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Table of Contents
LETTER TO EDITOR
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 157-158

Profile and outcome of advanced malignant melanoma in India: Need for cost-effective innovations


Department of Medical Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India

Date of Submission17-Jan-2022
Date of Decision25-Jan-2022
Date of Acceptance25-Jan-2022
Date of Web Publication31-Mar-2022

Correspondence Address:
Sameer Bakhshi
Department of Medical Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_30_22

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How to cite this article:
Ganguly S, Bakhshi S. Profile and outcome of advanced malignant melanoma in India: Need for cost-effective innovations. Cancer Res Stat Treat 2022;5:157-8

How to cite this URL:
Ganguly S, Bakhshi S. Profile and outcome of advanced malignant melanoma in India: Need for cost-effective innovations. Cancer Res Stat Treat [serial online] 2022 [cited 2022 May 21];5:157-8. Available from: https://www.crstonline.com/text.asp?2022/5/1/157/341289



The outcome of advanced malignant melanoma has improved significantly in the last decade with the incorporation of checkpoint inhibitors and targeted therapies in the treatment paradigm.[1] However, the impressive success seen in clinical trials has not translated into real-world benefit in Indian settings, where unaffordability and a distinct disease profile with scarce clinical evidence remain unique challenges.[2]

In this regard, the recently published retrospective study by Shishak et al.[3] is an important addition to fill the evidence gap. A significant proportion of patients in the study cohort had acral (n = 23 out of 93; 24.7%) and mucosal melanoma (n = 37 out of 93; 39.7%). The proportion of mucosal/acral melanoma is known to be higher in the Asian population as compared to the Western population and has a relatively poor prognosis[2] which could have been explored in this real-world cohort.

In the study, the authors have restricted their analysis of the progression-free survival to only those patients with evaluable formal response assessment (37/93; 39.7%); the overall survival analysis was done in only 70 patients (75.2% of cohort). Utilizing clinical documentation of symptomatic progression in medical records and telephonic follow-ups to update the survival data could have provided a more comprehensive picture of the survival outcome of advanced melanoma in our country.

Notably, a considerable proportion of patients (33/93; 35.4%) were advised best supportive care only, while only a minority (n = 16 out of 93; 17.2%) could receive standard of care immunotherapy. One option to address this treatment gap is to evaluate for targetable mutations with affordable therapeutic options, even if the response rate to these therapies is expected to be modest. In this study, mutation testing of c-kit (7.5%) and BRAF (4.4%) could only be done for a minority of patients, and only two patients could receive imatinib. It is pertinent to note that c-kit mutations may be observed in anywhere between 15% and 40% of mucosal/acral melanoma, and the use of imatinib in this cohort may yield a response rate up to 54%.[2] While BRAF/MEK inhibitors or checkpoint inhibitors remain unaffordable for the majority of patients in India, imatinib is relatively affordable and is also well tolerated. Given the higher proportion of mucosal/acral melanoma in India and scarce evidence on the genetic profile, it is prudent to test for c-kit mutation in all patients and, to explore the use of imatinib, even in patients with a poor performance status.

Soberingly, less than one-fifth of patients could receive the standard of care; thus, the treatment of advanced melanoma needs innovative and cost-effective solutions for our country.[4] Immune-checkpoint inhibitors have no dose-efficacy correlation. Hence, a low dose of these agents has been explored in multiple malignancies, including non-small cell lung cancer, with good efficacy.[5],[6] A similar strategy should be evaluated in advanced melanoma as well. The use of low-dose temozolomide instead of intravenous dacarbazine or metronomic chemotherapy should be explored as options to reduce hospital visits and health-care resource utilization and improve quality of life without compromising the survival outcome. Oral metronomic therapy has proved to be as effective as more expensive modes of therapy in various malignancies.[7],[8],[9] It may be a valid option in advanced melanoma as well. Besides exploring these alternative options, it is also important to incorporate patients' quality of life as a routine outcome measure in research studies on advanced melanoma.[10],[11],[12]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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2.
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Shishak S, Mittal A, Aswar H, Pandey R, Kalra K, Gupta A, et al. Clinical profile and outcomes of malignant melanoma in patients from an Indian institute: A retrospective analysis. Cancer Res Stat Treat 2021;4:621.  Back to cited text no. 3
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Ganguly S, Bakhshi S. Measuring quality of life in Indian children with cancer: Addressing an unmet need. Cancer Res Stat Treat 2020;3:851-2.  Back to cited text no. 12
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