Systemic (full body) treatment
Systemic therapies can be divided into two groups; those that are given in addition to the primary treatment to help increase the patient’s chances of survival (adjuvant) and those that are used to improve symptoms (palliative) or control the tumours (curative intent) once the cancer has spread.
There are currently no chemotherapy drugs suitable for use in an adjuvant setting for uveal melanoma.
Traditionally Dacarbazine (or DTIC) given as an IV infusion has been used to treat uveal melanoma that has spread from the eye to other parts of the body. Unfortunately, studies suggest that only 8% of patients will respond to this treatment, but that the effect is generally not prolonged and it is not considered to have any overall survival benefit.
Immunotherapy is an emerging area of cancer research. We do not yet know the benefits in patients with uveal melanoma. Further research is required.
Treatment uses parts of the patient’s own immune system to fight the cancer, either by stimulating the immune system to work more effectively, or by adding engineered components.
If you take immunotherapy drugs you should also be aware of the potentially lethal side effects, although with close supervision from your medical/clinical oncologist, and being aware yourself of the issues, these are generally well managed.
Ipilimumab (brand name “Yervoy”) is available on the NHS, through your medical/clinical oncologist. The treatment works by stimulating the body’s own immune system. It is a form of Anti-CTLA-4.
CTLA-4 is a molecule found on the surface of the T-Cells in the immune system. CTLA-4 is responsible for “switching off” the T-Cells’ response to avoid the immune system over-working and causing autoimmune disease. Ipilimumab reverses this process, forcing the T-Cells to remain “on” to fight the cancer.
Ipilimumab’s effectiveness in uveal melanoma is not fully clear. Early studies suggest that it may not have the same level of response rate in uveal melanoma as it does in cutaneous melanoma (skin cancer), however, it could be responsible for longer term survival in some patients.
It is of note that many of the patients involved in the studies and trials, have untreated and advanced liver disease. It is unknown what effect pre-treating the liver with a regional therapy would have had on those results.
PEMBROLIZUMAB AND NIVOLUMAB
Pembrolizumab (brand name “Keytruda”) and Nivolumab (brand name “Opdivo”) are both Anti-PD-1 drugs.
PD-1 is a protein found on the surface of a tumour cell that, along with PD-L1, protects tumour cells from being destroyed by the immune system. Anti-PD-1 blocks this action, allowing the immune system to attack the tumour cells.
Pembrolizumab is currently available on the NHS in England for patients who have already had Ipilumumab. This may be different in other areas of the UK. Nivolumab is currently available on the NHS in England as a “first-line” treatment (i.e. no pre-treatment required). This is a fast moving area with with new treatments availability and recommendations changing frequently. Your medical/clinical oncologist will be able to give you the most up-to-date information.
The National Institute for Health and Care Excellence (NICE) are continually monitoring these relatively new drugs. In particular, doctors are looking at combining Pembrolizumab with Ipilimumab, a combination which has shown promise in cutaneous melanoma (skin cancer).