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Case history

image A 77-year-old man was referred to the oncology clinic by the acute medical team following admission with shortness of breath on exertion. He informed the team that he had had a suspicious mole removed from his back a few years ago. He had grown up in South Africa. A full systems review elicited a further history of a 3-4 month gradual decline with fatigue, loss of appetite and weight loss of 3 kg in the last 6 months. He lived with his wife, who was in good health. Both were independent for personal and extended activities of daily living, although he admitted he was less active in recent months, leaving the house less and spending more of his day in a chair due to his breathlessness and fatigue. His Eastern Cooperative Oncology Group (ECOG) performance status (PS) was 2.

His past medical history included atrial fibrillation, for which he was receiving anticoagulation medication, type 2 diabetes mellitus, hypertension and angina. He did not regularly monitor his glucose levels but was under the care of his GP practice nurse who undertook regular cardiovascular and diabetes health checks. He had no known drug allergies and was taking digoxin, warfarin, metformin, ramipril and bisoprolol.

The acute medical team had organized a chest x-ray, which demonstrated a right-sided pleural effusion. A subsequent CT scan demonstrated widespread lymphadenopathy above and below the diaphragm, multiple lung metastases, liver metastases and a moderate right-sided pleural effusion. An ultrasound-guided liver biopsy revealed findings consistent with metastatic melanoma: molecular analysis did not demonstrate a BRAF V600 mutation.

What is the evidence for the use of contemporary treatments for metastatic melanoma in older patients?

What potential toxicities should physicians be aware of and what resources are available to guide their management?

What factors in our patient would influence treatment decision making and how should these be addressed?

What therapies are currently in development and is there any evolving evidence to support their use in older patients?

What is the evidence for the use of contemporary treatments for metastatic melanoma in older patients?

Malignant melanoma mortality rates have been rising since the 1970s, with the largest rise seen in those over the age of 75.1 Metastatic melanoma is an aggressive disease which historically has been associated with poor outcomes. Chemotherapy in the form of dacarbazine or biological agents such as interferon-alpha or interleukin-2 had little impact on the natural history of the disease.1-3 However, the advent of immunotherapy and targeted treatments has changed the therapeutic landscape for patients with metastatic melanoma. Ipilimumab is a fully human monoclonal antibody against cytotoxic T-lymphocyte-associated protein 4, an immune checkpoint molecule that downregulates T-cell activation. Inhibiting this crucial checkpoint mechanism increases T-cell activation and T-cell-mediated cell death. In 2010, a large phase III study of ipilimumab demonstrated for the first time an improvement in overall survival (OS) in patients with metastatic, previously treated melanoma.2...

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