Address the nursing challenges associated with treatment for advanced melanoma: as seen in the Clinical Journal of Oncology Nursing and Oncology Nursing Forum.

Melanoma, particularly advanced or metastatic disease in late stages, is deadly and difficult to treat or control. Few treatments have much effect on the disease; dacarbazine is the only chemotherapy agent approved for advanced melanoma (Ledezma, 2009), but no real standard of care exists for the disease (Rubin, 2009). Oncology nurses have an important role in helping patients with melanoma understand their disease, treatment options, and side effects of treatment.

Current Treatment Options

Late-stage melanoma is associated with low one-year survival rates ranging from 41%-59%. Most therapies do not offer much improvement on these numbers; dacarbazine, the only drug approved to treat advanced melanoma, is associated with a 7.5% response rate and approximately eight-month survival (Ledezma, 2009).

Other treatment options for metastatic melanoma include (Rubin, 2009)

* Surgery and regional chemotherapy

* Interleukin-2

* Interferon alpha, which is the only adjuvant treatment approved for high-risk resected melanoma

* Cytotoxic chemotherapy

* Temozolomide

* Biochemotherapy.

However, all of these treatments are associated with low response rates and have not demonstrated an impact on median survival or quality of life in randomized, controlled trials (Rubin).

Treatments under Study

Because of the dismal options available for advanced melanoma today, several promising therapies are being studied for future use. Two agents currently in clinical trials that are showing significant benefit are ipilimumab and tremelimumab, types of monoclonal antibody therapy. A study currently under way has found that response to ipilimumab appears to be durable for months to even years in some patients (Ledezma, 2009).

Other treatments under study include (Rubin, 2009)

* Vaccines

* T-cell adoptive transfer therapy

* Targeted therapies or inhibitors

* Novel agents such as oblimersen and elesclomol.

Ipilimumab

Ipilimumab works differently from chemotherapy in that it engages a patient's own immune system to fight the cancer. This means that the time to response depends on an individual's immune system and can vary from patient to patient (Ledezma, 2009). Patients receiving ipilimumab should be educated that radiographic response will not be measured until they complete the induction therapy, unlike with chemotherapy where response is measured after the second cycle.

Most patients see some type of response around week 12 of treatment (completion of induction), but even that can vary. In some cases, disease appears to worsen before a response is seen. New lesions also have developed during therapy, but most end up responding to treatment (Ledezma, 2009). Patients should be taught that worsening lesions or the appearance of new lesions does not always indicate treatment failure and progression needs to be confirmed.

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Side effects of ipilimumab are mostly immune related and include gastrointestinal effects (e.g., diarrhea, enterocolitis) and skin conditions (e.g., rash, dermatitis). Nurses should note that grade III or IV diarrhea from ipilimumab therapy should be treated with corticosteroids to reduce the immune response, rather than usual diarrhea treatments. Other less common side effects include hepatitis, hypophysitis, uveitis, nephritis, and endocrinopathies (Ledezma, 2009).

Nurses have an important role in educating patients and their families about what to expect from ipilimumab therapy, including response and side effects. See Figure 1 for nursing approaches to patient education regarding this treatment.

For more information on metastatic melanoma and ipilimumab therapy, refer to the full articles by Ledezma (2009) and Rubin (2009).

Key Definitions

Advanced or metastatic melanoma: stage IV disease that has spread beyond the surrounding tissue and lymph nodes to other parts of the body, such as the lungs, liver, or brain

Cytotoxic T-lymphocyte antigen-4 (CTLA-4): a negative feedback mechanism that limits the body's developing immune response to keep it from becoming overactivated and causing nonspecific damage

Ipilimumab: a monoclonal antibody that inhibits the activity of CTLA-4, enabling the body's immune system to fully attack the cancer key Definitions

Ledezma, B. (2009). Ipilimumab for advanced melanoma: A nursing perspective. Oncology Nursing Forum, 36(1), 97-104.

Rubin, K. (2009). Management of metastatic melanoma: Nursing challenges today and tomorrow. Clinical Journal of Oncology Nursing, 13(1), 81-89.

Elisa Becze, BA, ONS Staff Writer

Figure 1. approaches
to patient Education
regarding ipilimumab

* Provide a basic explanation of
how a patient's immune system
fights tumors and how ipilimumab
can stimulate the immune
system.

* Describe how ipilimumab differs
from chemotherapy.

* Review possible side effects with
patients and families at the beginning
of the study, at the time
of consent, and at every visit.

* Instruct patients and families
to have over-the-counter medications
on hand to treat any side
effects that may develop during
treatment.

* At every clinic visit, ask patients
about specific side effects they
may be experiencing.

* Have patients document every
side effect or symptom, even if
they do not appear to be treatment
related, and instruct them
to call their nurses or physicians
at the onset of any symptom or
side effect.

* Call patients daily or every other
day if they report any ipilimumab
side effects, and have a nurse
available by phone to reassure
patients who are waiting for a
response.

Note. Based on information from Ledezma,
2009.