Dabrafenib plus trametinib for compassionate use in metastatic melanoma: A STROBE-compliant retrospective observational postauthorization study

BRAF and MEK Inhibitors and Their Toxicities: A Meta-Analysis

PURPOSE

This meta-analysis summarizes the incidence of treatment-related adverse events (AE) of BRAFi and MEKi.

METHODS

A systematic search of Medline/PubMed was conducted to identify suitable articles published in English up to 31 December 2021. The primary outcomes were profiles for all-grade and grade 3 or higher treatment-related AEs, and the analysis of single side effects belonging to both categories.

RESULTS

The overall incidence of treatment-related all-grade Aes was 99% for Encorafenib (95% CI: 0.97-1.00) and 97% for Trametinib (95% CI: 0.92-0.99; I² = 66%) and Binimetinib (95% CI: 0.94-0.99; I² = 0%). In combined therapies, the rate was 98% for both Vemurafenib + Cobimetinib (95% CI: 0.96-0.99; I² = 77%) and Encorafenib + Binimetinib (95% CI: 0.96-1.00). Grade 3 or higher adverse events were reported in 69% of cases for Binimetinib (95% CI: 0.50-0.84; I² = 71%), 68% for Encorafenib (95% CI: 0.61-0.74), and 72% for Vemurafenib + Cobimetinib (95% CI: 0.65-0.79; I² = 84%). The most common grade 1-2 AEs were pyrexia (43%) and fatigue (28%) for Dabrafenib + Trametinib and diarrhea for both Vemurafenib + Cobimetinib (52%) and Encorafenib + Binimetinib (34%). The most common AEs of grade 3 or higher were pyrexia, rash, and hypertension for Dabrafenib + Trametinib (6%), rash and hypertension for Encorafenib + Binimetinib (6%), and increased AST and ALT for Vemurafenib + Cobimetinib (10%).

CONCLUSIONS

Our study provides comprehensive data on treatment-related adverse events of BRAFi and MEKi combination therapies, showing related toxicity profiles to offer a helpful tool for clinicians in the choice of therapy.

Safety of combining dabrafenib plus trametinib in elderly BRAF V600 mutation-positive advanced melanoma patients: real-world data analysis of Spanish patients (ELDERLYMEL)

Efficacy and safety of dabrafenib and trametinib in metastatic melanoma have been demonstrated in two-phase III and one-phase I/II clinical trials. However, patients at least 75 years old (y.o.) were largely underrepresented. Additionally, the safety profile of dabrafenib and trametinib based on age is unknown. ELDERLYMEL is a retrospective noninterventional multicenter study, describing the effectiveness and safety of at least 75 y.o. patients compared with less than 75 y.o. patients with advanced BRAF V600-mutated melanoma treated with dabrafenib plus trametinib or dabrafenib monotherapy. A total of 159 patients were included, 130 less than 75 y.o. and 29 at least 75 y.o. Clinical features were similar between the groups, except in the number of comorbidities, number of metastatic sites, Eastern Cooperative Oncology Group (ECOG) performance status, and BRAF V600-mutation type. Five patients per group received dabrafenib monotherapy. There were no differences in adverse events (AEs) rate or grade between the groups. However, AE profiles were different between the groups, being pyrexia infrequent in patients at least 75 y.o. (13.8% vs. 42.3%; P = 0.005). Dabrafenib and trametinib dose intensities were lower in at least 75 y.o. patients (P = 0.018 and P = 0.020), but there were no differences in effectiveness between the groups. Finally, in a multivariate analysis, sex (female) was the only variable independently associated with an increased risk of AE grade ≥3. Data from the ELDERLYMEL study demonstrate that dabrafenib plus trametinib is safe and effective in at least 75 y.o. patients with advanced BRAF V600-mutated melanoma without increasing toxicity. Additionally, we describe a different safety profile depending on age and sex.

The incidence and risk of cutaneous toxicities associated with dabrafenib in melanoma patients: a systematic review and meta-analysis

OBJECTIVE

Dabrafenib, an inhibitor of mutated BRAF, has significant clinical activity in melanoma patients but is linked to a spectrum of cutaneous toxicities. Thus, our meta-analysis was conducted to evaluate the type, incidence and risks of dermatological toxicities from dabrafenib.

METHODS

Systematic searches were performed using electronic databases such as Embase and PubMed and conference abstracts published by the American Society of Clinical Oncology. Eligible studies were limited to prospective phase I, II and III clinical trials and expanded-access (ie, outside clinical trials) programmes of melanoma patients receiving dabrafenib monotherapy (150 mg, twice daily) or combination therapy of dabrafenib (150 mg, twice daily) plus trametinib (2 mg, once daily). The outcomes were mainly the incidence rate and risk of all-grade cutaneous toxicities associated with dabrafenib in melanoma patients.

RESULTS

Twenty trials comprising a total of 3359 patients were included in the meta-analysis. The meta-analysis showed that the overall incidence of all-grade rash for melanoma patients assigned dabrafenib was 30.00% (95% CI 0.07 to 0.71), cutaneous squamous-cell carcinoma (cSCC) 16.00% (95% CI 0.11 to 0.24), alopecia 21% (95% CI 0.11 to 0.37), keratoacanthoma (KA) 20.00% (95% CI 0.12 to 0.31), hyperkeratosis (HK) 14.00% (95% CI 0.09 to 0.22) and pruritus 8.00% (95% CI 0.05 to 0.12). All-grade rash occurred in 19.00% (95% CI 0.15 to 0.25), cSCC in 10.00% (95% CI 0.04 to 0.22), alopecia in 6.00% (95% CI 0.03 to 0.12), KA in 6.00% (95% CI 0.04 to 0.09) and pruritus in 2/1265 patients assigned dabrafenib plus trametinib. The summary risk ratio (RR) showed that the combination of dabrafenib with trametinib versus dabrafenib was associated with a significantly increased risk of all-grade rash (RR 1.35, 95% CI 1.01 to 1.80) and a decreased risk of cSCC (RR 0.40, 95% CI 0.18 to 0.89), alopecia (RR 0.19, 95% CI 0.12 to 0.30) and HK (RR 0.25, 95% CI 0.10 to 0.62).

CONCLUSION

In summary, the most frequent cutaneous adverse reactions from dabrafenib were rash, cSCC, alopecia, KA, HK and pruritus. There was a significantly decreased risk of cSCC, alopecia and HK with the combination of dabrafenib with trametinib versus dabrafenib alone. Clinicians should be aware of these risks and perform regular clinical monitoring.

Comparative and combined effectiveness of innovative therapies in cancer: a literature review

To achieve therapeutic innovation in oncology, already expensive novel medicines are often concomitantly combined to potentially enhance effectiveness. While this aggravates the pricing problem, comparing effectiveness of novel yet expensive (concomitant) treatments is much needed for healthcare decision-making to deliver effective but affordable treatments. This study reviewed published clinical trials and real-world studies of targeted and immune therapies. In total, 48 studies compared and/or combined multiple novel products on breast, colorectal, lung and melanoma cancers. To a great extent, products evaluated in each study were owned by one manufacturer. However, cross-manufacturer assessments are also needed. Next to costs and intensive market competition, the absence of a regulatory framework enforcing real-world multiproduct studies prevents these from being conducted. Trusted third parties could facilitate such real-world studies, for which appropriate and efficient data access is needed.

Access to innovative medicines for metastatic melanoma worldwide: Melanoma World Society and European Association of Dermato-oncology survey in 34 countries

According to data from recent studies from Europe, a large percentage of patients have restricted access to innovative medicines for metastatic melanoma. Melanoma World Society and European Association of Dermato-oncology conducted a Web-based survey on access to first-line recommended treatments for metastatic melanoma by current guidelines (National Comprehensive Center Network, European Society for Medical Oncology [ESMO] and European Organization for Research and Treatment of Cancer/European Association of Dermato-oncology/European dermatology Forum) among melanoma experts from 27 European countries, USA, China, Australia, Argentina, Brazil, Chile and Mexico from September 1st, 2017 to July 1st, 2018. Data on licencing and reimbursement of medicines and the number of patient treated were correlated with the data on health expenditure per capita (HEPC), Mackenbach score of health policy performance, health technology assessment (HTA), ASCO and ESMO Magnitude of clinical benefit scale (ESMO MCBS) scores of clinical benefit and market price of medicines. Regression analysis for evaluation of correlation between the parameters was carried out using SPSS software. The estimated number of patients without access in surveyed countries was 13768. The recommended BRAFi + MEKi combination and anti-PD1 immunotherapy were fully reimbursed/covered in 19 of 34 (55.8%) and 17 of 34 (50%) countries, and combination anti-CTLA4+anti-PD1 in was fully covered in 6 of 34 (17.6%) countries. Median delay in reimbursement was 991 days, and it was in significant correlation with ESMO MCBS (p = 0.02), median market price (p = 0.001), HEPC and Mackenbach scores (p < 0.01). Price negotiations or managed entry agreements (MEAs) with national authorities were necessary for reimbursement. In conclusion, great discrepancy exists in metastatic melanoma treatment globally. Access to innovative medicines is in correlation with economic parameters as well as with healthcare system performance parameters. Patient-oriented drug development, market access and reimbursement pathways must be urgently found.