For Rick1981: Ipi then PD1 or Pd1 and IPI combo?

[Catherine Poole]

Here’s Rick’s post which is excellent: You definitely need prior Yervoy/Ipi (minimum of 2 treatments) and since we’re already taking the BRAF ones we didn’t ask about that, but will check next time!

We’re now debating whether we do Ipi and then Pembro in Europe (Brussels) or go to the US for Ipi plus Nivo in the USA. The latter will be more expensive (though the medicines will be free) and tough because we just have a baby girl.

The way I look at it:

Ipi followed by Pembro: will delay start of PD-1 by at least 6 weeks (2 treatments of Ipi) and after you fail Ipi (which 90% do) then the chance of success on Pembro drops from 40% to 28%.

http://www.ascopost.com/issues/july-10, … anoma.aspx

Ipi plus Nivo: start right away and response rate of 42%.

http://www.ascopost.com/issues/july-10, … anoma.aspx

So that seems to point to Ipi plus Nivo. What’s your view? And what about side effects?

rick1981

From expert Keith Flaherty, MD:

“Those summary statistics ignore the aggregate response rate to sequential ipi and novo. I would comfortably suggest staying put and receiving ipilimumab first and nivolumab, if needed”

[rick1981]

Hi Catherine,

Thanks for bringing the perspective of the sequential approach / aggregate response rate. So would that also hold for Pembro? The situation is that it’s either Ipi followed by Pembro in Europe (Brussels) or Ipi together with Nivo in the US (Yale). When MD Flaherty recommends he’d be comfortable to “stay put” did her refer to our sequential approach in Europe?

Thanks again!

Rick

[Catherine Poole]

Yes, there is still some dispute as to whether NIVO (BMS) or Pembro (merck) is the better PD1.

At the large oncology meeting in June, Pembro seemed in favor as a higher response with more data.

So based on that and the studies you mention that don’t bring into the picture the aggregate data, our scientific co-chair, felt that going for Yervoy (IPI) followed by Pembro, if you progress on IPI, was equally good to coming to the U.S. and doing the combo of Nivo/Yervoy. I believe Bart Neyns (your doctor?) in Brussels has stated similar opinion. There is much still unknown though but we are getting there!

[rick1981]

Hi Catherine,

Thanks for your help once again. It’s encouraging to hear Pembro and Nivo are not that far apart is terms of efficacy. Our ‘second opinion/specialist’ doctor is indeed Professor Neyns and he indeed recommended to stay in Europe for Ipi>Pembro as opposed to going to the US (Yale) for the Ipi+Nivo combo.

It makes life easier in terms of travel, is obviously cheaper (US is not covered by our insurance company as far as I can tell) and knowing we’re not missing out on a superior treatment is a big relief!

[Catherine Poole]

Please keep in touch and let us know how things are going. You are in good hands with Dr. Neyns, he is a truly caring doctor and very brilliant as well. It is good for you to now have a plan!

[rick1981]

Just another quick question… my wife is having some heart issues (pain when breathing deeply, high heart rate) and will ask our onc to perform a cardiogram. But is anything known about melanoma and/or the dabrafenib-trametinib combo and heart issues?

Thanks, Rick

…thinking this disease is making us hypochonders

[Gilly]

I know heart rhythm changes can be an uncommon side effect of Vem/zelboraf but I don’t know about Dab/Tram – get it checked !

[SimonC]

As part of the GSK Combi-V trial (Dabrafenib/Trametinib) I have an ECG and Echocardiogram every three months. No problems after 86 weeks but obviously GSK want it tested.

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