Help me understand the differences between states, and countries treatment plans!

Hi Erin, I will try to address a couple of the question that you have asked. First, if you guys have already gone the Ipi+Nivo route and then switched to targeted therapy drugs because of progression and it is working then switching wouldn’t make a lot of sense, I would want to give the targeted therapy time if no progression is happening. Some patients do go back to monotherapy nivo after a period of time on targeted therapy if signs of the targeted therapy drugs are developing resistance, but that one is a tough call of when to switch and can the progression be handled by radiation or is a switch to maybe T-vec + Pembro required. I have not seen anyone get a second round of ipi+ nivo after having ipi+ nivo then switching to targeted therapy, but I have seen patients at progression go back to nivo or pembro by itself. I think the reason of not going back to ipi+nivo would be toxicity. Now, there might be cases where the combination has been offered but I haven’t heard of any especially if there was toxicity the first time. The new trend with a case like your husbands would be if he progressed to look at adding something new to a Pd-1 drug, sort of using the Pd-1 drug as the back bone of treatment and adding something like NKTR-214 or Lag-3 to it. These options are in clinical trial and not approved yet but it is where things have been heading. Some also use chemo as a time buyer between treatments or options opening up. Radiation is being studied in combination with immunotherapy at several big hospitals, Dr. Jason Luke in Chicago has talked about this area as being very interesting and trials are being run in Chicago for sure. Surgery has been used for many if there is a stubborn spot that is not responding while other tumors are getting smaller but not usually offered if there are many active tumors in many areas, in that case they are usually looking for something that will have a system wide response. There are so many options and treatment approaches offered that it is hard to say what is the best since each patient can be so different, however the options that your husband has been offered seem like best practices from what I have read and experienced. Best Wishes!!!!Ed