Welcome to UAB MedCast, a continuing education podcast for medical
professionals, providing knowledge that is moving medicine forward. Here's
Melanie Cole.

Melanie Cole (Host): The field of melanoma has seen
dramatic advances in the past decade. Clinicians are now able to offer
innovative and effective therapies for patients at all stages of disease.
Welcome to UAB MedCast. I'm Melanie Cole. And joining me today, we have a
panel, Dr. Kristy Broman, she's a surgical oncologist and Assistant Professor;
and Dr. John Dubay, he's a medical oncologist and an Assistant Professor, and
they're both with UAB Medicine and they're here to speak about effective and
exciting therapies for melanoma patients.

Doctors, thank you so much for joining us today. Dr. Broman, I'd
like to start with you. I'd like you to sort of set the stage for us about
melanoma, the prevalence, what you've been seeing in the trends and the scope
of what we're discussing here today.

Dr Kristy Broman: Sure. Thanks for having me. At
its heart, melanoma is a cancer of the melanocytes, which are cells that make
pigment in the skin. Anyone can get it. There are certain factors that place
people at greater risk, including sun exposure, fair skin, and older age.
Because of those things, we are seeing an increase in the incidence of melanoma
over time as our population ages. We also know that melanoma is overall a
deadly cancer. However, as a result of the advances that we've seen, we've
actually seen a pretty dramatic decline in deaths due to melanoma, and our overall
survival rate with this disease has actually improved significantly in the last
decade, and that's largely related to some of the medications and treatments
that we have to offer in the systemic side, which Dr. Dubay will be talking
more about later today.

Melanie Cole (Host): Thank you so much, Dr. Broman.
And Dr. Dubay, I'd like you to just speak to other providers for a minute about
identification because it is such an important aspect of catching this disease
early. Would you please speak just a little bit about the presentation? What
might signal a visit to a surgical oncologist or medical oncologist and really
what other clinicians need to be looking for?

Dr John Dubay: What we typically look for is a
change in people's moles, and this is normally done by a dermatologist. And
they will examine the patient semi-annually or annually, and look for changes
in any moles that they have. The sooner we can get to these types of changes
and have them biopsied, the better the patient is likely to do.

Melanie Cole (Host): Then, Dr. Broman, speak about the
next steps. How do you approach a patient who's recently been diagnosed with
melanoma? Do they visit you first? Do they visit Dr. Dubay first? Tell us a
little bit about the course of action and how you work together.

Dr Kristy Broman: Yeah. So, it depends a little bit
on how they present. If they come in with a suspicious skin lesion that's been
biopsied by their dermatologist, they typically will go to a surgical
oncologist first. The majority of patients will present with cancer that's
localized to the skin, and so they can be cured with surgery alone, hence
seeing a surgical oncologist. And that operation typically involves widely
excising that tumor or that remaining biopsy site to ensure that all of the microscopic
disease has been removed. And then for patients who meet specific criteria, we
also perform a surgical lymph node biopsy that enables us to evaluate for
microscopic spread of cancer to the nodes. And that's essentially spread,
that's too small to detect on any exam or any potential imaging studies that
may have been done. This is all of course after performing a detailed history
and physical to make sure that we haven't identified any evidence of clinical
nodal disease and the patient isn't reporting any symptoms that might suggest
that they already have distant disease. In those situations, it's critical that
we immediately engage our collaborators in medical oncology and then we work
together to formulate a treatment plan.

Melanie Cole (Host): Dr. Dubay, I'd like you to expand
and speak about what that looks like. If it is determined it's not localized
and they've already seen someone like Dr. Broman and that it may have
metastasized, it may be in a different situation than it was, tell us a little
bit about treatment options that are available for patients with cancer that
has spread to the lymph nodes or other organs. So, I'd like you to speak just a
little bit about localized, even though Dr. Broman just was speaking about
that, but take it from there and then speak about advanced disease and the
medical treatment options.

Dr John Dubay: As you mentioned at the
beginning, we really didn't have effective treatment for melanoma up until the
last decade or so. And we have now very effective immunotherapy treatments,
which boost a person's own immune response and directs it to target and kill
the cancer cells. And we also have oral medications that some patients are
eligible for depending on the type of melanoma they have.

Where patients have just had melanoma spread to the lymph nodes,
we typically combine surgery with systemic immunotherapy. And these treatments
can help reduce the chance of the cancer coming back. And for those patients
whose cancer has already spread beyond the skin or lymph nodes to other parts
of the body, which is known as stage IV or metastatic disease, we use similar
types of therapy often in combination. These treatments remain very effective
even when the cancer is advanced and people are now living many years after
being diagnosed with metastatic melanoma.

Dr Kristy Broman: I want to add too, Dr. Dubay,
specifically for those patients that have disease spread to the nodes but not
distant, we've actually had kind of a recent paradigm shift in how we manage
those patients based on a recent study. So, we previously would take those
patients also straight to surgery, resect their primary site and do a complete
lymph node dissection.

But we at UAB recently participated in a trial or retrial doing
new adjuvant immune therapy before going to surgery. And then, we had them
complete a year of adjuvant treatment afterward. And we found that the
recurrence-free survival was improved with that sort of sandwich approach. I
think that's helpful for other providers to know. It's somewhat counterintuitive
for both patients and providers not to go straight to surgery to remove the
evident disease. But we have learned that we can improve oncologic outcomes by
starting with immune therapy and getting a few doses in before we go to surgery
and then completing the rest afterwards. So, that's pretty exciting to have
some sort of new sequencing strategies for these patients.

Melanie Cole (Host): Well, thank you both for that.
So, Dr. Broman, I'd like you to speak some more about some of the unique offerings
for patients with recurrent disease or refractory to standard treatments. You
mentioned some of the exciting things that you're doing there at UAB. Tell us
more about some of the unique therapies available at UAB, including
intratumoral injections and, you know, you mentioned immunotherapy. Speak about
anything that you feel is really exciting.

Dr Kristy Broman: So, being an academic center and
the only NCI-designated comprehensive cancer center in the state, we at UAB
have the opportunity to offer several treatments that aren't yet available
elsewhere through participation in clinical trials. And both Dr. Dubay and I
participate actively in identifying and reviewing potential trials and then
enrolling patients on those studies.

So, we currently have several ongoing trials of new treatments and
different combinations, which include all of the things you've mentioned,
systemic therapies, injections directly into the tumors, and melanoma vaccines
as well. In addition, we do have one intralesional therapy. We're injecting a
medication into the tumor, and that is FDA approved for treatment in advanced
melanoma. It is known as T-VEC or the brand name Imlygic. And it's something
that we can use for specifically disease that is palpable, for example, in-transit
metastases or subcutaneous lesions. And it's based on a herpes-1 virus that has
essentially been genetically modified to boost the innate immune response to
the tumor. So, we have seen pretty impressive responses to that and it provides
another option for us, for patients particularly who have had recurrent disease
or are refractory to our systemic treatments.

Dr John Dubay: And I'd just like to add UAB are
proud that we'll soon be able to offer a new treatment for patients with
advanced melanoma that has progressed despite the treatments we've discussed.
One of these is called cellular therapy or TIL therapy. And it involves taking
the patient's own immune cells, modifying them in the laboratory to be more
effective at detecting and killing melanoma, and then putting them back into
the body to do their work. This treatment has been shown to be highly
effective, even in patients for whom no other treatments have worked. So, we
feel like this is going to be one of the bigger advances we've seen in cancer management
in recent years.

Melanie Cole (Host): I'd like to give you each a
chance for a final thought as you're speaking to other providers. Dr. Dubay,
I'd like to start with you. If you were to look on the horizon, what would you
like to tell other providers about what you feel is not only coming down the
pike, but looking towards prevention, looking towards new ways to raise
awareness? I'd like you to just speak to other providers as they are counseling
their patients.

Dr John Dubay: Well, I think the biggest message
we'd all like to get across is that, unlike 10 years ago or 15 years ago,
developing melanoma is not a death sentence. We now have very effective
treatments for this, even when it's advanced and these treatments are well
tolerated and can make people live many years, even with advanced disease.

I think, as I mentioned, the TIL therapy is going to be a really
important treatment strategy heading forward for patients with advanced
disease. This is going to give patients an option where they have failed other
treatments and, potentially in the future, move further up in the treatment
line to newly diagnosed patients. So, I think those will be the most important
things in the future.

Melanie Cole (Host): And Dr. Broman, last word to you.
I'd like you to speak about the unique areas that set you apart, why it's so
important to refer to the specialists at UAB Medicine and when you feel is the
best time for other providers to do that.

Dr Kristy Broman: Yeah. Thanks for your question.
As you've heard, melanoma is now a very multidisciplinary initiative. And some
of the fun of what we do is thinking about all of the tricks up our sleeve and
how to best deploy them and what sequence to get the optimal outcome for the
patients. So as providers are thinking about where to refer their patients, I
would strongly recommend seeking out a place like UAB where there's
multidisciplinary management and active collaboration amongst all of the
different types of providers that take care of melanoma. And this can include
dermatologists, radiologists, pathologists, surgeons, medical oncologists who
give these systemic treatments as well as radiation oncologists. So, looking to
a group that has an active multidisciplinary team and who review their complex
cases regularly within a tumor board that combines all of these individuals, so
that all voices are heard and we're making the best recommendations to our
patients. I think that is something that sets UAB apart from some of the other
institutions. And it's something that we're really proud to have built here.
And we really enjoy working together to take care of our patients.

Melanie Cole (Host): Thank you both so much for
joining us and sharing your incredible expertise and the exciting advances in
the field of melanoma. And for more information or to refer a patient to UAB
Medicine, by visiting our website at uabmedicine.org/physician.

That concludes today's episode of UAB MedCast. For updates on the
latest medical advancements like you heard here, breakthroughs and research,
please follow us on your social channels. I'm Melanie Cole.