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BRAF/MEK Options and Protocols?
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BRAF/MEK Options and Protocols?

› Forums › General Melanoma Community › BRAF/MEK Options and Protocols?

  • Post
    • July 7, 2014 at 9:21 pm
    RJoeyB
    Participant
      Posting this as a conversation-starter and also trying to educate myself so if the time comes, I'm not scrambling to ask these questions.  My profile has my background, but long story short, I was diagnosed four years ago (yesterday, in fact) and found to be Stage IV within two weeks of diagnosis.  Very early on, prior to moving forward with a TIL trial at NCI/NIH in Bethesda, I considered a PLX4032 trial at the University of Pennsylvania (PLX4032 became vemurafenib/Zelboraf and as most of us around here know, was approved in the summer of 2011 by the FDA), but was told even by the top person at Penn that if I was eligible for the TIL trial, that was my best option at the time.  (To confirm, I am BRAF-positive).  We've been through a lot since then, with partial responses to some combination of the TIL, IL-2, and ipilimumab, along with many surgeries and courses of radiation.  
       
      All throughout, I've continually educated myself about what else is out there, so consider myself pretty informed about immunotherapy, checkpoint inhibitors, targeted therapies, and the roles of more "traditional" surgical and radiation options.  However, as the targeted therapies have evolved quickly, with both Roche's vemurafenib/Zelboraf and GSK's dabrafenib/Tafinlar approved as BRAF inhibitor monotherapies, GSK's trametinib/Mekinist approved as an MEK inhibitor monotherapy, and of course dabrafenib and trametinib approved as a combination therapy, I've found that the guidelines for how these options are being selected are vague, which leads to a number of questions:
       
      1) Vemurafenib vs. dabrafenib?  Has one shown superiority to the other?  Are doctors prescribing them equally and/or what criteria are they using to select one or the other?
       
      2) Monotherapy vs. combination therapy?  Given the approval of the combination therapy, are there still reasons to start with a single agent (either of the BRAF-inhibtors or the MEK-inhibitor)?  If so, what are they?  Perhaps the approval of the GSK combination is driving additional market share to dabrafenib?  (I know Roche and Exelixis have their own MEK inhibitor, cobimetinib, in trials)
       
      Again, for now, we have kept the BRAF/MEK targeted therapies in our proverbial back pocket and will cross the bridge if and when we reach it, but it seems that the playing field has become very muddy as to the best use of these options.  It's probable that there still aren't any real answers, yet; that those of us here are the ones ultimately providing answers through participation in trials and use of these new therapies, but if anyone has any insight from their own experiences, I think we could all benefit from hearing.
       
      Thanks,
      Joe
       
    Viewing 14 reply threads
    • Replies
        • July 7, 2014 at 10:13 pm
        Bubbles
        Participant

          Joey,

          Here's a real breakdown of BRAF: what it is and why BRAF inhibitors work for BRAF postive melanoma patients with what the data shows when administered alone, in combination, and in an intermittent dosing format:

          http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/02/braf-inhibitors-for-melanoma-dabrafenib.html

          The latest BRAF studies presented at ASCO:

          http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/06/braf-studies-from-ascoand-new-study.html

          I think the data is pretty clear that the combination of BRAFi with MEK (as well as other meds) works far better, with much less resistance, AND decreased side effects when compared to a single agent.  I can't foresee a condition in which a single med would be preferable given what we have learned over the past couple of years.

          Hope this helps.  Celeste

          • July 7, 2014 at 10:13 pm
          Bubbles
          Participant

            Joey,

            Here's a real breakdown of BRAF: what it is and why BRAF inhibitors work for BRAF postive melanoma patients with what the data shows when administered alone, in combination, and in an intermittent dosing format:

            http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/02/braf-inhibitors-for-melanoma-dabrafenib.html

            The latest BRAF studies presented at ASCO:

            http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/06/braf-studies-from-ascoand-new-study.html

            I think the data is pretty clear that the combination of BRAFi with MEK (as well as other meds) works far better, with much less resistance, AND decreased side effects when compared to a single agent.  I can't foresee a condition in which a single med would be preferable given what we have learned over the past couple of years.

            Hope this helps.  Celeste

            • July 7, 2014 at 10:13 pm
            Bubbles
            Participant

              Joey,

              Here's a real breakdown of BRAF: what it is and why BRAF inhibitors work for BRAF postive melanoma patients with what the data shows when administered alone, in combination, and in an intermittent dosing format:

              http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/02/braf-inhibitors-for-melanoma-dabrafenib.html

              The latest BRAF studies presented at ASCO:

              http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/06/braf-studies-from-ascoand-new-study.html

              I think the data is pretty clear that the combination of BRAFi with MEK (as well as other meds) works far better, with much less resistance, AND decreased side effects when compared to a single agent.  I can't foresee a condition in which a single med would be preferable given what we have learned over the past couple of years.

              Hope this helps.  Celeste

              • July 7, 2014 at 11:07 pm
              Mat
              Participant

                Joe,

                Celeste has pointed you to good sources of info.  I'll add that I believe that I'm being treated by the doctor to which you refer and that doctor prescribed the GSK combo as an initial Stage IV treatment when I was "bounced" by the NIH for TIL due to rapid disease progression.

                  • July 8, 2014 at 2:50 am
                  RJoeyB
                  Participant

                    Thanks Mat.  Yes, I was at Penn very early in my process in the summer of 2010 of looking at options and Zelboraf didn't even have a name yet, we just called it "that Plexxikon drug" at first.  We were at Fox Chase, working with them on the NIH TIL consultation, my surgical oncologist had done a fellowship there and one of the other fellows while he was there had stayed as a staff clinician, which helped move the process along.  I think Dr. Flaherty had just left Penn for Mass General.  The BRAF-inhibitor trial that was accepting patients then was a double-blind comparison of PLX4032 vs. dacarbazine, with, if I recall correctly, a crossover option after 12 weeks for those randomized to the dacarbazine arm.  We'd been to NCI for the intake appointment and scans and were waiting for what turned into another visit to Bethesda before being accepted into the trial.  It's hard to recall the exact words four years later, but the gist of the conversation when we saw Dr. Schuchter was that they were seeing impressive results with the BRAFi, but that durability was a big question mark, plus at the time of the appointment, I hadn't even been tested for BRAF.  Given all that, and some of the unique requirements of TIL that I met (resectable tumor plus additional and measurable disease to be left as a marker, etc.), and what they were seeing with TIL durability, she implied that it would be a good first step if everything lined up, and that the BRAF-inhibitor would still be an option later.  I always appreciate when doctors work with patients to offer some direction even if it involves saying, "Right now for you, there might be a better option elsewhere."

                     

                    • July 8, 2014 at 2:50 am
                    RJoeyB
                    Participant

                      Thanks Mat.  Yes, I was at Penn very early in my process in the summer of 2010 of looking at options and Zelboraf didn't even have a name yet, we just called it "that Plexxikon drug" at first.  We were at Fox Chase, working with them on the NIH TIL consultation, my surgical oncologist had done a fellowship there and one of the other fellows while he was there had stayed as a staff clinician, which helped move the process along.  I think Dr. Flaherty had just left Penn for Mass General.  The BRAF-inhibitor trial that was accepting patients then was a double-blind comparison of PLX4032 vs. dacarbazine, with, if I recall correctly, a crossover option after 12 weeks for those randomized to the dacarbazine arm.  We'd been to NCI for the intake appointment and scans and were waiting for what turned into another visit to Bethesda before being accepted into the trial.  It's hard to recall the exact words four years later, but the gist of the conversation when we saw Dr. Schuchter was that they were seeing impressive results with the BRAFi, but that durability was a big question mark, plus at the time of the appointment, I hadn't even been tested for BRAF.  Given all that, and some of the unique requirements of TIL that I met (resectable tumor plus additional and measurable disease to be left as a marker, etc.), and what they were seeing with TIL durability, she implied that it would be a good first step if everything lined up, and that the BRAF-inhibitor would still be an option later.  I always appreciate when doctors work with patients to offer some direction even if it involves saying, "Right now for you, there might be a better option elsewhere."

                       

                      • July 8, 2014 at 2:50 am
                      RJoeyB
                      Participant

                        Thanks Mat.  Yes, I was at Penn very early in my process in the summer of 2010 of looking at options and Zelboraf didn't even have a name yet, we just called it "that Plexxikon drug" at first.  We were at Fox Chase, working with them on the NIH TIL consultation, my surgical oncologist had done a fellowship there and one of the other fellows while he was there had stayed as a staff clinician, which helped move the process along.  I think Dr. Flaherty had just left Penn for Mass General.  The BRAF-inhibitor trial that was accepting patients then was a double-blind comparison of PLX4032 vs. dacarbazine, with, if I recall correctly, a crossover option after 12 weeks for those randomized to the dacarbazine arm.  We'd been to NCI for the intake appointment and scans and were waiting for what turned into another visit to Bethesda before being accepted into the trial.  It's hard to recall the exact words four years later, but the gist of the conversation when we saw Dr. Schuchter was that they were seeing impressive results with the BRAFi, but that durability was a big question mark, plus at the time of the appointment, I hadn't even been tested for BRAF.  Given all that, and some of the unique requirements of TIL that I met (resectable tumor plus additional and measurable disease to be left as a marker, etc.), and what they were seeing with TIL durability, she implied that it would be a good first step if everything lined up, and that the BRAF-inhibitor would still be an option later.  I always appreciate when doctors work with patients to offer some direction even if it involves saying, "Right now for you, there might be a better option elsewhere."

                         

                      • July 7, 2014 at 11:07 pm
                      Mat
                      Participant

                        Joe,

                        Celeste has pointed you to good sources of info.  I'll add that I believe that I'm being treated by the doctor to which you refer and that doctor prescribed the GSK combo as an initial Stage IV treatment when I was "bounced" by the NIH for TIL due to rapid disease progression.

                        • July 7, 2014 at 11:07 pm
                        Mat
                        Participant

                          Joe,

                          Celeste has pointed you to good sources of info.  I'll add that I believe that I'm being treated by the doctor to which you refer and that doctor prescribed the GSK combo as an initial Stage IV treatment when I was "bounced" by the NIH for TIL due to rapid disease progression.

                          • July 8, 2014 at 12:16 am
                          Bubbles
                          Participant

                            One other point….this is what Weber had to say when he had a chat with Ribas about the ASCO reports: 

                            "We heard Flaherty, who gave us an update on the BRF-113220 trial. [see abstract in June 4, 2014 post] …randomized study with 162 patients, of whom 54 received dabrafenib alone (the BRAF inhibitor), 54 received dabrafenib with a lower dose of the MEK inhibitor trametinib, and 54 received dabrafenib and what we hoped was the optimal dose of the MEK inhibitor.  The updated data showed a clear superior rate of response: 76% vs the mid-50% range for either of the other arms…..there was a 25-month median survival…our institution was the biggest accruer to that trial.  About 20% of our patients at 3-4 years are still on treatment and doing well, with many complete responses over time.  It is a very impressive treatment.  It makes you wonder:  Maybe a BRAF mutated patient who starts on this combination should not receive immunotherapy first.  I would like to know what happened to the patients who failed the combination and then went on to immunotherapy. A debate is raging in our field about whether we should give immunotherapy or targeted therapy first, but I can't argue with a 25 month median survival – the best in any phase 2 trial of a significant size that I have ever seen."

                            For my synopsis as well as a link to the whole conversation: 

                            http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/06/pretty-darn-impressivea-chat-between.html

                            For what it's worth….c

                             

                             

                            • July 8, 2014 at 12:16 am
                            Bubbles
                            Participant

                              One other point….this is what Weber had to say when he had a chat with Ribas about the ASCO reports: 

                              "We heard Flaherty, who gave us an update on the BRF-113220 trial. [see abstract in June 4, 2014 post] …randomized study with 162 patients, of whom 54 received dabrafenib alone (the BRAF inhibitor), 54 received dabrafenib with a lower dose of the MEK inhibitor trametinib, and 54 received dabrafenib and what we hoped was the optimal dose of the MEK inhibitor.  The updated data showed a clear superior rate of response: 76% vs the mid-50% range for either of the other arms…..there was a 25-month median survival…our institution was the biggest accruer to that trial.  About 20% of our patients at 3-4 years are still on treatment and doing well, with many complete responses over time.  It is a very impressive treatment.  It makes you wonder:  Maybe a BRAF mutated patient who starts on this combination should not receive immunotherapy first.  I would like to know what happened to the patients who failed the combination and then went on to immunotherapy. A debate is raging in our field about whether we should give immunotherapy or targeted therapy first, but I can't argue with a 25 month median survival – the best in any phase 2 trial of a significant size that I have ever seen."

                              For my synopsis as well as a link to the whole conversation: 

                              http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/06/pretty-darn-impressivea-chat-between.html

                              For what it's worth….c

                               

                               

                                • July 14, 2014 at 8:03 pm
                                awanning
                                Participant

                                  Interesting to hear this because I was just diagnosed last week with aggressive stage IV and it sounds like I'll be starting the BRAF/MEK combo tomorrow in an attempt to slow it down and get a better handle on it before moving to immunotherapy options. Sooo, I guess maybe I'll let ya know how it goes. Fingers, toes, and elbows crossed. 

                                  • July 14, 2014 at 8:03 pm
                                  awanning
                                  Participant

                                    Interesting to hear this because I was just diagnosed last week with aggressive stage IV and it sounds like I'll be starting the BRAF/MEK combo tomorrow in an attempt to slow it down and get a better handle on it before moving to immunotherapy options. Sooo, I guess maybe I'll let ya know how it goes. Fingers, toes, and elbows crossed. 

                                    • July 14, 2014 at 8:03 pm
                                    awanning
                                    Participant

                                      Interesting to hear this because I was just diagnosed last week with aggressive stage IV and it sounds like I'll be starting the BRAF/MEK combo tomorrow in an attempt to slow it down and get a better handle on it before moving to immunotherapy options. Sooo, I guess maybe I'll let ya know how it goes. Fingers, toes, and elbows crossed. 

                                    • July 8, 2014 at 12:16 am
                                    Bubbles
                                    Participant

                                      One other point….this is what Weber had to say when he had a chat with Ribas about the ASCO reports: 

                                      "We heard Flaherty, who gave us an update on the BRF-113220 trial. [see abstract in June 4, 2014 post] …randomized study with 162 patients, of whom 54 received dabrafenib alone (the BRAF inhibitor), 54 received dabrafenib with a lower dose of the MEK inhibitor trametinib, and 54 received dabrafenib and what we hoped was the optimal dose of the MEK inhibitor.  The updated data showed a clear superior rate of response: 76% vs the mid-50% range for either of the other arms…..there was a 25-month median survival…our institution was the biggest accruer to that trial.  About 20% of our patients at 3-4 years are still on treatment and doing well, with many complete responses over time.  It is a very impressive treatment.  It makes you wonder:  Maybe a BRAF mutated patient who starts on this combination should not receive immunotherapy first.  I would like to know what happened to the patients who failed the combination and then went on to immunotherapy. A debate is raging in our field about whether we should give immunotherapy or targeted therapy first, but I can't argue with a 25 month median survival – the best in any phase 2 trial of a significant size that I have ever seen."

                                      For my synopsis as well as a link to the whole conversation: 

                                      http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/06/pretty-darn-impressivea-chat-between.html

                                      For what it's worth….c

                                       

                                       

                                      • July 8, 2014 at 2:30 am
                                      RJoeyB
                                      Participant

                                        Thanks Celeste, helpful information as always.  I try to stay on top of the presentations out of ASCO and elsewhere and saw the Weber/Ribas video, too (over on Medscape, I believe) — regardless, thanks for sharing your blog posts and summaries.  Sometimes there's a disconnect, or at a minimum, a lag, between what the studies are demonstrating and what is actually being practiced by oncologists across the country, even at the larger institutions.  That said, I'm also wondering if the study results are being reflected in how BRAF and MEK inhibitors are being prescribed to patients.  

                                        So a couple of things…  I haven't heard or read of anyone these days being prescribed trametinib as a monotherapy (and it was just approved as such in the EU, but perhaps that's a necessary precursor to becoming approved as a combination with dabrafenib).  I see here and elsewhere folks getting either vemurafenib or dabrafenib, without a lot of detail of why one vs. the other — very possible that there isn't enough data to suggest any advantage.  Last, it sounds like dabrafenib may be getting a leg up on vemurafenib if not because of any monotherapy superiority but because it has an "approved partner" combination with trametinib, while vemurafenib plus an MEKi is going to require trial participation.  Would you say it's safe to say that today, in practice, (and setting aside other treatments for purposes of this discussion) the vast majority of BRAF-positive patients who are taking the targeted therapy route are going to be using the dabrafenib/trametinib combo?  If not, what are the reasons why a monotherapy was chosen (other than regulatory)?

                                        Joe

                                         

                                         

                                        • July 8, 2014 at 2:30 am
                                        RJoeyB
                                        Participant

                                          Thanks Celeste, helpful information as always.  I try to stay on top of the presentations out of ASCO and elsewhere and saw the Weber/Ribas video, too (over on Medscape, I believe) — regardless, thanks for sharing your blog posts and summaries.  Sometimes there's a disconnect, or at a minimum, a lag, between what the studies are demonstrating and what is actually being practiced by oncologists across the country, even at the larger institutions.  That said, I'm also wondering if the study results are being reflected in how BRAF and MEK inhibitors are being prescribed to patients.  

                                          So a couple of things…  I haven't heard or read of anyone these days being prescribed trametinib as a monotherapy (and it was just approved as such in the EU, but perhaps that's a necessary precursor to becoming approved as a combination with dabrafenib).  I see here and elsewhere folks getting either vemurafenib or dabrafenib, without a lot of detail of why one vs. the other — very possible that there isn't enough data to suggest any advantage.  Last, it sounds like dabrafenib may be getting a leg up on vemurafenib if not because of any monotherapy superiority but because it has an "approved partner" combination with trametinib, while vemurafenib plus an MEKi is going to require trial participation.  Would you say it's safe to say that today, in practice, (and setting aside other treatments for purposes of this discussion) the vast majority of BRAF-positive patients who are taking the targeted therapy route are going to be using the dabrafenib/trametinib combo?  If not, what are the reasons why a monotherapy was chosen (other than regulatory)?

                                          Joe

                                           

                                           

                                            • July 8, 2014 at 1:27 pm
                                            Mat
                                            Participant

                                              For a BRAF-positive patient that has elected to go the targeted therapy-route, I'm not aware of a reason to go with BRAFi alone–unless MEKi causes problematic side effects in that particular patient (e.g., eye problems must be an issue with MEKi because my specialty pharmarcy always asks about my eyes at refill time).  Generally speaking, the combo results in less side effects, but there are always exceptions.

                                              • July 8, 2014 at 1:27 pm
                                              Mat
                                              Participant

                                                For a BRAF-positive patient that has elected to go the targeted therapy-route, I'm not aware of a reason to go with BRAFi alone–unless MEKi causes problematic side effects in that particular patient (e.g., eye problems must be an issue with MEKi because my specialty pharmarcy always asks about my eyes at refill time).  Generally speaking, the combo results in less side effects, but there are always exceptions.

                                                • July 8, 2014 at 1:27 pm
                                                Mat
                                                Participant

                                                  For a BRAF-positive patient that has elected to go the targeted therapy-route, I'm not aware of a reason to go with BRAFi alone–unless MEKi causes problematic side effects in that particular patient (e.g., eye problems must be an issue with MEKi because my specialty pharmarcy always asks about my eyes at refill time).  Generally speaking, the combo results in less side effects, but there are always exceptions.

                                                  • July 8, 2014 at 10:43 pm
                                                  Bubbles
                                                  Participant

                                                    I'm with Mat on this one.  Combo's yield fewer side effects, better results, and less tumor work around!  c

                                                    • July 8, 2014 at 10:43 pm
                                                    Bubbles
                                                    Participant

                                                      I'm with Mat on this one.  Combo's yield fewer side effects, better results, and less tumor work around!  c

                                                      • July 8, 2014 at 10:43 pm
                                                      Bubbles
                                                      Participant

                                                        I'm with Mat on this one.  Combo's yield fewer side effects, better results, and less tumor work around!  c

                                                      • July 8, 2014 at 2:30 am
                                                      RJoeyB
                                                      Participant

                                                        Thanks Celeste, helpful information as always.  I try to stay on top of the presentations out of ASCO and elsewhere and saw the Weber/Ribas video, too (over on Medscape, I believe) — regardless, thanks for sharing your blog posts and summaries.  Sometimes there's a disconnect, or at a minimum, a lag, between what the studies are demonstrating and what is actually being practiced by oncologists across the country, even at the larger institutions.  That said, I'm also wondering if the study results are being reflected in how BRAF and MEK inhibitors are being prescribed to patients.  

                                                        So a couple of things…  I haven't heard or read of anyone these days being prescribed trametinib as a monotherapy (and it was just approved as such in the EU, but perhaps that's a necessary precursor to becoming approved as a combination with dabrafenib).  I see here and elsewhere folks getting either vemurafenib or dabrafenib, without a lot of detail of why one vs. the other — very possible that there isn't enough data to suggest any advantage.  Last, it sounds like dabrafenib may be getting a leg up on vemurafenib if not because of any monotherapy superiority but because it has an "approved partner" combination with trametinib, while vemurafenib plus an MEKi is going to require trial participation.  Would you say it's safe to say that today, in practice, (and setting aside other treatments for purposes of this discussion) the vast majority of BRAF-positive patients who are taking the targeted therapy route are going to be using the dabrafenib/trametinib combo?  If not, what are the reasons why a monotherapy was chosen (other than regulatory)?

                                                        Joe

                                                         

                                                         

                                                        • July 8, 2014 at 3:42 pm
                                                        arthurjedi007
                                                        Participant

                                                          I've done all 3 meds. I see no reason anyone would do Zelboraf alone unless the Tafinlar/Mekenist has too many side affects. In my case it was just the opposite. Zel had lots of side affects but the combo had very few. Also Zel did nothing good for me. The combo did stop most of the tumors from growing. So I really think it was the Mekenist that did some good for me. I doubt if the Tafinlar did much.

                                                          The way I understand my local doc is they are just starting trials with the next gene targetted further down the BRAF chain of mutations called ERB.

                                                           

                                                          • July 8, 2014 at 3:42 pm
                                                          arthurjedi007
                                                          Participant

                                                            I've done all 3 meds. I see no reason anyone would do Zelboraf alone unless the Tafinlar/Mekenist has too many side affects. In my case it was just the opposite. Zel had lots of side affects but the combo had very few. Also Zel did nothing good for me. The combo did stop most of the tumors from growing. So I really think it was the Mekenist that did some good for me. I doubt if the Tafinlar did much.

                                                            The way I understand my local doc is they are just starting trials with the next gene targetted further down the BRAF chain of mutations called ERB.

                                                             

                                                            • July 8, 2014 at 3:42 pm
                                                            arthurjedi007
                                                            Participant

                                                              I've done all 3 meds. I see no reason anyone would do Zelboraf alone unless the Tafinlar/Mekenist has too many side affects. In my case it was just the opposite. Zel had lots of side affects but the combo had very few. Also Zel did nothing good for me. The combo did stop most of the tumors from growing. So I really think it was the Mekenist that did some good for me. I doubt if the Tafinlar did much.

                                                              The way I understand my local doc is they are just starting trials with the next gene targetted further down the BRAF chain of mutations called ERB.

                                                               

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