75 NCCN Guidelines for Patients ® : Melanoma, 2018 5 Treatment guide Metastatic melanoma Targeted therapy may be preferred if it is needed for an early treatment response. Treatment responses to single-agent immunotherapy can take longer in some cases. Thus, targeted therapy may be preferred if melanoma is causing symptoms or progressing quickly or if your overall health is getting much worse. The immunotherapy drugs and targeted therapy drugs cause different side effects. Thus, your doctor will look at a number of factors to decide which treatment option is best for you. Such factors include your overall health, medical history, other current health problems, other current medicines, and your ability to take your medicine exactly as prescribed. Treatment results After starting systemic therapy, your doctor will give follow-up tests to check how well it is working. Progression is when the cancer grows, spreads, or gets worse. Maximum response is when the cancer is no longer shrinking or getting better in response to treatment. At this point, your doctor will consider second-line treatment options. Second-line treatment options The next systemic therapy options or second-line treatment options are recommended if the melanoma has progressed or stopped responding to first-line treatment. Your doctor will consider how well the first- line treatment is working. Second-line treatment will follow first-line treatment that did not work or cancer that progressed after completing first-line treatment. If disease progresses soon after, you may receive treatment with a different type of drug. If the disease comes back 3 months after the completing the first- line treatment, the same type of drug you got the first time may be given again. You may receive an immunotherapy drug—as a single agent—such as pembrolizumab or nivolumab which are anti-PD1 inhibitors. Other single agent immunotherapy options may include ipilimumab or high-dose IL-2. Or, you may receive both nivolumab and ipilimumab together—called a combination regimen. If you have melanoma that has a mutated BRAF gene, you may receive a targeted therapy. There are two combination therapy options: dabrafenib and trametinib or vemurafenib and cobimetinib. If you have melanoma that has a mutation of the c-kit gene, then another option is to receive imatinib. Imatinib is a type of targeted therapy. (See page 43 for details on imatinib.) Other systemic chemotherapy options are dacarbazine, temozolomide, paclitaxel, nab- paclitaxel, and carboplatin/paclitaxel. Most of these drugs are given alone—called single agents. But, carboplatin and paclitaxel may be given together— called a combination regimen. If your overall health is somewhat poor, and you can’t do all of your daily activities or much physical work, best supportive care may be recommended. Supportive care is treatment given to relieve symptoms caused by cancer or side effects of cancer treatment. It does not treat the cancer itself, but aims to improve your well-being and quality of life. NCCN experts also recommend participating in a clinical trial at any stage of disease. A clinical trial type of research that studies the safety and effectiveness of a test or treatment. See page 48 for more information on clinical trials or refer to the websites listed in Part 6.