Philip R. Cohen, MD
Dr. Cohen is from the University of Houston Health Center, Texas; the Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston; and the Department of Dermatology, University of Texas Medical School, Houston.
Dr. Cohen reports no conflicts of interest in relation to this post.
The February 2012 issue of the New England Journal of Medicine (2012;366:707-714) featured an original article that presented the results of a multicenter phase 2 clinical trial of vemurafenib (N=132). More than 50% of patients with previously treated BRAF V600–mutant metastatic melanoma achieved vemurafenib-induced clinical responses. In addition, the investigators demonstrated that the median overall survival was approximately 16 months.
What’s the issue?
As physicians, do we want to be reactive or proactive? Do we want to chase melanoma or cure cancer? I predict that the treatment of cancer will be revolutionized within the next decade, if not sooner. It will eventually become the standard of care for all newly diagnosed oncology patients to have comprehensive genomic analysis of their cancer to determine its molecular subtype, followed by the initiation of targeted therapy based on these results as first-line treatment; this regimen will not only be for patients with newly discovered melanomas but also for all individuals diagnosed with either a solid tumor or a hematologic malignancy. Vemurafenib is currently used in patients with BRAF V600–mutant metastatic melanoma. Why should physicians wait until the patient’s melanoma has metastasized before initiating this therapy in patients with BRAF V600–mutant melanoma? First, perhaps all melanomas, regardless of depth, should be evaluated for BRAF V600 mutation. Second, perhaps trials should be designed to treat all patients with BRAF V600–mutant melanoma, including those with sentinel lymph nodes that are negative for melanoma, with vemurafenib for 3, 6, or possibly 12 months. If you had a patient with a BRAF V600–mutant melanoma of 1.75-mm depth and absence of melanoma in the sentinel lymph node, would you consider advocating for him/her to receive therapy with vemurafenib? And if you were this patient, would you want to be treated with vemurafenib?