Immunotherapy for skin cancers such as melanoma

The goal is to arm a patient's immune system to destroy cancer cells. Cancer has managed to put the brakes on the lymphocytes (a type of white blood cells that are the soldiers of the immune system) in order to become invisible. Immunotherapy will remove these brakes so that the immune system can destroy the cancer again. All patients with cutaneous melanoma can receive this treatment.

There are two types of immunotherapy:

• Anti-PD1 antibodies (pembrolizumab and nivolumab): These drugs are administered intravenously every 2 or 3 weeks (KeytrudaÒ, OpdivoÒ). They will mask the brake present on the patient's lymphocytes.
• Anti-CTLA4 antibodies (ipilimumab): These drugs are also administered intravenously every 3 weeks (YervoyÒ). They will mask another brake present on the lymphocytes. They can sometimes be combined with nivolumab.

Even when melanoma has migrated to the lymph nodes, the surgeon can remove the cancer completely if there are no distant metastases. However, there is a risk that metastases will recur. Immunotherapy significantly reduces this risk. This is called adjuvant treatment. It is a curative treatment, since it has been shown to greatly reduce the risk of dying from melanoma.

If there are unfortunately distant metastases, immunotherapy can stabilize the disease or even induce a regression of the disease. In some patients, this regression can be substantial or even complete and last for several years.

All these treatments are carried out on an outpatient basis. They are administered intravenously every 2 or 3 weeks at the day hospital or Ambulatory Treatment Center (ATC). The infusion lasts a few hours.

When administered for preventing recurrence, immunotherapy is an adjuvant treatment. Anti-PD1 antibodies are then given for one year.

If there are metastases, the treatment is administered as long as there is a benefit for the patient. Check-ups are performed every 3 months to measure treatment effectiveness. If the patient has a complete response, i.e. the disease has totally disappeared, treatment can be stopped after 2 years.

As soon as you have been diagnosed with your illness, it is crucial that you discuss with your doctor whether this treatment is the most appropriate for your situation. There is no special test to do. Anyone can receive this treatment.

You will be admitted to the ATC or Oncology Day Hospital. An infusion will be placed and we will check that there are no contraindications to receiving the treatment by looking at your blood results, examining you, and especially asking you about your tolerance to the treatment. If all the lights are green, then the medication will be prepared by the pharmacy and the infusion will last 90 minutes. Afterwards, you can return home.

When treatment ends, there are no special procedures. Attention must be paid to autoimmune complications during the 3 months following cessation of treatment.

Immunotherapy is better tolerated than chemotherapy. It is a constraining treatment because you have to come every 2 or 3 weeks to the clinic to receive this treatment for a long period of time, since it is planned for the long course.

Some people complain of fatigue related to the administration of these drugs. A small number of patients may present autoimmune complications, at times severe and even fatal, if not managed quickly. 

The complications of these drugs are of autoimmune nature and related to their mode of action. Indeed, the purpose of these antibodies is to remove the brakes present on the lymphocytes. It is impossible to select only anti-cancer lymphocytes. 

These complications are rare with anti-PD1 antibodies, more frequent with anti-CTLA4 antibodies, and very common if anti-PD1 and CTLA4 antibodies are combined.

The most frequent complications affect the skin, colon, endocrine glands (thyroid), lungs, and liver. More rarely, other organs in your body may be affected. It is important to report any changes in your condition to your health care team. Complications most often occur during the first 3 months of treatment, sometimes even later, or within 3 months of stopping the medication.

Patients who have received a transplant (kidney, heart, liver) cannot receive this type of treatment because there is a risk of rejection of their transplanted organ.

People with autoimmune diseases are likely to see their disease worsen because of these drugs that stimulate the immune system. A discussion should take place between you, the doctor who is treating you for your autoimmune disease, and your oncologist to make sure that these medications can be given safely.

For more information or to make an appointment, please contact the oncology care coordinators of the Melanoma Clinic at +32 2 764 35 16.