Melanoma

Regimen Options

Last Updated: 11/05/2024 See Details

	Evolent Pathways	Febrile Neutropenic Risk	Emetogenic Risk	References
STAGE III
Neoadjuvant plus Adjuvant Therapy	nivolumab and ipilimumab	Low	Low	NCCN Guidelines® for Melanoma V.3.2024. Blank CU et al. DOI: 10.1056/NEJMoa2402604
STAGE III OR IV
Neoadjuvant plus Adjuvant Therapy	pembrolizumab	Low	Low	NCCN Guidelines® for Melanoma V.3.2024. Patel SP, et al. N Engl J Med 2023;388:813-823
STAGE III
High Risk Adjuvant Therapy	nivolumab	Low	Low	NCCN Guidelines® for Melanoma V.3.2024. N Engl J Med 2017; 377:1824-1835
	pembrolizumab	Low	Low	NCCN Guidelines® for Melanoma V.1.2017. Eggermont et al. N Engl J Med 2018; 378:1789-1801
ADVANCED/METASTATIC - BRAF MUTATION (-) OR UNKNOWN (IF UNKNOWN, RECOMMEND MOLECULAR TESTING FOR BRAF MUTATION)
Initial Therapy	pembrolizumab	Low	Low	NCCN Guidelines® for Melanoma V.3.2024. Robert C, et al. Lancet. 2014;384(9948):1109-17.
	nivolumab	Low	Low	NCCN Guidelines® for Melanoma V.1.2017 Wolchok JD Chiarion-Sileni V, Gonzalez R, N Engl J Med 2017; 377:1345-1356 Lebbé C, Meyer N, Mortier L, Clinical Oncology 37, no. 11 (April 10 2019) 867-875. Hodi FS, Chiarion-Sileni V, Gonzalez R, DOI:https://doi.org/10.1016/S1470-2045(18)30700-9
	nivolumab and ipilimumab x 4 cycles followed by nivolumab; ECOG 0-2*	Low	Low	NCCN Guidelines® for Melanoma V.1.2017 Wolchok JD Chiarion-Sileni V, Gonzalez R, N Engl J Med 2017; 377:1345-1356 Lebbé C, Meyer N, Mortier L, Clinical Oncology 37, no. 11 (April 10 2019) 867-875. Hodi FS, Chiarion-Sileni V, Gonzalez R, DOI:https://doi.org/10.1016/S1470-2045(18)30700-9
Subsequent Therapy	pembrolizumab	Low	Low	NCCN Guidelines® for Melanoma V.1.2017. Robert C, et al. Lancet. 2014;384(9948):1109-17.
	nivolumab	Low	Low	NCCN Guidelines® for Melanoma V.1.2017 Wolchok JD Chiarion-Sileni V, Gonzalez R, N Engl J Med 2017; 377:1345-1356 Lebbé C, Meyer N, Mortier L, Clinical Oncology 37, no. 11 (April 10 2019) 867-875. Hodi FS, Chiarion-Sileni V, Gonzalez R, DOI:https://doi.org/10.1016/S1470-2045(18)30700-9
	paclitaxel	Low	Low	NCCN Guidelines® for Melanoma V.1.2017.
	dacarbazine	Low	High	NCCN Guidelines® for Melanoma V.1.2017.
	temozolomide	Low	Moderate	NCCN Guidelines® for Melanoma V.1.2017.
	Best Supportive Care or Clinical Trial	NCCN Guidelines® for Supportive Care.
BRAF MUTATION (+)
Initial Therapy	cobimetinib and vemurafenib	Low	Low	NCCN Guidelines® for Melanoma V.1.2017. Mey UJ, et al. Hematol Oncol. 2016:abstract. Ascierto PA, et al. Lancet Oncol. 2016;17(9):1248-60. van der Hiel B, et al. BMC Cancer. 2017;17(1):649.
	pembrolizumab	Low	Low	NCCN Guidelines® for Melanoma V.1.2017. Robert C, et al. Lancet. 2014;384(9948):1109-17.
	nivolumab	Low	Low	NCCN Guidelines® for Melanoma V.1.2017 Wolchok JD Chiarion-Sileni V, Gonzalez R, N Engl J Med 2017; 377:1345-1356 Lebbé C, Meyer N, Mortier L, Clinical Oncology 37, no. 11 (April 10 2019) 867-875. Hodi FS, Chiarion-Sileni V, Gonzalez R, DOI:https://doi.org/10.1016/S1470-2045(18)30700-9
	nivolumab and ipilimumab x 4 cycles followed by nivolumab; ECOG 0-2*	Low	Low	NCCN Guidelines® for Melanoma V.1.2017 Wolchok JD Chiarion-Sileni V, Gonzalez R, N Engl J Med 2017; 377:1345-1356 Lebbé C, Meyer N, Mortier L, Clinical Oncology 37, no. 11 (April 10 2019) 867-875. Hodi FS, Chiarion-Sileni V, Gonzalez R, DOI:https://doi.org/10.1016/S1470-2045(18)30700-9
Subsequent Therapy	cobimetinib and vemurafenib if not used 1st line	Low	Low	NCCN Guidelines® for Melanoma V.1.2017. Mey UJ, et al. Hematol Oncol. 2016:abstract. Ascierto PA, et al. Lancet Oncol. 2016;17(9):1248-60. van der Hiel B, et al. BMC Cancer. 2017;17(1):649.
	pembrolizumab	Low	Low	NCCN Guidelines® for Melanoma V.1.2017. Robert C, et al. Lancet. 2014;384(9948):1109-17.
	nivolumab	Low	Low	NCCN Guidelines® for Melanoma V.1.2017 Wolchok JD Chiarion-Sileni V, Gonzalez R, N Engl J Med 2017; 377:1345-1356 Lebbé C, Meyer N, Mortier L, Clinical Oncology 37, no. 11 (April 10 2019) 867-875. Hodi FS, Chiarion-Sileni V, Gonzalez R, DOI:https://doi.org/10.1016/S1470-2045(18)30700-9
	paclitaxel	Low	Low	NCCN Guidelines® for Melanoma V.1.2017.
	dacarbazine	Low	High	NCCN Guidelines® for Melanoma V.1.2017.
	temozolomide	Low	Moderate	NCCN Guidelines® for Melanoma V.1.2017.
UVEAL MELANOMA
	tebentafusp-tebn	Low	Low	NCCN Guidelines® for Melanoma v.2.2022. Nathan P et al. N Engl J Med 2021; 385:1196-1206

STAGE III

Neoadjuvant plus Adjuvant Therapy

Evolent Pathways

nivolumab and ipilimumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

STAGE III OR IV

Neoadjuvant plus Adjuvant Therapy

Evolent Pathways

pembrolizumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

STAGE III

High Risk Adjuvant Therapy

Evolent Pathways

nivolumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

pembrolizumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

ADVANCED/METASTATIC - BRAF MUTATION (-) OR UNKNOWN (IF UNKNOWN, RECOMMEND MOLECULAR TESTING FOR BRAF MUTATION)

Initial Therapy

Evolent Pathways

pembrolizumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

nivolumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

nivolumab and ipilimumab x 4 cycles followed by nivolumab; ECOG 0-2*

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Subsequent Therapy

Evolent Pathways

pembrolizumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

nivolumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

paclitaxel

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

dacarbazine

Febrile Neutropenic Risk

low

Emetogenic Risk

high

References

Evolent Pathways

temozolomide

Febrile Neutropenic Risk

low

Emetogenic Risk

moderate

References

Evolent Pathways

Best Supportive Care or Clinical Trial

References

BRAF MUTATION (+)

Initial Therapy

Evolent Pathways

cobimetinib and vemurafenib

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

pembrolizumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

nivolumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

nivolumab and ipilimumab x 4 cycles followed by nivolumab; ECOG 0-2*

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Subsequent Therapy

Evolent Pathways

cobimetinib and vemurafenib *if not used 1st line*

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

pembrolizumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

nivolumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

paclitaxel

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

dacarbazine

Febrile Neutropenic Risk

low

Emetogenic Risk

high

References

Evolent Pathways

temozolomide

Febrile Neutropenic Risk

low

Emetogenic Risk

moderate

References

UVEAL MELANOMA

Evolent Pathways

tebentafusp-tebn

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

	Regimen	Alternative
LOW VALUE REGIMENS (NON-PATHWAY) WITH SUPERIOR ALTERNATIVES
Initial Therapy	vemurafenib and cobimetinib and atezolizumab	Alternative: vemurafenib and cobimetinib
Subsequent Therapy	ipilimumab and intralesional T-VEC (talimogene laherparepvec)	Alternative: ipilimumab
Subsequent Therapy	albumin-bound paclitaxel (Abraxane)	Alternative: paclitaxel

LOW VALUE REGIMENS (NON-PATHWAY) WITH SUPERIOR ALTERNATIVES

Initial Therapy

Regimen

** vemurafenib and cobimetinib and atezolizumab **

Subsequent Therapy

Regimen

** ipilimumab and intralesional T-VEC (talimogene laherparepvec) **

Subsequent Therapy

Regimen

** albumin-bound paclitaxel (Abraxane) **

Pathways and Low-Value Regimens

Melanoma