Melanoma is one of the major cancer types for which new immune-based cancer treatments are currently in development. This page features information on melanoma and immunotherapy clinical trials for melanoma patients, and highlights the Cancer Research Institute’s role in working to bring effective immune-based cancer treatments to people with melanoma.
Melanoma is the deadliest form of skin cancer. Although it comprises only 5% of skin cancer cases, melanoma accounts for 77% of skin cancer-related deaths. Over the past few years, immunotherapy has dramatically changed the landscape of melanoma treatment. The immune-based treatment ipilimumab (Yervoy®) was the first drug shown to extend survival among patients with advanced melanoma. A number of exciting new immune-based treatments in development promise to save more lives.
One of the world’s fastest-growing types of cancer, melanoma claims one life every hour. Although melanoma is often easier to detect in its earlier stages than most cancers, it is also more likely to spread (metastasize) to other parts of the body. Metastasis represents the most significant cause of death from the disease. The 5-year survival rate for localized (stage I and II) melanoma is 98%; however, this drops to 16% in cases where cancer has metastasized to distant sites or organs.
Treatment for melanoma depends on the properties of the tumor and the stage at which the cancer is detected. If discovered early, the tumor may be removed surgically. In the case of advanced disease, the tumor is removed along with surrounding normal tissue and a sentinel lymph node. If a biopsy reveals that the cancer has spread to lymph nodes, treatments may include more extensive surgery, immunotherapy, or clinical trial participation. Radiation therapy is sometimes used as well, depending upon properties of the tissue removed at surgery.
Two drugs were approved in 2011, the immunotherapy ipilimumab (Yervoy®) and vemurafenib (Zelboraf®), a therapy targeting a BRAF mutation found in approximately 50% to 60% of melanomas. Dabrafenib (another BRAF inhibitor) and trametinib (a MEK inhibitor) were approved last year for use in combination in BRAF mutated melanomas. Mek inhibitors are also being investigated in NRAS mutated cutaneous melanomas and in ocular melanomas. A small subset of melanomas have CKIT mutations and several studies have reported activity of imatinib and niltonib for patients with these tumors.
In September 2014, Merck's anti-PD-1 antibody, Keytruda (pembrolizumab, MK-3475), was FDA approved for the treatment of advanced or unresectable melanoma in patients failing prior treatment with ipilimumab and, if they have a BRAF V600 mutation, a BRAF or MEK inhibitor.
Despite the recent FDA approvals of these drugs, some patients with advanced metastatic melanoma still have a significant risk of mortality. A substantial unmet need remains for new successful therapies in patients with this disease.
Immunotherapies in Development
Melanoma has long been considered a promising target for immunotherapeutic approaches and has been a major focus of immunotherapy clinical development efforts. In 1998, the FDA approved the use of the immune molecule interleukin-2 (IL-2) to treat advanced melanoma. This provided the first proof-of-principle that an immune-based treatment could provide durable control of the disease. The immune molecule interferon alpha (IFNα) has also been used alone after surgery or in combination with other agents to treat advanced melanoma.
In 2011, the immunotherapy ipilimumab (Yervoy®) became the first drug ever shown to extend survival for patients with metastatic melanoma. Results from a large, phase III trial of ipilimumab demonstrated that it reduced the risk of death by 32% and nearly doubled the likelihood of patients surviving to 1 and 2 years, with some patients experiencing complete and durable clinical regressions lasting for years. Ipilimumab was first developed by CRI’s Scientific Advisory Council director James P. Allison, Ph.D., and tested in late-phase clinical trials by Jedd D. Wolchok, M.D., Ph.D., director of the CRI/Ludwig clinical trials network and associate director of CRI's Scientific Advisory Council.
To date, more than 300 clinical trials have been conducted testing immune-based therapies to treat melanoma, and more than 140 clinical trials are ongoing. Some of the new approaches to immunotherapy for melanoma that have shown promise in early clinical trials are described below.
A promising avenue of clinical research in melanoma is the use of immune checkpoint inhibitors. These treatments work by targeting molecules that serve as checks and balances in the regulation of immune responses. By blocking inhibitory molecules or, alternatively, activating stimulatory molecules, these treatments are designed to unleash or enhance pre-existing anti-cancer immune responses. Several checkpoint inhibitors, targeting multiple different checkpoints, are currently in development.
Bristol-Myers Squibb reported that nivolumab, an anti-PD-1 antibody, and ipilimumab (Yervoy®) attained one- and two-year survival rates of 94% and 88% from a phase Ib trial in advanced melanoma. BMS says it will seek U.S. marketing approval in the fall for advanced melanoma. In the meantime, nivolumab received its first regulatory approval in July for use in inoperable melanoma in Japan, under the name Opdivo, making it the first anti-PD-1 cancer therapy to clear this hurdle.
MEDI4736, an anti-PD-L1 checkpoint inhibitor made by MedImmune/AstraZeneca, is being tested in a phase I/II trial for melanoma (NCT02027961). MEDI4736 is also being tested in two phase I trials: one in combination with another checkpoint inhibitor, tremelimumab (anti-CTLA-4), for patients with melanoma (NCT02141542), and one by itself for patients with solid tumors (NCT01693562).
MPDL3280A, an anti-PD-L1 antibody being developed by Roche/Genentech, is being tested in numerous cancers in a phase I trial (NCT01375842) and tested in a phase I trial in melanoma (NCT01656642).
Cancer vaccines are designed to elicit an immune response against tumor-specific or tumor-associated antigens, encouraging the immune system to attack cancer cells bearing these antigens. Several phase II trials of vaccines, given alone or with other therapies, are currently enrolling patients:
A multi-peptide vaccine and an IDO1 inhibitor, INCB024360 (made by Incyte Corporation), are being tested in a phase II clinical trial in melanoma (NCT01961115). IDO is expressed by cancer cells in a range of tumor types and high IDO expression appears to correlate with poor outcomes in a number of cancers, including melanoma.
A DEC-205/NY-ESO-1 fusion protein CDX-1401 and poly-ICLC vaccine is being given with or without CDX-301, a recombinant flt3 ligand, in a phase II clinical trial in melanoma (NCT02129075).
A HyperAcute-Melanoma vaccine (dorgenmeltucel-L) is being tested along with ipilimumab in a phase IIb clinical trial for melanoma (NCT02054520).
Adoptive T Cell Therapy
Another major avenue of immunotherapy for melanoma is adoptive T cell transfer. In this approach, T cells are removed from a patient, genetically modified or treated with chemicals to enhance their activity, and then re-introduced into the patient with the goal of improving the immune system’s anti-cancer response. Several trials of adoptive T cell transfer techniques are currently under way for patients with melanoma, including:
A phase II trial of genetically modified T cells that express the receptor for the NY-ESO-1 molecule, being led by Steven Rosenberg, M.D., Ph.D., at the National Cancer Institute (NCT02062359).
A phase II trial of 4-1BB tumor infiltrating cells in melanoma, also being led by Steven Rosenberg, M.D., Ph.D., at the National Cancer Institute (NCT02111863). 4-1BB, also known as CD137, has costimulatory activity for activated T cells and can enhance immune activity to eliminate tumors in mice.
A phase I/II trial of T cells engineered with one of two receptors in melanoma, being led by Patrick Hwu, M.D., at The University of Texas MD Anderson Cancer Center (NCT01740557, not yet enrolling).
A phase II trial of cellular adoptive immunotherapy using autologous ("self") CD8+ antigen-specific T cells and anti-CTLA-4 in melanoma, led by Cassian Yee, M.D., at The University of Texas MD Anderson Cancer Center (NCT02027935, not yet enrolling).
A trial of ipilimumab and adoptive cell transfer plus high dose interleukin-2 in melanoma at the H. Lee Moffitt Cancer Center and Research Institute (NCT01659151).
Go to our Clinical Trial Finder to find clinical trials of immunotherapies for melanoma that are currently enrolling patients.
CRI Contributions and Impact
The Cancer Research Institute funds and coordinates a number of clinical and laboratory studies that are shedding light on immune-based treatment possibilities for melanoma, as well as on fundamental mechanisms of the disease. This research is leading directly to therapeutic advances that are helping patients with melanoma live longer and better lives.
Since 1982, CRI has dedicated nearly $30 million to fund laboratory and clinical research aimed at unlocking the power of the immune system to fight melanoma. This includes 36 clinical trials conducted through our global clinical trials network, which have enrolled nearly 750 patients with melanoma.
CVC clinical trials in melanoma are currently enrolling patients at Memorial Sloan Kettering Cancer Center, New York University Langone Medical Center, Fred Hutchinson Cancer Research Center/University of Washington School of Medicine, University of Virginia, Mount Sinai School of Medicine, University of Pittsburgh, and Austin Health/Ludwig Cancer Research in Melbourne, Australia.
See below for more information on current and past clinical trials conducted in the CVC network and other CRI-funded studies that are advancing the understanding and treatment of melanoma.
Currently, a minority (20%) of patients treated with ipilimumab (Yervoy®) experience clinical benefit. Identifying biomarkers that can help predict which cancer patients are most likely to benefit, as well as gathering further insights into ipilimumab’s mechanism of action, will be key to enhancing the efficacy of this treatment. Padmanee Sharma, M.D., Ph.D., and colleagues have discovered a biomarker to identify melanoma patients who are more likely to respond to ipilimumab (Yervoy®). Called ICOS+ CD4+ T cells, these biomarkers should enable scientists to determine whether patients receiving anti-CTLA-4 treatment strategies are responding positively to the therapy.
CRI researchers Jianda Yuan, M.D., Ph.D., Sacha Gnjatic, Ph.D., Jedd D. Wolchok, M.D., Ph.D., and others found that cancer patients who have pre-existing immunity to NY-ESO-1 are more likely to respond to ipilimumab than those who do not. At 24 weeks after ipilimumab treatment, NY-ESO-1-positive patients were nearly twice as likely to experience clinical benefit than NY-ESO-1-negative patients. In addition to helping to facilitate the identification of patients who may have greater benefit from the drug than others, these findings also hint at ways to improve the efficacy of treatment even in patients who initially may lack pre-existing immunity to NY-ESO-1, for example by combining ipilimumab treatment with vaccines to induce anti-NY-ESO-1 immune responses.
Based on these findings, CRI and Ludwig have designed a trial to test two vaccine formulations based on the NY-ESO-1 antigen in combination with ipilimumab to see if the combination yields additional clinical activity and results in increased clinical benefit among a larger percentage of patients treated. The trial will enroll up to 18 patients with unresectable or metastatic melanoma whose tumors express NY-ESO-1 or LAGE-1 (a cancer-testis antigen that closely resembles NY-ESO-1) and for whom treatment with ipilimumab is indicated.
Through CRI’s venture philanthropy program, a phase I trial in melanoma patients of an experimental antibody designed to target the GITR molecule to enhance the activity of T cells against cancer, was launched at Memorial Sloan Kettering Cancer Center under the direction of Jedd D. Wolchok, M.D., Ph.D., in 2010. The antibody is the first treatment of its kind to be tested in human cancer patients, and is part of a new class of highly promising therapies like anti-CTLA-4 and anti-PD-1 that work by counteracting immune suppression.
CRI investigator Timothy N.J. Bullock, Ph.D., at the University of Virginia Health System, showed that a monoclonal antibody designed to activate the CD27 costimulatory molecule, which plays an important role in the activation, survival, and differentiation of T cells, significantly reduced the progression of metastases and primary tumors in a mouse model of melanoma. Further analysis showed that the antibody treatment supports the maintenance of tumor-specific killer T cells within the tumor, reduces the frequency of regulatory T cells within tumors, and enhances the ability of tumor-infiltrating natural killer cells and killer T cells to produce interferon-gamma, a critical anti-tumor immune molecule, suggesting that targeting the CD27 costimulatory pathway may be a promising approach to enhance tumor immunity.
Reporting in The Journal of Experimental Medicine, CVC investigator Hassane Zarour, M.D., and colleagues at the University of Pittsburgh Cancer Institute found that cells that express both the Tim-3 and PD-1 molecules constituted a highly dysfunctional subset of tumor-specific killer T cells in patients with advanced melanoma, supporting the combination of Tim-3 and PD-1 blockade to reverse tumor-induced T cell dysfunction in therapeutic interventions for patients with this disease.
Other ongoing CRI-funded projects that are shedding light on melanoma include:
Margaret Callahan, M.D., Ph.D., the Lloyd J. Old Postdoctoral Fellow at Memorial Sloan Kettering Cancer Center, is working to understand how targeted therapies like vemurafenib, which is directed against the BRAFV600E mutation in melanoma, may impact the immune system generally, as well as how it may impact anti-PD-1 checkpoint blockade immunotherapy specifically. The insights gained from these studies may guide the rational development of combinations of targeted inhibitors and immunotherapies to take into the clinic. This project is directly applicable to the development of new treatment strategies for melanoma, and may also be extended to help in the treatment of other cancers.
Corrie Ann Painter, Ph.D., a CRI postdoctoral fellow at the University of Massachusetts Medical Center, is investigating the adaptive immune response to melanoma in the zebrafish, Danio rerio. In her project, she will determine the specific immune cells that are present in zebrafish melanomas and visualize their movement into and out of tumors, and then determine the functional role of each of these immune cells and define immunomodulatory factors that can provoke anti‐tumor responses. These studies will help identify genes that modulate the immune response to melanoma, toward the ultimate goal of augmenting current diagnostic and prognostic markers of melanoma and providing additional therapeutic strategies to combat the disease.
Jenna Elizabeth Geddes, the recipient of a Student Training and Research in Tumor Immunology (STaRT) grant at Harvard Medical School, is studying galectin-1 (Gal-1), a binding protein that is produced by melanoma cells and that may promote tumor immune escape by suppressing melanoma-specific killer T cells. She is investigating whether or not blocking the ligand for Gal-1 on killer T cells prior to adoptive T cell therapy makes T cells less susceptible to Gal-1 inhibition and can translate into enhanced melanoma control. If successful, these studies will greatly impact efforts to improve adoptive T cell therapy for melanoma.
One drawback of some immunotherapies is that they can have body-wide toxicities related to activating the immune system in a non-specific manner. CRI postdoctoral fellow Li Tang, Ph.D., of MIT, Cambridge, MA, has developed a novel technique to surmount this hurdle. The technique involves using nanotechnology in melanoma and other cancers to deliver immune-stimulating chemicals called cytokines directly to the site of tumors. In effect, the cytokines are smuggled in “on the backs” of T cells. This approach, which Dr. Tang recently patented, has the potential to greatly reduce systemic toxicities of immunotherapies.
Sources: National Cancer Institute; National Cancer Institute Physician Data Query (PDQ); American Cancer Society Facts & Figures 2014; GLOBOCAN 2008; NCI Surveillance Epidemiology and End Results (SEER); National Comprehensive Cancer Network (NCCN) Guidelines for Patients; ClinicalTrials.gov; Melanoma Research Foundation; Cancer Research UK; Bloomberg.com; CRI grantee progress reports and other CRI grantee documents
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