Immunotherapy for the melanoma patient with an autoimmune disease

In the past few years, advances in melanoma treatment have generated a flurry of activity, and much of that activity has focused on immunotherapy. From vaccines to checkpoint inhibitors to T-cell therapy, these strategies involve harnessing the body's immune system to kill cancer cells, and it has been used in a variety of other cancers, from lung to bladder to kidney cancer. But is immunotherapy appropriate for the patient with an autoimmune disease? Recently, two melanoma researchers at MD Anderson Cancer Center in Houston addressed that point during an OMEDLive webinar hosted by the Albert Einstein College of Medicine at Yeshiva University in New York. "We often have these kinds of patients that come in and have other diseases, such as autoimmune diseases, where the immune system is already attacking the body," said Patrick Hwu, chair and professor at MD Anderson's Department of Melanoma Medical Oncology, who co-hosted the webinar with Sapna Patel, an assistant professor. These diseases include, among others, psoriatic arthritis and ulcerative pancolitis, both of which might require medications that suppress the immune system. In some cases, either immunotherapy is ineffective because of the immune-suppressing drugs, or it can exacerbate a condition, like in the case of ulcerative pancolitis. "The issue is whether you would withhold immunotherapy from somebody who has an essentially life-threatening melanoma simply because they have an underlying autoimmune disease," explained Patel. "However, it is also the idea that if you're stimulating the immune system, and someone is on therapy that may be blocking the immune system, how effective will that be, or are you setting them up for toxicity?" In addition, transplant patients on anti-rejection medication might not be good candidates for immunotherapy, as those therapies might enhance the possibility of organ rejection.With this in mind, what are the options for melanoma patients who must take immune-suppressing drugs? "You first go looking for actionable mutations in that patient," explained Patel. "Maybe there is a way to treat them outside of using immunotherapy." Some targeted therapies, such as BRAF inhibitors and MEK inhibitors, are showing promise in treating melanomas with certain mutations. She added that chemotherapy might still be an option as well. "But also you have to have a really important discussion with the patient if they have a very aggressive melanoma that could be terminal if it's untreated and unchecked, and yet they have this underlying autoimmune disease," said Patel, regarding determining the risks and benefits of immunotherapy. "If your back is up against the wall, you may have to bite the bullet."For the full presentation, click here.