Management of advanced melanoma in the COVID‐19 era

Dear Editor,

The coronavirus disease 2019 (COVID‐19) pandemic, caused by an RNA virus, called SARS‐CoV‐2 (severe acute respiratory syndrome coronavirus 2), ¹ required many unnecessary outpatient procedures and dermatological treatments to be postponed. Otherwise, urgent visits and surgery that cannot be postponed are carried out regularly. For patients undergoing treatment with immunosuppressive or immunomodulating drugs for chronic dermatological diseases, such as psoriasis, several guidelines suggest to assess on a case‐by‐case basis the initiation of a new therapy with a biological drug as well as the possible suspension in case of positivity. ² Apart from psoriasis, which can sometimes also be treated in an alternative way, we must focus our attention on the most fragile patients in dermatology, that is, oncologic patients suffering from advanced melanoma. In fact, we should remember that cancer‐related treatments may cause immunosuppression, and the first available data suggest that patients with cancer have a risk of excess mortality due to SARS‐CoV‐2. ³

Many of melanoma patients are treated with targeted therapy or immunotherapy (eg, dabrafenib + trametinib, vemurafenib + cobimetinib, encorafenib + binimetinib, pembrolizumab, nivolumab, ipilimumab) in an adjuvant or palliative setting, and currently data are lacking how to manage oncologic COVID‐19‐positive patients. Few guidelines suggest that patients should not discontinue ongoing therapy but do not provide guidance on how to behave in case of an asymptomatic or symptomatic COVID‐19 patient on treatment with target therapy or immunotherapy. ⁴

The Italian Association of Medical Oncology (AIOM), considering that the continuity and timeliness of antineoplastic treatments must always be guaranteed, has also suggested to consider case by case the possibility of postponement of a treatment, based on the biological characteristics of the tumor and the clinical features of the patient. ⁵

The European Society for Medical Oncology (ESMO) suggests that all patients undergoing surgery, radiotherapy, chemotherapy, or immunotherapy should be swabbed for SARS‐CoV‐2 if possible and ideally before each treatment/cycle. Decisions for initiation or continuation of treatment should be discussed for both noninfected and SARS‐CoV2‐positive patients, both asymptomatic and paucisymptomatic. ⁶

At the moment we have no clear data and we need as dermato‐oncologist to have a common conduct for these patients. For this reason, based on current considerations of the major oncologic societies and our clinical practice, we suggest (a) to encourage patients not to discontinue ongoing target therapy or immunotherapy independently, (b) in case of flu symptoms patients should not discontinue therapy but contact immediately their oncologist or dermato‐oncologist, (c) to perform a swab before starting or continuing medical chemotherapy/immunotherapy or in the case of major surgeries requiring frequent attendance to the hospital, and (d) in case of COVID‐19‐positive (symptomatic or paucisymptomatic) patients, we suggest to evaluate patients on a case‐by‐case basis and if necessary consider suspending a cycle of treatment for both treatments.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.