Medications

Melanoma

When is medication used to treat melanoma?

Medications are used to treat melanoma when it:

• Cannot be removed with surgery (unresectable) or
• Has spread to distant parts of the body (metastasized).

Medications also can be used as adjuvant treatment for certain advanced melanomas. Adjuvant therapy is an additional cancer treatment given after the primary (main) treatment, such as surgery. It can help lower the risk that the cancer comes back.

Treatments for melanoma

Medications for metastatic melanoma include targeted therapies and immunotherapies. Medication selection depends on several factors, including:

• Cancer stage.
• Presence of certain genetic mutations.
• Melanoma treatment history.
• Full medical history.
• Ability to tolerate side effects.

Targeted therapy for melanoma. Targeted therapies block molecules that send signals for cancer cell growth and division. Genetic mutations cause abnormal changes in these signals. Targeted therapies aim at the features that make cancer cells different.¹

Targeted therapies that treat melanoma with BRAF mutations include:

• Tafinlar® (dabrafenib), possibly in combination with Mekinist® (trametinib), a MEK inhibitor
• Zelboraf® (vemurafenib), possibly in combination with Cotellic® (cobimetinib), another MEK inhibitor
• Braftovi (encorafenib) and Mektovi (binimetinib) are a combination targeted therapy to treat melanoma that cannot be surgically removed (unresectable) or metastatic melanoma with a BRAF V600E or V600K mutation
• Gleevec® (imatinib) is a targeted therapy that may be used for advanced melanoma with c-KIT mutation

Immunotherapy for melanoma. Immunotherapies turn your immune system against the cancer.² Some immunotherapies help your immune system identify cancer cells. Some give your immune system a general boost, and others create an immune response at the tumor.

Drugs called immune checkpoint inhibitors prevent melanoma cells from hiding from your immune system. These medications include:

• Keytruda® (pembrolizumab)
• Opdivo® (nivolumab)
• Yervoy® (ipilimumab)
• Tecentriq® (atezolizumab) - used together with vemurafenib and cobimetinib targeted therapies

Cytokines.Cytokines are general immune system boosters.² They rally your immune system’s defenses to fight cancer cells. The cytokines used to treat certain forms of melanoma include:

• Interleukin-2

Talimogene laherparepvec. Immunotherapy drugs can be injected directly into the tumor. This is called intralesional injection. Talimogene laherparepvec is an “oncolytic virus” that is injected into tumors. The virus kills tumor cells directly, which leads to the release of antigens.³ This triggers an immune response. The virus also causes the cells to make a protein, called GM-CSF, that causes a general immune response.

Intralesional Bacillus Calmette-Guerin (BCG) vaccine. The BCG vaccine is used infrequently for melanoma now. However, this intralesional immunotherapy was used for many years to treat melanoma by creating a general immune response in the area where the tumor is located.^4,5

Chemotherapy.Chemotherapy is often not as effective as immunotherapy and targeted therapy for melanoma.⁶ Today, it is not used often to treat melanoma. However, it remains an option in some circumstances.

Basal cell carcinoma

What medications are used to treat low-risk basal cell carcinoma?

Topical medications can be used to treat some basal cell carcinoma if surgery, curettage and electrodesiccation, or radiation therapy are not possible.⁷ Topical medications are medications that are applied to the skin.

Approved options for thin basal cell carcinomas include:

• Fluorouracil (5% concentration)
• Imiquimod (5% concentration)

Topical medications are only used for basal cell carcinoma that is unlikely to return (recur). For higher-risk basal cell carcinoma, more effective treatments are available.⁷

What medications are used to treat advanced basal cell carcinoma?

Advanced basal cell carcinoma is rare. Less than 1% of cases are locally advanced. Only 0.04% of cases are metastatic (spread throughout the body).⁸ However, locally advanced basal cell carcinoma can cause substantial damage to tissue, cartilage and bone.⁷

Targeted therapies are available to treat certain forms of advanced basal cell carcinoma. They include:

• Odomzo® (sonidegib) treats locally advanced basal cell carcinoma.
• Erivedge® (vismodegib) treats locally advanced and metastatic basal cell carcinoma.
• Cemiplimab-rwlc (Libtayo®) immunotherapy may be used to treat people with certain forms of advanced basal cell carcinoma.

Sonidegib and vismodegib are called SMO inhibitors. SMO is short for “Smoothened.” SMO is a receptor in the Hedgehog pathway. Mutations cause an overactive Hedgehog pathway in about 80% of basal cell carcinomas.⁹

Squamous cell carcinoma

What medications are used to treat low-risk squamous cell carcinoma?

Squamous cell carcinoma in situ (Bowen’s disease) may be treated with topical medications, according to national cancer guidelines.¹⁰Squamous cell carcinoma in situ is an early form of SCC. At this stage of disease, the cancer cells are only in the top layer of skin (epidermis). The two medications which may be suggested for early squamous cell carcinoma are:¹⁰

• Fluorouracil
• Imiquimod

Neither medication is approved by the US Food and Drug Administration for this use. Topical medications have lower cure rates than surgical treatments for squamous cell carcinoma in situ.

What medications are used to treat high-risk squamous cell carcinoma?

Chemotherapy may be used together with radiation therapy for squamous cell carcinoma that is likely to return (recur).¹⁰ This treatment may be used if surgery is not an option. Chemotherapy plus radiation therapy is also an option for squamous cell carcinoma that has spread to the lymph nodes.¹⁰

Cemiplimab-rwlc (Libtayo®) and pembrolizumab (Keytruda®) immunotherapy may be used to treat people with certain forms of advanced cutaneous squamous cell carcinoma.

Actinic keratosis

How are medications used to treat actinic keratosis?

Topical medications are a common way of treating actinic keratosis. Topical medications are useful for people who have multiple lesions. Medications approved for actinic keratosis include:

• Fluorouracil
• Imiquimod
• Diclofenac
• Ingenol mebutate

Rare skin cancers

How are medications used to treat Merkel cell carcinoma?

The first drug approved specifically for Merkel cell carcinoma is an immunotherapy called Bavencio® (avelumab). Bavencio is an immune checkpoint inhibitor.¹¹ It prevents cancer cells from hiding from your immune system. It also attracts your body’s defense cells to destroy the cancer cells. Keytruda (pembrolizumab) is also approved to treat Merkel cell carcinoma.

Chemotherapy has been used to shrink or slow the spread of MCC tumors.¹²

How are medications used to treat Kaposi sarcoma?

Chemotherapy is a standard treatment for Kaposi sarcoma. If there are only a few lesions, the drug may be injected directly into them. If the cancer is widespread, chemotherapy may be used systemically.¹³

Liposomal doxorubicin is the main chemotherapy drug for Kaposi sarcoma. The doxorubicin is attached to tiny fat particles (liposomes). The liposomes prefer Kaposi sarcoma tissue over normal tissue. This directs the drug to the tumor and spares some healthy tissue.¹³

Pomalidomide (Pomalyst®) may be used as a form of immunotherapy to treat certain forms of Kaposi sarcoma.