Ascierto Paolo A, Bastholt Lars, Ferrucci Pier F, Hansson Johan, Márquez Rodas Iván, Payne Miranda, Robert Caroline, Thomas Luc, Utikal Jochen S, Wolter Pascal, Kudlac Amber, Tuson Harriet, McKendrick Jan
Istituto Nazionale Tumori Fondazione G. Pascale, Naples.
Odense University Hospital, Odense, Denmark.
Melanoma Res. 2018 Aug;28(4):333-340. doi: 10.1097/CMR.0000000000000455.
Treatment decisions for advanced melanoma are increasingly complex and guidelines provide limited advice on how to choose between immunotherapy and targeted therapy for first-line treatment. A Delphi study was carried out to understand which patient characteristics and disease-related factors inform clinicians' choices of first-line treatment for BRAF-mutated melanoma. Twelve European melanoma specialists experienced in using immunotherapies and targeted agents participated in a double-blind two-phase Delphi study. In phase 1, participants completed a questionnaire developed after reviewing patient characteristics and disease-related factors reported in trials, clinical guidelines, and health technology assessments. Phase 2 was an expert panel meeting to explore outstanding issues from phase 1 and seek consensus, defined as 80% agreement. Twenty patient-related and disease-related characteristics were considered. There was consensus that tumor burden (83% of clinicians) and disease tempo (83%) are very or extremely important factors when selecting first-line treatment. Several components were deemed important when assessing tumor burden: brain metastases (82% of clinicians) and location of metastases (89%). There was consensus that disease tempo can be quantified in clinical practice, but not on a formal classification applicable to all patients. Lactate dehydrogenase level is a component of both tumor burden and disease tempo; all clinicians considered lactate dehydrogenase important when choosing first-line treatment. The majority (92%) did not routinely test programmed death ligand-1 status in patients with melanoma. Clinicians agreed that choosing a first-line treatment for advanced melanoma is a complex, multifactorial process and that clinical judgment remains the most important element of decision-making until research can provide clinicians with better scientific parameters and tools for first-line decision-making.
晚期黑色素瘤的治疗决策日益复杂，而关于如何在免疫疗法和靶向疗法之间选择一线治疗方案，指南提供的建议有限。开展了一项德尔菲研究，以了解哪些患者特征和疾病相关因素会影响临床医生对BRAF突变型黑色素瘤一线治疗方案的选择。12位在使用免疫疗法和靶向药物方面经验丰富的欧洲黑色素瘤专家参与了一项双盲两阶段德尔菲研究。在第1阶段，参与者完成了一份问卷，该问卷是在回顾试验、临床指南和卫生技术评估中报告的患者特征和疾病相关因素后制定的。第2阶段是一次专家小组会议，以探讨第1阶段中未解决的问题并寻求共识，共识定义为80%的一致意见。共考虑了20个与患者和疾病相关的特征。达成的共识是，在选择一线治疗方案时，肿瘤负荷（83%的临床医生）和疾病进展速度（83%）是非常重要或极其重要的因素。在评估肿瘤负荷时，几个因素被认为很重要：脑转移（82%的临床医生）和转移部位（89%）。达成的共识是，疾病进展速度在临床实践中可以量化，但不适用于所有患者的正式分类。乳酸脱氢酶水平是肿瘤负荷和疾病进展速度的组成部分；所有临床医生在选择一线治疗方案时都认为乳酸脱氢酶很重要。大多数（92%）临床医生在黑色素瘤患者中不常规检测程序性死亡配体1的状态。临床医生一致认为，为晚期黑色素瘤选择一线治疗方案是一个复杂的多因素过程，在研究能够为临床医生提供更好的一线决策科学参数和工具之前，临床判断仍然是决策中最重要的因素。
