sclerosis (MS). Dr. Brown is director of neuro-rehabilitation at the EvergreenHealth Multiple Sclerosis Center, which cares for about 800 patients. His clinical duties include managing patients with established MS through … (read full article)