Melanoma

New drugs aid in the fight against melanoma, the deadliest skin cancer

 

Doctors are optimistic that new drug combos can treat Stage 4 melanoma patients when surgery is no longer an option.

Avoiding melanoma

The new drugs, solo and in combos, are exciting to researchers but, better yet, people should avoid getting skin cancer in the first place. “I’m excited about Stage 4 treatments but if I don’t see it ever again I would be a happy man,” said Dr. Atif Hussein, a hematology expert at Memorial Regional Hospital in Hollywood.

Skin cancers include basal cell and squamous cell, both most often the result of sun exposure and indoor tanning booths, the latter of which is estimated to cause about 419,000 cases of skin cancer yearly.

Basal cell affects the top layer of the skin and is the most common form of skin cancer. Basal cell usually appears on the face, back or chest, is pearly in appearance and can bleed. A dermatologist can remove the bumps.

Squamous cell appears as a rough, scaly surface on the upper layers of the skin on damaged areas like the face, head, back and arms. These cancers tend to impact fair-haired, light-skinned people and those with freckles are at particular risk.

Melanoma, however, can spread to internal organs like the lymph nodes, lungs, brain and retinas of the eyes. Melanoma can appear as lesions in the pigment, or moles in shades of tan, brown, black, red, white or blue and can also result from family history and can target all skin types and ethnic backgrounds.

“Use common sense,” Hussein said. “We are blessed with the sun but a lot of anything is not good and moderation is the rule and responsible behavior. Treatment early is the best treatment for any cancer, especially melanoma. We need to educate people in this community. We are lucky to be here but with luck comes responsibility.”

Prevention

Use sunscreen liberally on all exposed areas, before and after swimming, even if the product claims to be “waterproof.” Sun protection factors (SPF) or 15 to 30 are fine, anything greater than that is marketing. Skin damage is cumulative so children, especially, should be protected to ward off the development of skin cancer later in life.

“We should be doing more early intervention,” said Dr. José Lutzky of Mount Sinai Medical Center in Miami Beach. Lutzky urges schools to introduce sun-smart behavior. Students engaged in outdoor classes should be provided with sunscreens and hats.

Annual skin exams “is a part of caring for people, especially in South Florida,” Hussein said. See a dermatologist.

Get vitamin D, essential for bone health, from your food or supplements, rather than sunlight. Examples include Omega-3-rich fish like wild salmon, tuna, mackerel. Also egg yolks, fortified milk. Sunlight provides vitamin D but people often overdo the exposure so it’s smarter to opt for the healthy foods.

Avoid tanning booths, especially if you are a minor. The lamps emit ultraviolet rays, and these can lead to melanoma.

Detection: Seek medical attention if a blemish exhibits the ABCD warning signs, suggests the American Cancer Society and American Melanoma Foundation: A. Asymmetical shape. B. Border irregularity, including ragged, blurred or notched edges. C. Color variability, which can be shades of tan, brown, black, red, white or blue. D. Diameter of the mole or lesion is larger than 6 millimeters, although some melanomas can be smaller.

HOWARD COHEN


hcohen@MiamiHerald.com

The future is so bright, you’ll have to wear shades.

Timbuk3’s old song’s title is the message from health care professionals who are charged with treating melanoma, a particularly problematic form of skin cancer that, when metastasized, is projected to kill nearly 10,000 people in the States in 2014, according to the National Cancer Institute. More than 76,000 cases will be diagnosed in 2014.

Grim, yes. But you can avoid skin cancers by simple preventative measures like limiting sun exposure with clothing, shades and sunscreens. Also, new drugs have been used in clinical research trials at Mount Sinai Medical Center in Miami Beach and Memorial Healthcare System in Hollywood, as well as other locations nationwide.

“It’s not just exciting but probably the most exciting time ever in the treatment of melanoma,” said Dr. José Lutzky, director of the melanoma program and chair of the Cancer Research Committee at Mount Sinai. “Melanoma used to be called the disease that gave cancer a bad name. It was so dreadful and now it has become a new paradigm to treat cancer. A lot of new immunology has been learned in the last few years.”

The newer drugs include Ipilimumab (aka Yervoy) that target a protein that suppresses the T-cell immune response that feeds melanoma cells. Nivolumab and Lambrolizumab are among the newest drugs; they recognize melanoma cells and attack them.

Another new treatment is Vemurafenib, which targets a mutation in a gene called BRAF that helps melanoma cells grow. Drugs that target the BRAF protein, which also includes Dabrafenib and Trametinib that target related proteins, can, in combination, shrink tumors. “They team-up to kill the cancer cell,” said Dr. Atif Hussein, medical director of the Memorial Cancer Institute at Memorial Healthcare System.

“We have done a lot of studies in the last three years, and there have been two main drugs that have improved the outcome of patients with advanced melanoma,” he said. “The first one is targeting a mutated BRAF, a gene present in every cell. But in half the patients with melanoma this gene is turned on all the time. And this gene tells the cancer cells to keep on growing and multiplying. We have a drug that targets that gene and it works amazingly well as an oral agent. Vemurafenib is the first drug. Since that time, another drug was approved and targets the same BRAF. Dabrafenib is the other.”

With these drugs, patients with advanced disease, or Stage 4, are living longer with real hope for long-term survival, experts say. Those who catch melanoma in its earliest stage will usually opt for surgery to scoop the cancer out and, in most cases, the patient can resume a normal life.

The new drugs for Stage 4 patients may also be viable in fighting other cancers, Lutzky said.

“We’re seeing interesting responses not only in melanoma but in lung cancer responses, and in kidney cancers. The same PD-1 pathway seems to be important in not only melanoma but in other solid tumors. And that research started in melanoma,” Lutzky said.

Patina Santo is an example.

Santo, 40, a Delray Beach Police intelligence analyst, was referred to Lutzky for clinical trials of Nivolumab and Lambrolizumab to block the PD-1 and PDL-1 proteins. Santo, a fair-skinned redhead who grew up in Alabama, was first diagnosed with skin cancer in 2006.

“When I was a kid, I never wore sunscreen. I sunburned a lot. And as a teen, I did the tanning bed thing. The combination of all of that was the perfect cocktail to get melanoma. I didn’t think about that stuff when I was a teen. Hopefully, now people are starting to think about it more,” she said.

By 2011, Santo began to notice vision problems — dots and flashes before her eyes. An ophthalmologist found nothing wrong with her eyes. A primary care doctor figured her problem could be migraine-related but sent her for an MRI, and that test detected a golf-ball sized tumor in her brain. “A shock,” she says.

Santo had surgery and was treated with Yervoy, which had just received approval. The drug leeched the red out of her hair, she said. But by 2013 the cancer reappeared in her lungs and two spots on her shoulder. This is when she began seeing Lutzky, who ushered her into the clinical trial.

“She’s doing great, very little disease left,” Lutzky said.

Santo goes for treatment every two weeks, which amounts to an infusion of the two drugs.

“I credited him with my having a 40th birthday,” she said. “I started the trial about a year ago, and I really had no side effects other than being tired. I had tumors on my lungs and they have virtually disappeared. I also have one on my right shoulder, which is smaller, but still here. Without these trials, I’d probably be dead. I try not to focus on negatives, but when I was first diagnosed, I went to Google, and the average life span with Stage 4 was 10 months. I had ‘Patina’s Not Dead Party’ once I hit 10 months.”

“The future is very bright,” said Hussein. “These drugs are called checkpoint inhibitors, and these are amazing drugs. They are still in clinical research, but I’m sure they will be approved very soon. My gut feeling is they will add a new dimension to treating patients with the most advanced deadly skin cancer we call melanoma.”

Follow @HowardCohen on Twitter.

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