Fetal and Maternal Factors Must Be Considered In Melanoma Management, ASCO Posters Argue

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Managing melanoma during pregnancy presents a substantial challenge as fetal and maternal factors must be considered. At the 2024 American Society of Clinical Oncology annual meeting, 2 posters presented real-world data concerned with the management of cutaneous and advanced stage melanoma during pregnancy, as well as explored associated outcomes.

The Management of Cutaneous Melanoma for Pregnant Patients

Ashley Hickman et al’s poster titled, “Cutaneous melanoma during pregnancy: Management and real-world outcomes,” investigated the incidence rates of antepartum melanoma.¹ Pregnancy-associated melanoma is rare, affecting 1 out of every 2200 pregnancies and 1% of female patients who have melanoma. Therefore, the researchers' study was designed to call attention to the treatment and management patterns for this patient population because, as they wrote, melanoma during pregnancy is a “high-risk scenario” that currently lacks standardized procedure.

Data were gathered from the Mayo Clinic electronic medical record system between 1987-2023. The key terms “pregnancy” and “melanoma” were used to identify 25 pregnant patients with melanoma; however, 6 of these patients were excluded from the analysis because notable skin changes throughout their pregnancy were not officially diagnosed as melanoma until after their delivery.

A total of 19 patients were eligible for inclusion. On average, individual melanoma diagnoses came at 30 years of age and a fetal age of 20 weeks. The authors noted that each patient experienced a term delivery, and 4 patients received a labor induction at the 37th week. There were pregnancy-related imaging or treatment delays that occurred for 60% of patients.

During pregnancy, 82% of patients with stage I-III disease had a wide local excision, yet, in 35% of patients the sampling of sentinel lymph nodes was put off until postpartum. After delivery, there were 3 stage II or III patients who underwent adjuvant therapy with either sargramostim or interferon. There was 1 patient with stage IV disease who underwent an MRI PET scan before receiving vemurafenib monotherapy throughout their pregnancy.

Overall, 7 patients (37%) went on to have another pregnancy. One patient from this group had a melanoma recurrence in their subsequent pregnancy (stage II in the first, stage IV in the second). “Melanoma diagnosed during pregnancy can be safely and effectively staged with sentinel lymph node surgery, MRI imaging (PET-MRI vs standard), and CT imaging with shielding without a need for early induction of labor nor a delay in cancer care,” the authors concluded.

Pregnant Patients With Advanced Stage Melanoma

Jessica SW Borgers et al’s poster titled, “Advanced stage melanoma during pregnancy: Real-world management,” noted the lacking available data regarding treatment guidelines for pregnant patients with advanced-stage disease.² Because treating advanced-stage disease throughout pregnancy presents great obstacles, they designed a study to gather real-world data on the management of melanoma with the aim of developing standard management guidelines for affected patients.

Between January 2011 and June 2023, the researchers collected patient information for those who had advanced melanoma during pregnancy (group 1) or had been receiving systemic melanoma treatment when they conceived (group 2). This data included characteristics of patients, primary tumors, melanoma, as well as the treatment interventions applied during pregnancy and maternal/fetal outcomes.

In total, 68 patients, constituting 72 across 7 countries, were identified. Patients were aged 32 years on average at the time of their pregnancy. For those designated to group 1, 38% received their melanoma diagnosis in the 1st trimester, 22% in the 2nd, 32% in the 3rd, and 8% at an unknown trimester. Overall, 76% of patients had cutaneous melanoma, 50% had stage IV disease, 48% stage III, 2% stage II, 7% mucosal, and 17% had another subtype. Pregnancies were terminated in 15% of cases. Additionally, 70% of patients exhibited a mutation to the BRAF gene.

There were 8 patients who received systemic treatment such as targeted therapy (63%) or immunotherapy (37%). After their pregnancy, 90% of patients switched or began a new systemic therapy. There was a median time of 28 days till the new therapy started (immunotherapy in 65%, targeted therapy in 27%, and chemotherapy in 8%). The overall survival rate at 5 years was 49% (95% CI, 34-69). In this group there were 50 live births, 68% of which were induced and 56% were preterm.

Throughout group 2, cutaneous melanoma was diagnosed in 82% of patients and 91% exhibited a BRAF mutation. Systemic treatment was initiated for 42% of patients with stage III melanoma and 58% of those with stage IV (TT 25%, IT 75%). Pregnancies needed to be terminated in 33% of cases, and 8% experienced miscarriage. The researchers noted that 43% of live births were preterm and 29% were induced. After pregnancy, 50% of the patients either continued or began a new treatment (TT 50%, IT 50%). The overall survival at 5 years in this group was 78% (95% CI, 55-100).

No children went on to develop melanoma. “This is the largest contemporary dataset of pts diagnosed with advanced melanoma during pregnancy and pts who became pregnant on systemic melanoma therapy, and provides a basis for developing clinical guidelines for this challenging population,” the authors concluded.

References

1. Hickman A, Smith KER, Nelson CK, et al. Cutaneous melanoma during pregnancy: Management and real-world outcomes. J Clin Oncol. 2024;42 (suppl 16):Abstract 21554. doi:10.1200/JCO.2024.42.16_suppl.e21554
2. Borgers JSW, Johnson DB, Livingstone E, et al. Advanced stage melanoma during pregnancy: Real-world management. J Clin Oncol. 2024;42 (suppl 16):Abstract 9540. doi:10.1200/JCO.2024.42.16_suppl.9540

[This article was originally published by our sister publication, American Journal of Managed Care.]