Oral Presentation Australasian Melanoma Conference 2018

What it feels like for an understudied group of survivors- the survivorship experience of patients with metastatic melanoma on long-term immune checkpoint inhibitors and combination BRAF and MEK inhibitors (55275)

Julia Lai-Kwon 1 , Chloe Khoo 1 , Serigne Lo 2 , Donna Milne 3 , Mustafa Mohamed 3 , Jeanette Raleigh 4 , Kortnye Smith 1 , Karolina Lisy 3 , Shahneen Sandhu 1 , Michael Jefford 1 3 5
  1. Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
  2. Melanoma Institute of Australia, University of Sydney, Wollstonecraft, NSW, Australia
  3. Department of Cancer Experiences Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
  4. Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
  5. Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia

Introduction

The prognosis of patients with metastatic melanoma (MM) has improved vastly following the introduction of immune checkpoint inhibitors (ICI) and BRAF and MEK inhibitors (BMi).  This has resulted in an emerging cohort of long-term responders whose survivorship experience remains virtually undescribed.  We characterised the survivorship issues faced by these patients using a cross-sectional survey.

 

Methods

Eligible patients had MM, aged >18, ≥ 6 months post initiation of ICI or BMi, and attained an objective response or stable disease at the time of enrolment. A 72-item questionnaire including items from validated measures and customised questions covering physical and psychological effects, impact on lifestyle, access to information, satisfaction with care, and availability of supports was administered. The impact of treatment status (on/off) and duration on treatment (ICI: <12 vs >12 months; BMi: <24 vs >24 months) was assessed.

 

Main findings

105/ 120 patients [median age 62 years (range 24-88); 60 (57%) male; 83 (79%) on 1st line therapy] responded from August-December 2017.  69 (66%) received ICI, 36 (34%) received BMi.  In the ICI cohort, 39 (56%) were on treatment at the time of study. The main reason for treatment cessation was toxicity (63%); the remainder ceased after a sustained response. In the BMi cohort, 31 (86%) were on treatment.

 

Patients reported experiencing long-term toxicity as a consequence of treatment (ICI: 59%; BMi: 56%). Dry/itchy skin (ICI: 74%; BMi: 69%), arthralgias (ICI: 58%; BMi: 64%) and fatigue (ICI: 90%; BMi: 92%) were reported.  In the ICI cohort, the prevalence and severity of symptoms were similar regardless of treatment status (on vs off) or duration on treatment (£12 or >12 months); for the BMi cohort, physical symptoms were more prevalent and severe in those on treatment for >24 months.

 

Psychological morbidity was significant including concerns about stopping treatment (ICI: 86%; BMi: 94%), long-term side effects (ICI: 74%; BMi: 83%), and anxiety awaiting results (ICI: 72%; BMi: 81%). Patients reported fear of cancer recurrence (FCR) (ICI: 81%; BMi: 86%) and death (ICI: 64%; BMi: 72%). In ICI cohort, FCR was more common in those off treatment than those receiving ongoing treatment (87% vs 77%).  In the BMi cohort, fear of death was more common in those on treatment for >24 months compared to those on treatment for <24 months (86% vs 65%).

 

Patients reported difficulties with domestic tasks (ICI: 52%; BMi: 39%) and recreational activities (ICI: 62%; BMi: 64%). Most patients would value a survivorship care plan (SCP) (ICI: 91%; BMi: 94%) and screening for other malignancies (ICI: 97%; BMi: 95%).

 

Conclusions and implications for the field

Understanding the issues faced by long-term responders is essential to optimise patient care.  Patients may benefit from regular discussions regarding treatment duration and long-term toxicities, tailored psychological support including programs to manage anxiety and fears of recurrence or progression, and a SCP with recommendations for screening for new skin cancers and other malignancies.