M Doutlook 2009 Melanoma Physicians Report

Melanoma Physician Report

Melanoma Treatment Goals, Influences
and Treatment Practices in the U.S.

Differential Practices Among Medical Oncologists,
Dermatologists, Surgical Oncologists & Radiation
Oncologists

Source: MDOUTLOOK 2009 Semi-Annual Survey on
Melanoma

May 2010 | Slide 1 2009 Melanoma Physician’s Report © MDOUTLOOK, LLC | Powered by The Arcas Gro

Melanoma Physician Report

Report Index

Report Module Slide
• Patient Flow in Melanoma 3
• Factors Driving the Selection of Treatment Options for Melanoma 8
• Current Practices and Attitudes of Adjuvant Treatment 15
• Aggregate Treatment Practices for Melanoma 21
• Patient Referral Practices in Melanoma 25
• Clinical Trials & New Therapeutic Options in Melanoma 32
• Survey Methodologies and Demographics 36


Melanoma Patient Flow

Patient Flow in Melanoma



Melanoma Makes Up Only a Small Portion
of Most Treaters’ Practices
Proportion of Practice Involving Melanoma
Proportion of Practice
8%
0%
3%
1-10%
3%
3% 4% 11-20%
21-30%
0.4% 31-40%
10% 2% 41-50%
0% >50% MedOnc
>50% HemOnc
1% 4%
72% >50% Derm
>50% RadOnc
>50% SurgOnc

Key Conclusions Additional Information
• For most survey respondents, melanoma • Includes all stages of disease
patients make up only a small portion of their • Includes all medical specialties:
practice • MedOnc (n=121), HemOnc (n=55), Derm
• ~10% of practices are specifically focused on (n=38), RadOnc (n=16), SurgOnc (n=23)
melanoma
• Mostly either Medical or Surgical Oncologists



Frequency of Patient Visits Increases with Disease Severity
During the 1st Year of Treatment
Overall Frequency of Patient Visits During 1st Year of Treatment
Onc Derm RadOnc SurgOnc
1.5
Avg. # Patient visits / month

1.25

1

0.75

0.5

0.25

0
Stage IA/IB/IIA Stage IIB/C Stage IIIA Stage IIIB/C Stage IV

Key Conclusions
• Most medical specialists will see their melanoma patients with increasing frequency as disease
progresses
• Surgical oncologists are pretty consistent at ~1.25 x / month
• Patients with early melanoma are typically seen quarterly or semi-annually during the 1st year
• Patients with advanced melanoma average monthly visits during their 1st year of treatment



Frequency of Patient Visits Increases with Disease Severity
During Five Years of Follow-up
Frequency of Patient Visits During 5 Years of Follow-up
10

8
Avg. # Patient visits / year

6

4

2

0

Key Conclusions
• Most medical specialists will see their melanoma patients with increasing frequency as disease
progresses
• Oncologists (medical + hematologic) are most likely to keep the closest follow-up with their
melanoma patients, especially those with metastatic disease



Conclusions on Patient Flow in Melanoma

• Physicians who treat melanoma patients typically see a broad array
of other malignancies
• Melanoma comprises only a small portion of physician practices
• There is a small subset of 10% of physicians, mostly medical and surgical
oncologists, who specifically focus on melanoma. >50% of their practice
consists of melanoma patients
• Frequency of melanoma patient visits is strongly dependent on disease
stage
• Stage I & II melanoma is initially seen a couple of times each quarter
with occasional follow-up over the next 5 years
• Patients with stage III melanoma are seen many times each quarter
with regular, quarterly follow-up
• Stage IV melanoma is closely monitored, ~1x/month during treatment
and with every 1-2 months during follow-up periods
• Regular follow-up during the 5 years after treatment is performed by
almost all melanoma treaters, regardless of the stage of disease


Melanoma Treatment Drivers

Factors Driving the Selection of Treatment
Options for Melanoma
Including: Incidence and Importance Of Sentinel
Lymph Node Biopsy & Lesion Ulceration



Efficacy is the Most Important Driver of Treatment
Selections for Melanoma
Importance of Various Factors on Treatment Decisions in Melanoma
10
Most
Important
8.09 6.90 6.71 6.53
8 Onc
5.80 5.33 5.07 4.84 4.70 3.68 (n=147)
Average Ranking

6
Derm
(n=30)
4 RadOnc
(n=13)
2
SurgOnc
Least (n=18)
Important
0
Efficacy Performance Safety Tolerability Co-morbidity Patient Payer Age Availability Administration
status preference coverage /
Cost

• Efficacy is the main driver of treatment decisions in melanoma • Overall score for each
o Administration (route, schedule, etc) is seen as the least reason in shown above
important factor each set of bars
• Radiation oncologists are more concerned with safety and • Includes all disease stages
tolerability than other medical specialties



Recommendations for Sentinel Lymph Node Biopsy Are Primarily for
Stages II & III Melanoma
Overall Proportion of Melanoma Patients For Biopsy by Disease Stage
80%
recommended to have LN biopsy
Proportion of melanoma patients

60%

40%

20%

0%
Stage IA/IB Stage IIA Stage IIB/C Stage IIIA Stage IIIB/C Stage IV

• Most melanoma patients with stage II and stage III melanoma • Includes all medical specialties
are recommended to have their sentinel lymph nodes biopsied • Calculated from % of patients
• Probably includes those who have already had SLN recommended to have biopsy
biopsies • IIIA data may represent max % ever
• Sentinel lymph node biopsies are NOT routinely recommended to have SLN biopsy
for most patients with earliest and malignant forms of melanoma


Lymph Node Involvement Is a Very Important Consideration for the
Treatment of Melanoma
Overall Importance of Lymph Node Involvement
4% 2%

11% Additional Information
• Importance as to treatment decision &/or
Extremely important decision to refer
46% Very important • Lymph node involvement includes number
Somewhat important of nodes, number of sites, or the
combination
Not very important
Not at all important
• Includes all medical specialties combined
• Includes all stages of disease
37%

Key Conclusions
• Almost ½ of melanoma treaters see lymph node involvement as “Extremely” important to treatment /
referral decisions
• Additional 1/3 rate LN involvement as “Very” important
• Very few melanoma treaters see lymph node involvement as being unimportant to treatment decisions



Incidence of Ulcerated Lesions in Melanoma increases With Disease
Progression
Overall Incidence of Ulcerated Melanoma Lesions by Disease Stage
40%
Proportion of patients with ulcerated lesions

30%

20%

10%

0%
Stage IIB/C Stage IIIA Stage IIIB/C

• ~1/6 of patients with stage II B/C melanoma have ulcerated lesions • Includes all medical
• ~1/4 of patients with stage III A melanoma lesions have ulcerated specialties
lesions • Calculated from the
• ~ 1/3 of patients with stage III B/C melanoma have ulcerated proportion of patients with
lesions ulcerated patients



Ulceration Status Is an Important Consideration for the Treatment of
Melanoma
Overall Importance of Lesion Ulceration
4%
to Treatment Selection
7%

28%
Additional Information
• Respondents were instructed to consider Extremely important
the importance of ulceration status “in and Very important
of itself” 26%
Somewhat important
• Includes all medical specialties combined
Not very important
• Includes all stages of disease
Not at all important

35%

Key Conclusions
• The ulceration of melanoma lesions is a “very important” consideration for ~1/3 of treaters when
deciding on a treatment regimen
• Ulceration is an “extremely important” treatment consideration for >1/4 of melanoma treaters
• Very few melanoma treaters see ulceration status as being unimportant to treatment decisions



Conclusions on Factors Driving the Selection of Treatment Options for
Melanoma

• Efficacy is the key overall driver of treatment considerations for
melanoma
• Radiation oncologists are also very concerned with safety and tolerability of
the treatment options they use
• Sentinel lymph node biopsies are consistently recommended for stage II
and stage III melanoma and are a strong driver of a treater’s decision on
treatment / referral
• SurgOncs percentage probably reflects the overall acceptance of SLN biopsy
by this group
• Ulcerated lesions increase in frequency as melanoma progresses but still
represents only a minority (~1/3) of clinical cases by stage III disease
• Lesion ulceration plays a very important consideration for most
melanoma treaters when deciding on the treatment plan


Melanoma Adjuvant

Current Practices and Attitudes of Adjuvant
Treatment in Melanoma


Melanoma Adjuvant

Interferon is the Primary Adjuvant Therapy Offered
in Melanoma
By Type of Adjuvant Therapy By Disease Stage
IIB/C IIIA IIIB/C Observation IFN Clinical Trial
60% 60%
Overall Proportion of Patients Receiving

50% 50%

40% 40%

30% 30%

20% 20%

10% 10%

0% 0%
Observation IFN Clinical Trial IIB/C IIIA IIIB/C
Adjuvant Treatment Melanoma Stage

Key Conclusions
• Use of adjuvant interferon increases with disease severity
• Some type of adjuvant therapy is offered to most patients with stage IIB/C through IIIB/C
• Adjuvant interferon is the dominant choice for adjuvant therapy, especially in stage III
disease

Melanoma Adjuvant

No Overriding Reason for NOT Offering Adjuvant Interferon Therapy

Overall Reasons for Not Offering Adjuvant Therapy
(n=156) (n=18) (n=12) (n=22)
60% Key Conclusions
• In general, no single reason dominates a physician’s
50% decision to NOT offer interferon as an adjuvant treatment in
Overall Proportion of Patients

stages IIb & III melanoma
40% • Each reason is relatively equally faced by all medical
specialties
30% • Surgical oncologists proportionally have/report more reasons
for not offering adjuvant interferon
20% • Patients’ ability to handle the interferon (PS and co-
morbidities) are slightly more common as a reason for not
10% offering adjuvant interferon

0%

Additional Information
• Calculated from the % patients for whom each physician has
that reason
• Individual respondents’ totals did not have to equal
100%, representing the fact that multiple reasons may exist
• “Onc” includes medical & hematologic oncologists
Reasons Selected


Melanoma Adjuvant

Overall Usage of Adjuvant Interferon in Melanoma Increases with
Disease Severity and is Mostly Consistent Across Medical Specialties
IIB/C IIIA IIIB/C
70%

60%
Receiving Adjuvant IFN
Proportion of Patients

50%

40%

30%

20%

10%

0%
Total Onc Derm RadOnc SurgOnc
(n≥152) (n ≥19) (n ≥13) (n ≥20)

• Usage of adjuvant interferon increases with disease • Overall usage calculated
severity, regardless of medical specialty from median proportion of
• Overall pattern and amount of adjuvant interferon usage in melanoma patients receiving adjuvant
is similar across medical specialties IFN
• 1 exception: lower usage with Surgical oncologists in stage IIB/C


Melanoma Adjuvant

Patients’ Fear of Side Effects is a Key Reason
Adjuvant Interferon is Not Used
Reasons Given By Patients* for Not Using Adjuvant Interferon
50%
Overall Proportion of Patients

40%

30%

20%

10%

0%
Cost / Financial Do not think Fear of side Induction Inconvenience No specific
considerations adjuvant effects schedule not of dosing reason given
therapy is feasible schedule
needed
Reasons Given * As reported by the physicians

• Reason most commonly given to NOT use Adjuvant Interferon was a • Individual respondents’ totals
fear of side effects did not have to equal
100%, representing the fact that
• Most physicians have some patients who give each of these reasons multiple reasons may exist
for not using adjuvant interferon • Includes responses from all
medical specialties combined


Melanoma Adjuvant

Conclusions on Current Practices And Attitudes of
Adjuvant Treatment in Melanoma

• For earlier stage IIB/C melanoma patients, no standard practice exists for
offering adjuvant therapy. Only a minority are offered or take adjuvant
interferon
• Adjuvant interferon is commonly used for many stage III (A and B/C)
melanoma patients
- Interferon is the PRIMARY adjuvant treatment being OFFERED by physicians
• NOT offering adjuvant interferon treatment occurs for many divergent
reasons, but the patient’s ability to handle the treatment is the top reason
• Various medical specialties are mostly similar in their rationale
• Overall usage of adjuvant interferon in melanoma increases with disease
severity and is mostly consistent across medical specialties
• Patients – as reported by physicians - appear to be most afraid of the
potential side effects when receiving adjuvant interferon


Melanoma Treatment Practices

Aggregate Treatment Practices for Melanoma



Following Surgical Excision, Observation is Primarily Used for
Stages IA – IIA; Adjuvant Interferon is Added for Stage III Melanoma
Interferon Usage Vs. Observation Following Surgery / Excision Across All Stages of Melanoma
125%

100%

%
75% Adjuvant IFN
Physician
Observation usage
50%
Adjuvant IFN % Patient
Observation receiving
25%

0%
IA (n=129) IB (n=120) IIA (n=121) IIB/C (n=126) IIIA (n=137) IIIB/C IV m1ab IV m1c
(n=135) (n=152) (n=153)

• After surgical excision of melanoma • % of patients receiving each modality is strongly
lesions, observation is the standard of care for correlated with the % of physicians using that therapy
stages IA – IIA • These are the main treatment choices of
• The addition of adjuvant IFN is the main protocol physicians for stages I – III melanoma
for stage III disease • Still, not every patient will be treated the same
• Relatively even split between observation and way
adjuvant IFN for stage IIB • As expected, surgical excision in not used for stage IV


Treatment Modality Used for Metastatic (Stage IV) Melanoma
Is Not Dependent on Location of Metastases
Systemic Therapy Usage in Stage IV Melanoma
100%

80% Biochemotherapy
Chemotherapy %
Physician
60% Immunotherapy usage
Targeted agents (e.g. TKI inhibitors)

40%
Biochemotherapy
Chemotherapy
% Patient
20% Immunotherapy receiving
Targeted agents (e.g. TKI inhibitors)
0%
M1a/b M1c

• Chemotherapy is the main treatment modality for • % of patients receiving each modality is
metastatic melanoma strongly correlated with the % of
• Presence of metastases at visceral or distant sites physicians using that therapy
(M1c) has little effect on the treatment modalities used
• Physicians are comfortable with their general
approach to treat stage IV melanoma


Conclusions on Aggregate Treatment Practices for Melanoma

• For melanoma stages I through III, surgical excision of the lesion is the
main treatment modality used for treatment
– Stage IIB is the inflection point between following surgery with either
observation alone or adjuvant IFN
• For stages I – IIA, observation is the main follow-up approach
• For stage III, adjuvant IFN is the main follow-up approach
• Chemotherapy is the main approach used to treat stage IV (metastatic)
melanoma
– However, much lower level of consensus, especially outside of the
oncologists, suggesting an effective, widely-accepted standard of care does
not exist for this stage


Melanoma Referrals

Patient Referral Practices in Melanoma


Melanoma Referrals

Each Medical Specialty Has Its Own Referral Pattern in Melanoma

Overall Referral Amounts by Medical Specialty
100%
Melanoma Patients Referred

80% IA/IB/IIA
Overall Percentage of

60% IIB/C

40%
IIIA

IIIB/C
20%

IV
0%
(n=148) (n=36) (n=12) (n=20)

• Each medical specialty has its own referral pattern in melanoma • Calculated from the range of
• Amount of referral for oncologists is consistent and independent of disease patients referred at each disease
stage stage
• For dermatologists and Surgical oncologists, the amount of referral increases
with disease severity
• “Onc “includes both Medical and
• Slight reduction in referral amounts for radiation oncologists with disease Hematologic oncologists
progression
• Implies that derms function as “gatekeepers” for melanoma treatment

Melanoma Referrals

Number of Lines of Treatment Before Referral Is Highly Specific to
Medical Specialty
Referral of Melanoma Patients by Line of Treatment
5

4
IA/IB/IIA
Average Line of Treatment
Before Referring

IIB/C
3

IIIA
2

IIIB/C
1
IV
0
(n=124) (n=33) (n=11) (n=20)

• Oncologists will consistently try 1.5 – 2.5 lines of treatment • Calculated from the line of treatment
before referring a melanoma patient, regardless of disease when referral typically occurs
stage • Future studies will need to link this
• Derms and SurgOncs will repeated treat early stage info with the treatment referred for
melanoma but rapidly refer later stage patients
• Radiation is rarely given in successive lines of treatment

Melanoma Referrals

Multiple Lines of Treatment Are Typically Tried Before Referral in Stage
I & II Melanoma
Referral of Melanoma Patients by Line of Treatment
5

4
Average Line of Treatment

Onc (n=124)
Before Referring

3 Derm (n=33)

2 RadOnc (n=11)

SurgOnc (n=20)
1

0

• With stage I / IIA melanoma, most treaters will try multiple • Calculated from the line of treatment when
lines of therapy before referring a patient referral typically occurs
• At stage IIB/C, dermatologists join RadOncs as early • Future studies will need to link this info with
referrers the treatment referred for
• For stage III and IV melanoma, most referrals occur before
2nd line of treatment

Melanoma Referrals

Stage III and IV Melanoma Patients Are Typically Referred to Medical
Oncology ThoughtLeaders for Additional Treatment
Primary Referral Target
60%
MedOnc
50%
Derm / DermOnc
Physician Respondents

40%
Academic MedOnc /
30%
ThoughtLeader
Academic DermOnc /
ThoughtLeader
20%
SurgOnc
10%
RadOnc

0% Plastic Surgeon
(n=167) (n=183) (n=189) (n=199) (n=217)

• Early stage I & IIA melanoma patients are primarily referred to • Top selection per stage only
dermatologists and surgical oncologists for treatment • Limited to those who refer melanoma
• MedOnc ThoughtLeaders are referred stage III and IV patients for treatment
melanoma patients most often, although some physicians • Includes all medical specialties
send these patients to community oncologists combined
• Limited use of plastic surgeons and radiation oncologists for
referral

Melanoma Referrals

Main Reason Melanoma Patients Are Referred Are to Participate in
Clinical Trials
Reasons for Melanoma Referrals

10% Clinical trial
participation
7%
30% Additional Information
Local ThoughtLeader
available • Includes all disease stages
Disease stage • Includes all medical specialties
10% combined
Disease progression • Physicians could select top 3
choices
Patient preference

12% Proficiency required

18%
Other* Other* includes : Availability, Co-morbidity /
13% PS, Age, and Side effects

Key Conclusions
• Clinical trial participation is the top reason melanoma treaters refer patients to other physicians
• Local ThoughtLeader usage is the 2nd most important reason for patient referral
• “Treatment side effects” was the least often selected reason for patient referral (by 2% of respondents)


Melanoma Referrals

Conclusions on Patient Referral Practices in Melanoma

• Overall amount of referrals in melanoma increase with disease severity
with changes in the specialization of referral targets
• However, oncologists refer about the same proportion of their melanoma
patients across every stage of disease (~20%)
• For stages I & II of melanoma, most physicians will try multiple lines of
treatment before referring. Referral occurs sooner in stage III and IV
disease.
• Early stages of melanoma are typically referred to dermatologists or
surgical oncologists for treatment. Advanced stages are referred to
oncology ThoughtLeaders for additional treatment.
• Type of referral target is key – referral for surgery many times is different
than to begin systemic therapy
• Top reasons for referral are for inclusion in a clinical trial and to be
treated by a ThoughtLeader


Melanoma Clinical Trials

Factors Driving U.S. Clinical Trial Participation
& New Therapeutic Options in Melanoma



Factors Driving U.S. Clinical Trial Participation in Melanoma

Melanoma Treaters' Reasons for Clinical Trial Participation
Onc (n=176) Derm (n=38) RadOnc (n=16) SurgOnc (n=23)
Physician Respondents (%)

80%

60%

40%

20%

0%

Respondents
could select
top 3 choices

Key Conclusions
• Top drivers to match patient with specific trials are “Available Treatment Options” and “Patient's Eligibility”
• Secondary reasons are: Advancing Medicine, Convenience of Location, and Results from Earlier Phase
Trials (e.g. Phase I & II results drive Phase III recruitment)
• Following drivers considered far less important: Drug Familiarity, Individualized Approach through Molecular
Signature, and Reputation of Study Chairs
• Relative importance of reasons are mostly consistent among medical specialties



Vaccine Therapies Are Most Expected to Have the Greatest Future
Impact on Treatment of Melanoma
Drugs Currently Under Investigation Expected to Impact Melanoma Treatment Protocols

Onc (n=176) Derm (n=38) RadOnc (n=16) SurgOnc (n=23)
60%
Physicians Selecting

50%
40%
30%
20%
10%
0%

Most Least
Important Important

• For most medical specialties, vaccine therapy is expected to have the biggest • Respondents could make up to
impact on melanoma treatment protocols 3 selections
• In spite of the past 5 years worth of randomized data • “Onc” includes responses from
• Little awareness of the two drugs that are likely to gain approval for metastatic medical & hematologic
disease in near future oncologists
• Surgical oncologists’ selections are very different from others



Conclusions on Factors Driving U.S. Clinical Trial Participation
& New Therapeutic Options in Melanoma

• Lack of available treatment options drive clinical trial participation

• Vaccine therapies are expected by about half of melanoma treaters to
have a significant impact of treatment protocols in the near future

• Each medical specialty has its own distinct pattern of expectations about
new drug treatments for melanoma
– Surgical oncologists had the most individual selection pattern


Melanoma Methodology

Survey Methodologies and Demographics


Melanoma Methodology

Stats Summary: 2009 Semi-Annual Survey on
Melanoma

Distribution of Survey Respondents Background
By Medical Specialty • Survey open ~6 weeks from October 27, 2009 and
continued through to December 14, 2009
9%
• 256 total respondents from 39 states
6% • Representation from multiple disciplines
• Oncologist (Medical + Hematological) – 176
Onc (69%)
15% Derm • Dermatologist – 38 (15%)
RadOnc • Radiation Oncologist – 16 (6%)
SurgOnc • Surgical Oncologist – 23 (9%)
• 98 respondents (~38%) were academic
70%
• Includes “Specialty treatment centers” (i.e. MD
Anderson, Mayo, etc.) and VA centers
• Thirty-three (33) of the respondents were
recognized by their peers as ThoughtLeaders


Melanoma

The material in this report is restricted to non-commercial
activities only. Distribution of these materials for
educational purposes to colleagues, staff, or patients is
freely allowed. PowerPoint slides of the information in this
report for use in educational presentations are available and
may be obtained upon request.

Contact: survey@mdoutlook.com

888.3OUTLOOK | 888.368.8566 (North America)
+1.404.496.4136 (International)

© 2008-2010| MDoutlook, LLC – All rights reserved
May 2010 Slide 38 2009 Melanoma Physician’s Report © MDOUTLOOK, LLC | Powered by The Arcas Gro

M Doutlook 2009 Melanoma Physicians Report

Recommandé

Recommandé

Contenu connexe

En vedette

En vedette (14)

Similaire à M Doutlook 2009 Melanoma Physicians Report

Similaire à M Doutlook 2009 Melanoma Physicians Report (20)

M Doutlook 2009 Melanoma Physicians Report