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Melanoma Concerns: Am I at Risk During the Coronavirus Crisis?

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Published on April 14, 2020

Key Takeaways

  • For early-stage melanoma, curative surgery may be delayed up to 90 days without an adverse outcome.
  • Regular surveillance visits for stage I or II melanoma can be delayed for three to six months. For stage III, where it has gone to the lymph nodes and has a higher risk of recurrence, it should be done as a telehealth visit.
  • With the asymptomatic spread of coronavirus, stay-at-home measures and social distancing go a long way in limiting and preventing transmission. 

Coronavirus is anxiety-triggering for many melanoma patients, raising concerns about treatment, testing and staying safe from exposure. Is care being modified during the outbreak? What kind of support is available?

Dr. Sapna Patel, from The University of Texas MD Anderson Cancer Center, and Shelby Moneer, from the Melanoma Research Foundation, share some melanoma-specific guidelines and resources to help patients navigate care during the pandemic.

Watch as Dr. Patel explains how different melanoma therapies impact immune function, and the key things that patients should discuss with their medical team. Shelby also provides financial assistance resources and ways to connect with the melanoma community in this time of social distancing.

[Due to extreme load on our website and Zoom platform, viewers may experience a time delay between the audio and video of the interview - please note the transcript can be read below.]

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Transcript | Melanoma Concerns: Am I at Risk During the Coronavirus Crisis?

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Recorded on April 10, 2020

Esther Schorr:
Hi there. This is Esther Schorr with Patient Power, and welcome to our discussion today; April 10th, 2020, talking about melanoma during the time of this coronavirus pandemic. Our guests today, who I want to welcome to join me, are Dr. Sapna Patel; she is an associate professor at the Department of Melanoma Medical Oncology at MD Anderson. We also have with us Shelby Moneer, the director of education at the Melanoma Research Foundation; so, welcome to the both of you, and thank you so much for being here.
 
I also want to say right at the top to thank the Melanoma Research Foundation for joining us today, and we'll get to her a little bit, along with all of the good medical information that Dr. Patel will give us, we'll also hear about what the foundation is doing to support patients during this pandemic and beyond. Of course, they're there for you always.
 
I want to do one housekeeping thing, that if you are listening to our program today and you have questions that you would like us to ask of our experts, at the bottom of your screen, there is a Q&A button, and I have a special associate producer in the background who is looking at those questions and will make sure that we see them. That happens to be Andrew Schorr, who is the co-founder of Patient Power, and also my husband and beloved, so, thank you, Andrew.

Shelby Moneer:
Yes, please.

Esther Schorr:
Okay, or would you like Sapna, Dr. Patel? Your preference.

Dr. Patel:
Oh, either one is fine.

Esther Schorr:
Okay. We'll have equality here.

Let's talk about melanoma. What I do know is that there are different types of melanoma. They require different kinds of treatment along the way, depending on the stage and the type. Let's start with you, Sapna. Can you please give an overview of the key things that melanoma patients should be discussing with their medical teams in light of the current coronavirus situation?

Dr. Patel:
Sure. For melanoma, there are three main ways to treat a melanoma, predominantly, that occurs on the skin. We either use surgical excision, sometimes we supplement that with radiation, and then there are times that we use drug therapy for melanoma. At this moment in time, melanoma experts have produced some expert guidelines on how to manage melanoma in the time of the COVID outbreak and pandemic, and the guidelines suggest that for early-stage melanomas, the definitive surgical maneuver, the curative surgery can be delayed up to 90 days without an adverse outcome; there is literature to support this. So, rather than utilize an operating room, anesthesia, which may have some issue with aerosolization of respiratory secretions, and then using up the personal protective equipment and hospital resources, this can be delayed until we're out of this COVID pandemic situation. This could be for newly diagnosed melanoma patients.
 
For patients who are already in the middle of treatment, perhaps they're post-operative and thinking about radiation or drug therapy, radiation is typically being held off and postponed in favor of drug therapy if a patient is a candidate for either or both. The medical therapy is really carrying the bulk of the experience during the COVID pandemic. We are using medical therapy for patients who have palpable lymph nodes; rather than take them to a large lymph node surgery, we're using medical therapy for a couple of months, perhaps eight to 12 weeks, and medical therapy is the mainstay for stage IV or metastatic melanoma. Our medical clinics are still maintaining good patient volumes, but we do have direction on what to do if you're looking for surgery or radiation for your melanoma.

Esther Schorr:
Okay, so to kind of sum that up for the layperson, it kind of depends. If you're an early-stage, there must be some decision about whether to proceed or not proceed with treatment, or just delay it a while. If you're in a later stage or you're getting certain kinds of treatment, maybe radiation or something else, there might be a decision to either delay or put you on a different kind of therapy?

Dr. Patel:
That's right.

Esther Schorr:
Okay.

Dr. Patel:
Esther, there's the in-between patient. There's the patient who has been treated with melanoma, and they come for their regular surveillance visit. And so, we have guidance that says for a stage I or II melanoma, this should be delayed about three to six months. And if it's a stage III melanoma, where it has gone to the lymph nodes and perhaps a higher risk of the melanoma returning, this should be utilized as telemedicine visits, sort of like what we're doing here, where a patient and a doctor would communicate via video visit, and radiology scans can still take place, but they would be passaged electronically to the doctor's office rather than them having to go into the office and review the scans in-person.

Esther Schorr:
Okay, so we're talking here about the potential to delay treatment. Shelby, I want to ask you, in the context of your interaction with patients, I would think that a trigger here might be just the anxiety of, "Oh, my God, I want to get treated." What are you hearing, and how can patients deal with that, and what kind of support is there for that side of the equation?

Shelby Moneer:
What a great question. Yeah, that term "scanxiety" is really common, I think, probably in many cancers, but certainly amongst melanoma patients. And so, to hear that possibility of a delay, whether it has to do with scans for surveillance or maybe even lab blood work—just to Sapna's point, it's a one-on-one basis and those conversations have to be happening with those healthcare providers, and making sure that the patient has that advocacy confidence to ask those questions and to advocate for their own care and feel empowered to have those discussions with their healthcare provider. That's what we're hearing a lot of on the patient side, "Should I be concerned about a recurrence at this time, and how long is okay?"
 
The fact that those guidelines exist has been a huge sigh of relief for the patient perspective that we've heard so far.

Esther Schorr:
Are those guidelines, and either of you can answer—so, the guidelines that you're talking about, are they something that a patient should ask about, or the assumption is that the practitioner will say, "Okay, here's the guidance about this, and to alleviate your concern about delaying something, here's why we're doing it."

Dr. Patel:
Yeah, Esther, the National Cancer Comprehensive Network, the NCCN, has guidelines for each stage of cancer, and there are certain cancers—breast cancer, melanoma, and some others—that have the task forces that got together very quickly and formulated COVID-specific guidelines. Not every cancer has that. With all the information that's coming in every direction to everyone, patients and providers and advocacy groups and everywhere, it never hurts for somebody to be informed. And so, for a patient to say, "Are there specific guidelines for what to do? I heard perhaps that there may be some on the NCCN," this might prompt a practitioner to go double-check, and there are—NCCN has a COVID link, and then in there are these melanoma-specific guidelines. The normal guidelines are 110 pages. These guidelines are four pages. It's very succinct, so very clear and directional.

Esther Schorr:
Great, okay. That's helpful. Let me back up to the 10,000-foot level again for a second. One question that's come up across all cancer types from patients has been, when we say somebody with cancer, the big group, is at higher risk related to the virus, with melanoma patients, does higher risk mean a higher risk of getting the illness, or of it being more severe if they get it, or both? Does it depend on which type of melanoma or how recently you've had treatment? What is higher risk, and does that apply to melanoma patients?

Dr. Patel:

Yeah, that's a great question. A lot of this data comes out of China, since they had such a head start. And what they have published in 54,000 cases that happened in the Hubei province where Wuhan is, they looked at the 1,000 or so patients that had cancer, and the rate of fatality once you have contracted coronavirus was higher in the cancer population. This is essentially what the message has been through the World Health Organization, is that a cancer population perhaps is more vulnerable once they have the infection.
 
As far as obtaining the infection, we know that stay-at-home measures and social distancing measures go a long way in preventing you from contracting this. There is a quite a bit of asymptomatic community spread of coronavirus, and really, the best thing you can do is stay at home. A cancer patient who is on treatment perhaps is more susceptible if their immune system is lowered—not all cancer treatments lower your immune system. Traditional chemotherapy does, but traditional chemotherapy is not a mainstay treatment for melanoma these days. We've been very fortunate for about nine years now to be shying away from chemotherapy and using more of these immunotherapy-based agents.
 
Immunotherapy agents do not weaken your immune system, but by no means should a patient think the opposite, "Oh, I am strengthened, and I am fortified against coronavirus." In fact, the inflammation that is induced from immunotherapy treatments may actually make complication from coronavirus more severe if you were to contract it. We don't know that a melanoma population, specifically, is more susceptible, but we certainly do want everybody to enact stay-at-home and social distancing measures where possible just to limit even the contraction of it in a melanoma population.

Esther Schorr:
What about radiation specifically, because that's one I know that is used very often? Is that one that patients should be more concerned about in terms of what it does systemically?

Dr. Patel:
Yeah, similar to immunotherapy, it's not a direct poison like chemotherapy, but there is a limitation to what it does to the immunity. So, it's typically going through skin and then targeting either a deeper soft tissue area or an organ. On its way, there is some destruction of the immune system that can be happening. Certainly, we would want to protect our radiation population.
 
In melanoma, our COVID-specific guidelines are suggesting that if radiation is necessary for stage IV disease, that it's limited to a one day, one dose of radiation for symptomatic control. That's quite different than what we normally do outside of COVID, which is multi-day radiation treatments for longer-term control.

Esther Schorr:
Okay. Other than in New York City, everybody else has not quite been at the front line of what the real intense confrontation with this disease is. Is there yet any data on melanoma patients who have contracted the virus, maybe from New York City or other places, that is giving any additional guidance to the rest of the practitioners?

Dr. Patel:
Right now, I think the bulk of our guidance is coming from our Italian colleagues; so, Italy, of course, is even a few weeks ahead of New York City. We have a melanoma expert who has been on the forefront of treating coronavirus at the cancer hospitals in Italy, so we do have some information. It's not broken down in terms of numbers of melanoma patients. Melanoma remains about the fifth and sixth most common cancer in U.S. male and females, and so, really, the numbers are lumping all cancer patients together, the majority of which are lung cancer, breast cancer, prostate cancer, colon cancer patients. We don't have great annular data right now on melanoma.

Esther Schorr:
Okay. We're going to switch gears a little bit back and forth, so we have some patient perspective questions and the real medical stuff. I have a question for you, Shelby. If people are having trouble paying for their co-pays, for example, or they have the insurance issues with covering medicines during this—we have a lot of people that are now out of work, et cetera—what are the resources for them? Maybe that will also lead to a bigger question, but if you want to talk just for a minute about what your foundation is doing overall to support patients with melanoma?

Shelby Moneer:
Yeah, absolutely. The Melanoma Research Foundation primarily raises funds to fund research done in labs and clinics and major academic medical centers, but we partner with several organizations, one of which is the PAN Foundation; they're a patient assistance fund organization. We also work really closely with an organization called CancerCare. They're based out of New York, actually, so they're all working remotely like we are, but the mission continues, as we say, and we're going to continue fighting for the melanoma community.
 
We are also working really closely with our generous pharmaceutical partners who fund our education and our advocacy programs, and to some extent, some of our research programs, and they are really beefing up their already existing and great financial resource programs. They're taking applications online, they're lowering some of the bars, I guess, if you will, or standards for receiving free treatments and out-of-pocket expenses. We've just been really trying to make those connections and make sure that the patient community and the caregiver community knows that there are a great deal of resources out there.
 
We're also really working to make sure that patients are staying connected with one another, so we're encouraging some online support to stay connected and to bounce ideas off of each other. We have a really active online patient forum, and so we're seeing a lot of uptick there in getting patients and caregivers connected to one another in this time of social distancing when they might be really used to, of course, seeing family and friends and doing their usual routine, but also seeing their treatment providers and maybe even other patients who might not be melanoma patients, but patients they see in waiting rooms and places like that. We're really trying to work together with other organizations who focus on both financial assistance and that psychosocial portion of a diagnosis to make sure that the community is still a community.

Esther Schorr:
No, that's great. Who should a patient call for the kind of assistance you're talking about? Should they contact your foundation first, or should they work through their local hospital or clinic? What's the go-to?

Shelby Moneer:
Probably both and all of the above. I take the majority of the patient questions at our foundation. Sapna knows my colleague, Lauren, well. Lauren is our Programs Officer for our rare subtypes. So, I tend to take more of the cutaneous, the skin melanoma patient questions, and my colleague Lauren tends to take more of the mucosal and the ocular, sometimes the pediatric-related questions. Ultimately, when it comes to the patient support services and the financial assistance resources, those can all kind of be filtered through the general melanoma phone number. They most often come to me, and we'll kind of get them going down the right direction.
 
When I'm on the phone with a patient or exchanging emails with a patient, of course, we don't offer medical advice. We're not doctors. We don't see or treat patients, but providing them with all of those resources—maybe they tell me that they're on a particular treatment, and we can kind of go into that drug company's site and provide the phone number or the email address and kind of go through the bullets of each of those foundations or drug companies' protocol.

Esther Schorr:
Thank you. What I think we should do is, for sure, we're going to have a replay of this program in a few days on our website, but would the best website to start with be the Melanoma Research Foundation? Is it dot org, MRF.org?

Shelby Moneer:
It's melanoma.org.

Esther Schorr:
Melanoma.org, okay.

Shelby Moneer:

Yep, and then I can be contacted directly at education@melanoma.org, so both fairly easy to remember, and I'm the person, so they all come to me.

Esther Schorr:
Okay, perfect. Thank you so much.

Shelby Moneer:
Absolutely.

Esther Schorr:
Let's get back to some of the medical stuff. Dr. Patel. If someone is on an oral therapy, does anything change during this virus period? The dosage—and is this for all oral treatments?

Dr. Patel:

Good question, Esther. In melanoma, when we start thinking of how our treatments are administered, we have the oral agents, and we have the intravenous immunotherapy agents. Where possible, we are shifting patients to oral therapy right now. Because of ease of delivery, patients are in control of their own supply, you don't have to come to an infusion office periodically. But recognize we should tell the audience that oral therapies are not an option for the entire melanoma population. You have to be genomically categorized and eligible for that treatment. It's similar in breast cancer where you have to have certain markers in order to take certain drug—same thing in melanoma.
 
The oral therapies have this co-pay issue, and so, co-pay assistance using Melanoma Research Foundation, the patient assistance programs, could be vitally important during this time, and that co-pay assistance usually is in the form of paperwork and that sort of stuff that can still happen remotely during this time of COVID.
 
Medications are typically not able to be picked up at your local pharmacy. So, in Texas, where a Kroger/H-E-B kind of grocery store chain, we use Walgreen's and CVS for our drug stores, you would not be able to pick up your melanoma prescriptions at those types of pharmacies. They'd have to be dispensed throughout outpatient specialty mail-order pharmacies, and to our knowledge, these are all still up and running and processing prescriptions. Then those medications get delivered to a patient's house by mail order once a month.
 
This is that being the easiest way to maintain a patient on therapy. They're on oral therapy that comes through the mail, you do these telemedicine visits to check their toxicity. Ask them to show you their skin, ask them a number of symptoms, and manage their side effects. There is periodic testing that still needs to be done, EKGs need to be done, echocardiograms for heart monitoring. These will require office visits periodically, but usually only about every six to 12 weeks at the start of medication therapy.

Esther Schorr:
Yeah, so that really is one of the questions—I actually got a question from an 84-year-old stage IV melanoma patient in New York City, and his concern was whether it was too dangerous to go into the hospital three times a month—which he's on pembrolizumab (Keytruda) and T-VEC (Imlygic), a couple of different things. I guess this is sort of around this question of, how long can he go without treatment during this pandemic period?

Dr. Patel:

Good question. Let me shift over to the intravenous drug.
 
With the oral therapies, probably no dose adjustments, they can take it as normal. The intravenous agents, which would be more broadly applicable to the melanoma population—they don't have to be genomically matched to anyone's melanoma. Roughly speaking, most melanoma patients would be eligible to receive some form of intravenous immunotherapy. You'd have to come into an infusion center, a nurse has to start an IV, the drug has to be infused, you're monitored, and then you're sent home.
 
We do have dosing guidelines now in the expert COVID-19 melanoma guidelines that we published. We do have guidelines suggesting how to sort of broaden the dosing so that the patient comes less often to the visit. Typical dosing for Keytruda, for example, is 200 milligrams every three weeks. Now, there is evidence, and the European regulatory agencies have already approved alternate dosing of Keytruda, where it can be dosed at 400 milligrams every six weeks, and this was based on a number of preliminary laboratory-based studies that the company did showing that the clearance of the drug is very linear in the body, that the maximum levels it achieved at 400 milligrams and the minimum levels it achieves at 400 milligrams dosed every six weeks is adequate, it's safe. It's probably more than safe compared to other doses they have tested, and it has full receptor occupancy. It's hitting the target on the T cell that you need it to.
 
All of that combined, our expert guidelines have suggested even in light of the FDA not approving an extended dosing schedule, that this would be reasonable to decrease resource utilization at this time and decrease patient exposure. As I mentioned, the European regulatory authorities have already approved Keytruda doses at this six-week dosing, based on this preliminary evidence. That is all on pause at the moment in the U.S., the FDA re-review of this information. But we have empowered the medical oncologists to look at these alternate dosing strategies to minimize interaction with an office.
 
You brought up something else that's very interesting, and it's this idea of T-VEC (Imlygic). The melanoma population will know that what T-VEC is, is an inactivated herpes virus that is injected into the skin tumors, the skin and subcutaneous tumors. And what happens is that gets taken up by the cancer cells—the herpes virus takes over some of the cancer cell machinery to replicate, and then ruptures the cell as viruses do. As coronavirus does in your lung tissue, this is what the herpes virus does in the skin tissue.
 
The herpes virus is a non-infectious strain, so it has lost the gene to actually cause herpes blisters or viral exanthem, but what it does do is it takes over host machinery and ruptures. Injecting it directly into a cancer cell can be very beneficial, but this is a very resource-utilized procedure. We do these procedures, T-VEC injections, even outside the time of coronavirus, fully in PPE. We have a mask with a face shield for in case the drug or the virus splashes back. We have a gown. We have sterile gloves that we put on. It's quite an activity alone, so in this moment, T-VEC injections are recommended to be postponed, simply because of the amount of sort of bodily fluid interaction and protective equipment that it can utilize. But the Keytruda in the background could continue for somebody who is doing a T-VEC plus Keytruda type of maneuver.

Esther Schorr:
It sounds like it's a bit of a moving target, and that all of you are trying to stay ahead of what are the options during this unusual time, and that you really have to be, as a patient, talking to your practitioner where you are to see what makes sense for you given your particular profile.

Dr. Patel:
That's right, and, Esther, one more point with the infusion medications, as opposed to oral medication, an infusional medication stays in your body for 25 days. The intravenous Keytruda, nivolumab (Opdivo), ipilimumab (Yervoy) a little bit less than that; maybe 20, 21 days. In medical science, we think it takes four of those sort of half-lifes—I should say, it's 25 days for the medicine to reach half of its potency, so it actually stays in your body for 100 days. It takes four of these half-lifes to clear the medicine out.
 
One dose of something during this time of COVID pandemic, and then a delay of your subsequent treatments, still leaves plenty of drug in your body for 100 days.

Esther Schorr:
Got it. Okay, so those of you who are listening, this is a lot to absorb. I'm guessing it may prompt even more questions, and if you have them, hit that Q&A button, and Andrew will get us those questions.
 
One area that we haven't yet explored is clinical trials. There are probably folks listening who are either on a clinical trial for melanoma, or may be considering one, and I would—sort of the general question is, what happens to a clinical trial if you're in the middle of it? Can there be any kind of accommodation made for some of the things that you would normally, say, have to travel for? If you have to go to a regional center, can that be coordinated, so you can stay home or stay close to home? Talk to us a little bit about that.

Dr. Patel:
Sure. Clinical trials are all also moving targets, and they're all individualized to the sponsor and the patient, and how far they're traveling. It always behooves the patient to have a local oncologist. If they're traveling somewhere for a clinical trial—say, you're traveling to an MD Anderson, a Memorial Sloan Kettering, Dana-Farber—it always behooves you to have a local oncologist in your hometown. If side effects were to hit on a treatment, they're likely going to hit when you've left that clinical trial site and traveled back home. So, for just the bare reasons, that's why it's important.
 
In this moment, it's becoming even more important, because just as you say, the clinical trial sponsors are allowing us to transfer some of the responsibility to a local physician, should a patient already have one. This is a very difficult time for a patient to try to get a new patient appointment with any type of physician back home, because dermatologists’ offices are being closed, eye doctors’ appointments are limiting availability—even cancer clinics are limiting the cancers that they're intaking right now simply because of staffing and resources.
 
If they have an existing local oncologist, clinical trial by clinical trial, we're evaluating what can be done locally. Oral agents now have National Cancer Institute approval to be shipped. That may come with some oversight of the FDA. Normally, oral clinical trial agents have to be picked up in-person, and they rarely can cross state lines through the mail. But we're in a unique time, and so this has been allowed now.
 
The intravenous agents are very tricky, and so there are all sorts of answers there. No, they can't be moved. They can be delayed. If it's standard of care, it can be administered back home, but then you have to have in writing, “Are they going to bill the clinical trial hospital or bill the insurance?” Very complicated question for patients already on it, but the good news is if they are already on a clinical trial, the rug should not be pulled out from under that. The difficulty is somebody who is getting ready to start a clinical trial. This is where the rug is getting pulled out, because clinical trial operations at most clinical trial centers across the country have been reduced to less than 10 percent of their effort. If you were just about to start a clinical trial, there may be complications now, but instead, they will buy you some time with just standard treatment until the clinical trial re-opens.

Esther Schorr:
Got it. I think, looking at the time, the last area that I want to talk about is, we're all hoping, praying, and we do have confidence, at some point, we're all going to get back to some sense of normalcy. Now, obviously, cancer patients, their normal is different than somebody who isn't dealing with cancer, but I just wanted to get some commentary, both from a medical standpoint and from your standpoint, Shelby, in the services that you're providing to patients about—what might that look like?
 
For example, testing for the antibodies, where—that might be something that you could talk to, Dr. Patel. How important is that going to be in the scheme of things to know about your antibody profile? Will research resume as normal? Just give me a little color commentary on that, on the projection of what normal will look like.

Dr. Patel:
Yeah. Normal, for me, when I engage with a cancer patient in clinic, it’s very personal, and it's very tactile. I am a hugger. I like to put my hands on their back. I like to—of course, we do an exam, and I like to end the visit often with a hug or a handshake. Of course, Dr. Fauci is saying, we may be entering an era where there are no more handshakes. In the oncology office, I suspect we will be the exception to that. It is such a personal relationship that a cancer patient has with their oncologist.
 
I cannot imagine, and it has been very difficult the last four weeks with a mask covering your face, saying, "Okay, take care. I'll see you, or I'll talk to you on the phone next time," and not having that tactile embrace. I project that I will go back to that sense of normalcy.
 
As far as antibody testing, I think this is paramount for the cancer population. As every fall comes along, we strongly advise for flu vaccination, and coronavirus is not a flu, of course, it is a type of respiratory virus of the nasal passages and the lungs. If our cancer patient population either is more susceptible, or the treatments could lead to more complications should they get a strain of coronavirus, it would be vitally important to know if somebody already has immunity. Being able to test for antibodies is, in my opinion, vitally important, but as people are probably aware, this testing is not up to capacity. And it's very unclear if this will be in the hands of private companies, if state or local governments have to jump in and provide this laboratory testing, or if the federal government and things like National Infectious Diseases, CDC, WHO will come in and help with these testings. I think that would be vitally important for a cancer patient to know their immunity to coronavirus. As we know, so many people have been asymptomatic carriers.
 
As far as clinical trial operations, I think we're going to get back up to normal speed. And we're going to find a wave of patients who have been doing standard therapy during these six to eight weeks for all types of cancer, who now need some additive therapy, and we'll have a wave of big, interesting clinical trials after all of this.

Esther Schorr:
Great, thank you. Shelby, in this sort of path toward getting back to normal, can you comment a little bit on what your organization, and perhaps other ones like it, will be doing over the next weeks and months to help people make this transition?

Shelby Moneer:
Absolutely. First, I want to just say, it's always been clear, but I feel like it's never been more clear now that these healthcare workers, the folks on the front line, the Sapna Patels of the melanoma space—it's just half-art, half-science in this treatment world. Like I said, that's always been the case, but it's just never been more clear that the dedication of our physician and nurses in that healthcare provider space is just unreal. It's hard to even put it into words, so just another kudos to our providers.
 
The MRF actually just closed our RFP, which is a request for proposals window, and that is when researchers submit proposals to us for review. It's a really strong peer-reviewed process. We actually received 73 applications for funding, and so we are just kind of lining up reviewers right now. Last year, we implemented for the first time a patient review process. So, we will also have some of the lay-level reviewers that will take part in our review panels. We're just right now accepting applications for that part of our peer review process, but the research continues, the funding will continue. We're all having to be really creative.
 
We don't have that burden that our healthcare providers have, but we do have that burden of, like everyone, we've had all of our events canceled. We've all of our fundraising events canceled. Our in-person patient education events were canceled, many of them postponed, so we're trying to secure dates, and next weekend was our Ocular Melanoma Patient symposium, which is an annual event bringing together hundreds of patients and caregivers. We're just trying to be creative and come up with those replacements.

Esther Schorr:
Virtual!

Shelby Moneer:
Yeah, exactly. Everything is virtual. We're going to have a lot of webinars.

Esther Schorr:
Thank God for technology.

Shelby Moneer:
Exactly. We're going to have a lot of webinars, Zoom meetings. Our fundraising team put together a really fun—it's called April 30 in 30. It's 30 events in April. We are trying to raise $30,000, which will fund 10 medical student awards. We really want to make sure that we're still encouraging those young researchers to stay involved and really change the space and move the needle in the melanoma community.

Esther Schorr:
Well, I mean, I can only speak as a care partner to a wonderful cancer patient who is not a melanoma patient, but the issues are the same and the thanks from the bottom of our heart to people like you, Dr. Patel, and you, Shelby Moneer, for the work that you do collaboratively, separately, together—we just can't thank you enough.
 
In closing, Shelby, are there any other burning questions we should ask Dr. Patel from a medical standpoint during this crisis that we haven't asked yet? I'm sure once we all hang up, we'll think of five questions.

Shelby Moneer:

A lot of the questions that we have been receiving, we've tackled. Other things that we've been hearing would include side effect management, especially from the immunotherapy standpoint. These drugs are all so new. I mean, they're not quite as novel as this coronavirus, but we're still learning so much in the melanoma space about what the long-term side effects are of these immunotherapy drugs that have been approved in the last eight to nine years. We're learning things like, “Does it make sense to go into the hospital when I've been on prednisone (Deltasone or Rayos)?” which is a medication that is compromising my immune system. But it's not related to the melanoma specifically, it's related to a side effect.
 
We're kind of navigating those waters, and I'm sure Dr. Patel can speak for 30 minutes on that subject, but something like that has been coming up, and again, part of that half-art, half-science perspective—so I think, probably, that would be kind of a nice topic for her to touch on for a second.

Esther Schorr:

Well, yeah, if you could, Dr. Patel—just basically, I'm hearing the question is, side effects of whatever it is you're taking for whatever reason as a patient, what do you do with that? Go to your practitioner? Wait? What do you do?

Dr. Patel:
What do you do? Actually, in our COVID-19 guidelines, we've actually decided. And we've pretty clearly said, when you are debating between treatment A and treatment B, and there is a clear difference in side effect panels, go for the less side effects one.
 
This really means we're taking people away from the combination immunotherapy and giving them single agent Keytruda, single agent Opdivo. The side effect rate, the severe adverse event rate, is less than half than what you see when you start combining Keytruda with other agents, or Opdivo with other agents. We are going for the mono therapies, and threefold reasons: one, the rate of side effects is lower; two, those side effects, as Shelby said, are managed with steroids, and that steroid could be detrimental should you contract coronavirus, and then you are also on steroids; and thirdly, the side effects often lead to a systemic inflammation or there are results of systemic inflammation, which then, if you contract coronavirus, could be doubly bad—a double hit, sort of, on the lungs.
 
For all of those reasons, we're really recommending providers stick to the less side effect profile regimens. And if the patient were to have a side effect, telehealth with your provider, see what can be managed over the phone, what can be done to keep you out of the clinic, out of urgent care, and out of emergency rooms. Knowing that there will still be 3 to 5 percent of patients that need to be managed by an emergency system, we would prefer to do this over the phone and be a telemedicine if we can.

Esther Schorr:
Great, thank you. I have a feeling that there will be more questions as time goes on, but I want to thank both of you for taking time to do this. For our audience, you can continue to send us questions and comments to comments@patientpower.info, and we will have a replay that will include a transcript early next week of this discussion.
 
Last thing, I just want to give a round of applause and a religious prayer of thanks to medical practitioners, to support people who are helping not only the melanoma community, but all communities that are struggling right now in this crisis. Thank you both, and thank you to those who are watching, and remember, this is Esther Schorr, and knowledge can be the best medicine of all.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.
 
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