Transcription:
Improving Survival Outcomes for Melanoma Patients

Melanie Cole (Host):  According to the American Cancer Society, rates of melanoma have been rising rapidly over the past few decades with an estimated 96,000 cases diagnosed in 2019 alone. Joining me today is my guest Dr. Jeffrey Wayne. He’s the Chief of Surgical Oncology at Northwestern Medicine and the Associate Director for Clinical Affairs at the Robert H. Lurie Comprehensive Cancer Center at Northwestern University. Dr. Wayne is here today to share the latest advances and treatment of melanoma and Northwestern Medicine’s approach to comprehensive melanoma treatment. Welcome Dr. Wayne. It’s such a pleasure to have you with us. As we mentioned, melanoma incidence is on the rise. Can you tell us why this is the case?

Jeffrey Wayne, MD, FACS (Guest):  Absolutely. In fact, the incidence of melanoma has actually increased about 15 times in the past 40 years. and it’s interesting if you look across the world, we’ve seen a similar increase both in this country and for instance say over in the United Kingdom. This tends to be a disease of lighter skinned individuals who have less melanin in their skin, the pigmented element of the skin that protects us from UV rays, so the rays from the sun and other sources.

And so patients who have had more UV exposure are more likely to get melanoma and that’s one of the areas we would focus on as a cause for the rising incidence of melanoma. And so if you look across the world, the incidence actually increases with decreasing latitudes. So, in other words, the closer you get to the equator, the higher the incidence of melanoma becomes and so Australia for instance, has one of the highest incidences of melanoma in the world. And there’s other things that have been postulated for instance, are we simply detecting more cases, we are doing better screening for these cases. And if you look across those increasing number of cases that you quoted earlier; we actually are seeing not just a rise in the early stage cases, so in other words if you were just doing better screening; you might see an increased number of early cases of melanoma, but we are actually seeing an increase in cases across the spectrum of melanoma from very early stage cases to metastatic cases.

So, it’s an interesting phenomenon but it seems to be linked to UV exposure both from the sun and from tanning beds. And it also probably has a little something to do with the aging nature of our population. In other words, probably one of the strongest risk factors for any cancer is increased age. So, I think as out population ages; we are going to see more and more cancer in general but certainly skin cancers in particular.

Host:  What interesting points you brought up Dr. Wayne. So, since we know that early detection plays a critical role in improving survival rates; how does your team approach screening and how is it identified?

Dr. Wayne:  Great question. I think it’s an issue that really has fallen to a lot of the dermatologists, in other words, people who know they have a family history of skin cancer or have a personal history of skin cancer, well they are usually are seeing a dermatologist and getting screened regularly. But I think something we preach to all of our patients is that first of all, once you have melanoma, not only are you at increased risk for a melanoma but your first degree relatives now have a first degree relative with melanoma and so they should probably be screened regularly.

The other thing I think that we like to promote is that from my perspective, screening someone’s skin should be just like screening for any other disease and so I’d love to see a focused effort on getting primary care physicians trained to do a simple skin screening on all their patients and have that become part of their practice as they see patients for their yearly physicals. And if they do a quite skin screening and something is noted to be abnormal; then that patient can be referred on hopefully in an early fashion to a dermatologist and then on to appropriate treatment from there once the diagnosis is secured.

Host:  So, why is it considered a multidisciplinary team approach and why is this important for something people might think is a skin cancer?

Dr. Wayne:  That’s a great question. The way we view melanoma, keeping in mind that you might be talking about a very early melanoma which certainly could be handled in a dermatologist’s office but for the more serious cases of melanoma; and melanoma is a disease that unlike some of the other more common skin cancers, basal cell cancer, squamous cell cancer; melanoma can spread to other organs and spread to lymph nodes so it’s really important that we identify which patients are at high risk and need to have additional perhaps surgical procedures such as a sentinel lymph node biopsy and additional treatments such as immunotherapies or targeted therapies that we might give after surgery to lower their risk of this coming back in other places.

In other words, to cure people; we need a multidisciplinary approach that involves not only a dermatologist, but perhaps most importantly a good dermatopathologist who will read their slides. In other words a pathologist who is an expert in skin cancers and then surgical oncologists to do some of the complex procedures that we just mentioned. And then medical oncologists to administer those therapies that might be necessary after even a successful surgery or in cases where surgery is not possible.

So, it’s a group approach. We all bring something to the table but by managing our patients in a multidisciplinary fashion; often through our multidisciplinary melanoma patient management conference where we present patients and develop individualized treatment plans; we are able to render the best possible care for our patients.

Host:  Certainly. So important. So, tell us about some of the latest advances in melanoma treatment Dr. Wayne, immunotherapy. You mentioned targeted therapy. Tell us a little bit about what’s going on.

Dr. Wayne:  Yeah, it’s really an exciting time to be a physician that treats melanoma. For many, many years; we didn’t have good medical therapies for our patients. So, in other words, they either had a successful surgery and lived or they had a surgery sometimes and then didn’t do so well. Lately, there’s been an incredible boon in the number of therapies that are available to patients with melanoma. So, first of all, we have immunotherapies. In other words, we know that the immune system interacts with skin cancer and can often fight skin cancer and that’s why we see increased numbers od skin cancers in patients who are immunosuppressed. In other words, patients who are elderly, or patients who say have had an organ transplant or are on medications that decreases their immune system.

So, what these immunotherapies which are often called check point inhibitors do is they essentially unleash the immune system to attack the cancer cells. And now a number of these treatments were developed for melanoma and are now used in a variety of different cancers. So, that’s one of the new and exciting treatments that we have. The other one that you mentioned, targeted therapies attack specific genetic mutations that we see that cause the melanoma. So, in other words, think of these as light switches that get turned on and then can’t be turned off and they drive the progression and development of melanoma.

These targeted therapies can go in and shut off those genetic switches and oftentimes makes these melanomas regress markedly and then it’s often not a lasting effect, but it allows us to then intervene surgically or then move on to other therapies that give the patient a more durable control or perhaps even a cure. So, it’s interesting in 2019, we are actually talking about curing some patients. In other words, having patients who live longer than five years after a diagnosis of even metastatic melanoma and that’s incredibly exciting and something that just wasn’t even feasible say five or six years ago.

Host:  Wow. Isn’t that amazing? As you say, what an exciting time to be in this field. Do you have any research, new research that you are working on that you’d like other providers to know about?

Dr. Wayne:  Yeah, we actually, you know as I mentioned, the way these therapies come to clinical use is through what we call clinical trials and so we have a number of exciting new clinical trials that are open in cooperation with some of the big clinical groups around the country that we partner with to do these studies. One is a trial using the immunotherapy in patients with high risk disease which has either spread to the lymph nodes or to other organs and we give it to patients in preparation for surgery. So, in other words, the patient may be a candidate to have that disease taken out, but it would be a large complex surgery. In this trial, half of the patients in the trial actually get the immune therapy first and then are taken to the operating room after that.

And what we are seeing is we are seeing complete responses in some patients. We are certainly seeing surgeries that are able to be done with less difficulty than if the patient went to surgery up front and we need to obviously approve enough patients into that trial to see if that’s an effective strategy. That’s a called the neoadjuvant treatment strategy. In other words, doing the chemotherapy or the immunotherapy in this case, before a planned surgery.

The next trial I’d love to talk to you about is called the Keynote trial, the Keynote 716 trial and that’s giving the immunotherapy to patients with high risk stage two disease, so in other words, patients who wouldn’t normally get any therapy after their surgery; they would just be followed for recurrence. Well we know that a significant proportion of those patients will actually then go on to develop metastatic disease. So, in this trial, we are randomizing the patients, in other words, taking half the group and giving them just a placebo and the other half are actually getting the immunotherapy and we are going to see if this has an effect of decreasing the number of patients who go on to develop that metastatic disease. So, those are two really exciting trials that we are doing.

We are also doing work in developing a melanoma tissue bank with three other partners in this country, the Knight Cancer Center out at Oregon Health Sciences University and the California Pacific Medical Center through a grant through AIM which is a patient advocacy group for melanoma patients. We’re hoping to get up and running a group of four institutions which will collect primary melanoma tissue and bank it so that additional research can be done from researchers all over the world and we have a repository of that tissue linked to clinical information so we can know which are the high risk tumors and which are lower risk tumors and if we can target certain tumors with certain of these new treatment agents and keep things in the pipeline and hopefully continue to better the care of our patients.

Host:  Absolutely fascinating Dr. Wayne. What would you like other providers as we wrap up to know about screening and treatment for melanoma and when you feel it’s important for them to refer to the specialists at Northwestern Medicine?

Dr. Wayne: I think melanoma is a sufficiently rare disease and the treatments are changing every day such that I think patients especially with complex melanoma cases; are really best handled by institutions like Northwestern Medicine that have complete melanoma care teams that can really bring the patient the best of all the different treatment modalities we have for them, specialized surgery, specialized personalized medical approaches and long term follow up in a dedicated pigmented lesion clinic to pick up additional lesions down the line in an early fashion.

Host:  Wow, what an informative segment. That was great. Thank you so much Dr. Wayne for joining us and sharing your expertise and telling us about the exciting advances in melanoma treatment. That wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer a patient or for more information on the latest advances in medicine please visit www.nm.org to get connected with one of our providers. If you found this podcast as informative as I did, please share on your social media, share with your friends and family and be sure to check out all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole.