|LETTER TO EDITOR
|Year : 2022 | Volume
| Issue : 1 | Page : 159-160
Malignant melanoma in India: Is it time to set the wheels in motion?
Bivas Biswas, Somnath Roy, Sandip Ganguly
Department of Medical Oncology, Tata Medical Center, Kolkata, West Bengal, India
|Date of Submission||19-Jan-2022|
|Date of Decision||25-Jan-2022|
|Date of Acceptance||28-Jan-2022|
|Date of Web Publication||24-Feb-2022|
Department of Medical Oncology, Tata Medical Center, 14 MAR (EW), New Town, Rajarhat, Kolkata - 700 160, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Biswas B, Roy S, Ganguly S. Malignant melanoma in India: Is it time to set the wheels in motion?. Cancer Res Stat Treat 2022;5:159-60
Malignant melanoma, an aggressive malignancy, is very rare in India and constitutes 0.3% of all malignancies with a recorded incidence of 3916 cases/year as per the data from GLOBOCAN 2020.
Despite dramatic improvements in survival over the last decade owing to the discovery of immunotherapy and novel targeted therapy (BRAF inhibitors), the outcome of malignant melanoma remains very dismal in India, as has also been reported by Shishak et al. in the last issue of the journal. Similar results were echoed recently by two other large publications on malignant melanoma from India.,
There is a scarcity of outcome data on malignant melanoma from India apart from these three publications.,, Shishak et al. reported anorectum as the most common primary site, followed by acral location, and this is consistent with the two previous reports., We request the authors to comment on the proportion of mucosal primaries, as the previous two studies reported a very high proportion of mucosal location.
The authors tested only 4 (4.3%) patients for BRAF V600E mutation. Bajpai et al. reported a BRAF mutation rate of 10.8% (n = 5/46, all cutaneous origin) which represented only 7% of the tested population (n = 659). This emphasizes the underutilization of BRAF testing in Indian patients with melanoma, which may be due to poor access to novel BRAF inhibitors, as mentioned by all the authors and correctly pointed out in the accompanying editorial. In our study, 35% of patients underwent mutational testing (all underwent next-generation sequencing), and 20% of the patients had BRAF mutation (v600 codon). Almost 50% of patients received systemic therapy in the current study, similar to the study by Bajpai et al. The study reported a dismal progression-free survival (PFS) of 2 months (95% confidence interval [CI], 1.2–2.7 months) which is inferior to the reported event-free survival of 3.98 months with systemic therapy and 3.1 months with best supportive care reported by Bajpai et al. We observed a median PFS of 6.1 months (95% CI, 4.4–9.1 months) in our cohort of patients with metastatic melanoma. Shishak et al. reported that the outcome was dismal even in the 16 patients who received nivolumab without a single objective response noted. The possible explanation for the poor results with nivolumab could be poor patient selection (immunotherapy may not be very effective in mucosal melanomas), high disease burden (providing the details of the lactate dehydrogenase levels could have been helpful), poor performance status, and the large number of metastatic sites.
Testing for c-kit mutation was only performed in 7 (7.5%) patients despite the large number of mucosal primaries. Mutations in c-kit have been reported in 28%–39% of mucosal melanomas. Imatinib has shown efficacy in c-kit-mutated mucosal melanoma. Detection of molecular mutations by newer techniques such as next-generation sequencing will lead to higher utilization of novel and effective targeted therapies. We expect that the cost of therapies will decrease gradually and improve patient access over time.
Access to immunotherapy and novel BRAF inhibitors is a major challenge in India. The outcome is dismal with conventional cytotoxic chemotherapy, as reflected in the study by Shishak et al. and the other two Indian studies.,, There is a significant heterogeneity in the demography and treatment pattern of malignant melanoma throughout India. A higher disease burden, delayed referral to higher centers, and poor coordination between dermatologists and oncologist lead to the dismal outcomes of melanoma in India. The creation of a country-wide melanoma registry and a coordinated, multidisciplinary approach with better access to novel targeted therapies will be the way to improve the outcome of malignant melanoma in India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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