Options for patients progressing on targeted and immunotherapy

What to do when the best options are exhausted?

I. chemotherapy
- preferably lower toxicity regimens as the quality of life is important
- status performance should be carefully considered
- bridge to other treatments

II. IL2 - seems less toxic

III. Surgical resection whenever possible

IV. Radiation therapy
CNS disease -radiation or surgery
Shorted courses of radiations more recommended -the same effect like long course of radio

V. Intratumoral treatments
T-VEC - 16% RR
IPI+T-VEC 38% RR
IPI+ HF10 41%

VI. Re-initiation of previous systemic therapies 
a) Ipilimumab - the same response rate was observed at re-initiation
b) anti-PD1s
b) Braf/Mek- duration of re-challenge is shorter than first time
- intermittent dosing?

Discussions
Steroids use during immunotherapy
Efficacy of immuno on corticosteroids not known, so oncs prefer NOT to have patients on high dose corticosteroids at the start of immuno.
Why two years duration for the treatment with immuno (as no data behind)? Oncs prefer to stay on the safe side because is less likely that after 2 years patients will progress.

Caroline R.:
- education of radiologists, surgeons, and other specialists working together- a must for better management of pts.
-immunotherapy -61 pts stopped the immuno -so far 2 years no one relapse (data from real life -France -Caroline Robert)
- relapse should be well documented by biopsy and pathologic test
- data to come on sequential treatment from the trial run by Paulo Ascierto et al.,(stopping Braf/Mek and switch to immuno , SECOMBIT, NCT02631447).