Recurrence — wait-and-see or Opdivo?

Hi Patrick,

I was diagnosed with stage 3a in 2014, did interferon for a year, NED until 7/2017 with in transit reoccurence, just did surgery and watch and see until 12/2017 but another in transit popped up. Had surgery to remove it and started Keytruda in 1/2018, CT scan in 3/2018 showed liver lesions and 1 lesion in my lung.  Stopped Keytruda and tried taf/mek for a few weeks, but could not tolerate the side effects.  Now I have another in transit again as of last week. Dr appt this Thursday to see what is next.  That is my situation, hopefully yours will be NED from here on out.  I probably would have done Keytruda after the first in transit if it was offered, but it was not at that time.  I think adjuvant Opdivo or Keytruda is having some impressive results from what I have read, but others here are much more knowledgable and will give you some great advise.  Best wishes to you for continued good health.

Vince

Not really in your shoes exactly. 3B last year. "Best results with lower tumor burden" is a phrase that burned into my brain. When is that? Probably as early as possible. Release the pac-men before there are too many pre-tumor ghosts to eat.

After a year of Opdivo treatment my thoughts are basically 1) very glad I did it, 2) hope it works, 3) if it doesn't work, I will be far better off for knowing that I am a "non-responder".  Being a PD-1 non-responder is not the end of the road upon re-occurance.

Remember adverse selection on side-effect reports. I wouldn't ordinarily come here to report to tell you I had virtually none. So if you had no side effects, WITF would you not take the meds?

I loved my surgical onc. But he was not up to date on melanoma treatment based on the standards of knowledge in this layperson's forum. Perhaps yours has a more POV to share. Get treatment seems like the rebuttable presumption, this is not a jump ball question (w/ watch/wait) anymore.

Just my opinion.

Hi Patrick, the data has been coming in fast and furious in the adjuvant setting with many new options opening up that are showing great # when it comes to recurrence free survival. You have Nivo, Pembro and targeted therapies as well as combination Ipi+Nivo in trial and may be soon available as well. Watching and waiting has become a thing of the past with these great options. Here are a couple of link of articles talking about adjuvant treatments. Best Wishes!!!Ed https://www.onclive.com/publications/oncology-live/2018/vol-19-no-3/focus-moves-to-earlier-settings-in-melanoma?p=1     https://www.onclive.com/publications/oncology-live/2017/vol-18-no-20/new-adjuvant-therapy-era-builds-in-melanoma

Sounds all to familiar.  I had a primary removed that was .9 with no lymph node biopsy.  14 years later (This March) I end up with a swollen lymph node.  The biopsy on the lymph tested positive for melanoma (3c).  Had all of my axillary nodes removed and 5 of those tested positive.  Nothing was ulcerated and they referred to this as regional.  In my discussion with my onco, watch and wait was never discussed.  In fact we went right to the discussion on treatments available today that 14 years ago would not have been available.  His recommendation was Opdivo for one year.  These little cancer buggers can float around along time (even 14 years).  I'm not a medical professional but I think I would go for the Opdivo.  If your medically NED, now would be a great time to do "mop up".  Oh, and if I was 42, I'd say lets wrap this up and get on with life.

Have you seen those memes….Don't be like_______________, be like____________!?  Well, there you go.  In 2003 at age 39…melanoma to right back…positive node to right axillae….Stage 3B.  No options other than interferon…which is no option.  2007, second melanoma primary to left arm, all nodes negative this time.  Still no treatment…because there was none.  2010 lung and brain mets.  Surgery to lung.  Radiation to brain.  Lucky to get in nivolumab (Opdivo….called MDX1106 back in the day) trial for 2 1/2 years.  Last dose in June of 2013.  Still NED (no evidence of disease).  So….

Don't be like Celeste without treatment and disease progression!  BE like Celeste once Opdivo was an option…and stay NED!!!  This primer might help you become acquainted with treatment options and the vernacular:

  http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2017/08/melanoma-intel-primer-for-current.html  

I wish you my best.  Celeste

I am also stage 3C after surgeries and radiation.  After 10 doses of Nivo I developed AE's only a fraction of patients deal with including myocarditis, type 1 diabetes, and colitis.  To me it is a small price to pay for being NED and I would not hesitate to take it again.  The chance of recurrence is a much greater risk than life altering AE's.  

My 17 year old son was just fully diagnosed at Stage 3a…he will be starting Opdivo next week.  Wait and watch is just not an option we are willing to take. Our surgical oncologist and the medical oncologist both told me of it were their child they would do the medication….and as a nurse I definitely agree!!!! So many people have positive results from the Opdivo, the benefits of the medication outweigh the risks at this point. All it takes is one melanoma cell to get away and hide somewhere else in your body only to pop back up somewhere else in a worse case scenario…..once the treatment was approved it was an easy decision for us to make. So Opdivo here we come!!!!   Good luck!!!!! 

Hi Patrick,  

I have Stage 4 Met/Mel with a current re-occurance, surgically removed,  after 3 1/2 years of remission.  My doc ordered genetic testing from ,"Caris Life Sciences, " covered by insurance, to see which drugs might best work for me.  Much to my surprise I had 0% of PD-L1… which in my understanding means that for me, Opdivo and Keytruda would not work as I do not posess the mutation that it uses. t Wishing you all the best.  Ann

Hi Annalive, you might want to take a look at Onclive presentation from last June that discuss the topic of biomarkers and tests run on patients to inform treatment options for melanoma. The advice that you are giving is not accurate based on current medical research on the topic. Here are two presentation by Melanoma expert panels on the topic of biomarkers. The second link is on topic for the first couple of minutes then it goes into other ideas. https://www.youtube.com/watch?v=HvB8cZj_qeI            https://www.youtube.com/watch?v=KhV1Zyi6r8E

In addition to getting on immunotherapy, please consider seeing a different oncologist. What your oncologist said about preferring to watch-and-wait does not sound like a melanoma specialist. Another thing to consider is that even though your current oncologist can get you immunotherapy medications, their inexperience with patients on immunotherapy will put you at risk if side effects occur because the on oncologist won’t know the real world early signs of side effects. Lastly, I’ve heard that insurance will only cover adjuvant immunotherapy if it is started within 3 months of surgical resection, so watch your timeline. All the best and hoping for recurrence-free survival for you.