Treatment Patterns and Outcomes of Targeted Therapy and Immunotherapy Among BRAF-Positive Melanoma Patients Treated in the Adjuvant Setting and Among BRAF-Positive Metastatic Melanoma Patients With Low Tumor Burden

Study Overview
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Brief Summary
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This was an observational study utilizing electronic health record (EHR)-derived data collected retrospectively during routine care of real-world patients with advanced melanoma from NOBLE (Novartis Braf+ meLanoma patients ObsErvational) dataset.

Detailed Description
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The NOBLE database was built from the harmonization of two customized oncology specific EHR databases: Flatiron Health Spotlight and Concerto Custom Patient360. BRAF v600 mutated advanced (i.e., stage III or IV) patients treated at oncology practices across the US were identified in these two databases for potential inclusion. Both the Flatiron Health EHR-derived database and the Concerto Patient360 database contain clinical, demographic, treatment, and mortality information for melanoma patients from the time of initial diagnosis until death or the most recent data cut-off, which is August 31, 2020 (for population 1), and May 31, 2020 (for population 2). For population 1 (patients treated in the adjuvant setting): included patients were aged more than or equal to 18 years, were required to have a diagnosis of melanoma (ICD-9 172.x & ICD-10 C43.x or D03.x), pathologic stage III disease, evidence of resection, adjuvant treatment with Immunotherapy (IO) (e.g., Nivolumab (nivo) or Pembrolizumab (pembro)) or Targeted Therapy (TT) (e.g., Dabrafenib+ Trametinib (dab+tram)) on or after January 1, 2014 and prior to August 30,2020 (data cut-off), and any evidence of a BRAF+ result. Patients were required to have at least 6 months of follow-up after initiation of adjuvant treatment. Patients were followed until the earlier of death, data cut-off, loss of follow-up, or received MM diagnosis. While the first systemic therapy approved for use in the adjuvant melanoma setting occurred in 2015, the study period of interest begins on January 1, 2014, to include any potential off-label use of these therapies as adjuvant therapies. For population 2 (patients with Low tumor burden (LTB) treated in the metastatic setting): included patients were aged more than or equal to 18 years, and were required to have a diagnosis of melanoma (ICD-9 172.x & ICD-10 C43 or D03x), a pathologic stage IV diagnosis, treatment with IO (e.g. Ipilimumab (ipi), nivo, pembro, ipi+nivo) or TT (dab+tram, Vemurafenib+Cobimetinib, Encorafenib+Binimetinib (vem+cobi, enco+bini) on or after January 1, 2014 and prior to May 31, 2020 (data cut-off), and evidence of a BRAF+ result after therapy initiation. Patients were required to be classified as LTB at the time of stage IV diagnosis. LTB was defined as having normal LDH and <3 metastatic sites at the time of stage IV diagnosis. To align with recent FDA approvals for combination therapies use in the MM setting, the study period of interest began on January 1, 2014. Furthermore, this sampling interval allowed for a maximum of 6 years of follow-up from the start of study period.

Official Title
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Real-World Treatment Patterns and Outcomes of Targeted Therapy and Immunotherapy Among BRAF-Positive Melanoma Patients Treated in the Adjuvant Setting and Among BRAF-Positive Metastatic Melanoma Patients With Low Tumor Burden: An Observational Study

Conditions
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Metastatic Melanoma

Intervention / Treatment
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* Drug: Nivolumab
* Drug: Pembrolizumab
* Combination Product: Dabrafenib+Trametinib
* Combination Product: Ipilimumab+Nivolumab
* Combination Product: Vemurafenib+Cobimetinib
* Combination Product: Encorafenib+Binimetinib


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Population 1(patients treated in the adjuvant setting) Diagnosis of melanoma (ICD-9 172.x & ICD-10 C43.x or D03.x) Pathologic stage III on or after 2011 Evidence of resection Adjuvant treatment with IO (nivo, pembro) or TT (dab+tram) on or after 1/1/2014 and prior to 8/31/2020 At least 6 months of follow-up time (until death, end of data cut-off, loss-of-follow-up, or progressed to stage IV diagnosis) from the initiation of therapy Evidence of a BRAF+ result ≤30 days after therapy initiation in the adjuvant setting At least 18 years of age at the time of initiation of treatment No documented receipt of a clinical trial treatment for cancer at any time on or after January 1, 2014 Population 2 (patients with LTB treated in the metastatic setting) Diagnosis of melanoma (ICD-9 172.x & ICD-10 C43.x or D03.x) Pathologic stage IV at initial diagnosis on or after 1/1/2011, or earlier stage disease accompanied by development of a first locoregional recurrence on or after 1/1/2011 1L treatment with IO (ipi, nivo, pembro, ipi+nivo) or TT (dab+tram, vemu+cobi, enco+bini) on or after 1/1/2014 and prior to 5/31/2020 At least 6 months of follow-up time (until death, loss of follow-up, or end of data cut-off) from the initiation of therapy Evidence of a BRAF+ result ≤30 days after 1L therapy initiation LTB, defined as having <3 involved organ sites and normal LDH test (less than upper limit of normal) at the time of receiving MM diagnosis At least 18 years of age at the time of initiation of 1L treatment No documented receipt of a clinical trial treatment for cancer at any time on or after 1/1/2014 Exclusion Criteria: None

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Population 1: BRAF+ melanoma patients treated with either TT or IO in the adjuvant setting<br>Included patients were aged more than or equal to 18 years, were required to have a diagnosis of melanoma (ICD-9 172.x & ICD-10 C43.x or D03.x), pathologic stage III disease, evidence of resection, adjuvant treatment with IO (e.g., nivo or pembro) or TT (e.g., dab+tram) on or after January 1, 2014, and prior to August 30,2020 (data cut-off), and any evidence of a BRAF+ result. | Drug: Nivolumab<br>* Nivolumab<br>Drug: Pembrolizumab<br>* Pembrolizumab<br>Combination Product: Dabrafenib+Trametinib<br>* Dabrafenib+Trametinib<br>|
| Population 2: BRAF+ melanoma patients with LTB treated with TT or IO in the metastatic setting<br>Included patients were aged more than or equal to 18 years, and were required to have a diagnosis of melanoma (ICD-9 172.x & ICD-10 C43 or D03x), a pathologic stage IV diagnosis, treatment with IO (e.g. ipi, nivo, pembro, ipi+nivo) or TT (dab+tram, vem+cobi, enco+bini) on or after January 1, 2014 and prior to May 31, 2020 (data cut-off), and evidence of a BRAF+ result after therapy initiation. Patients were required to be classified as LTB at the time of stage IV diagnosis. LTB was defined as having normal LDH and <3 metastatic sites at the time of stage IV diagnosis. | Drug: Nivolumab<br>* Nivolumab<br>Drug: Pembrolizumab<br>* Pembrolizumab<br>Combination Product: Dabrafenib+Trametinib<br>* Dabrafenib+Trametinib<br>Combination Product: Ipilimumab+Nivolumab<br>* Ipilimumab+Nivolumab<br>Combination Product: Vemurafenib+Cobimetinib<br>* Vemurafenib+Cobimetinib<br>Combination Product: Encorafenib+Binimetinib<br>* Encorafenib+Binimetinib<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of patients receiving TT and IO therapy in the first-, and second-line | To describe treatment patterns among patients prescribed with TT versus IO in both the populations. | throughout the study period, approximately 6 years (i.e., 01 January 2014 to 30 August 2020 for population 1 and 01 January 2014 to 31 May 2020 for population 2 | 
| Proportion of patients switching from TT 1L therapy to IO 2L therapy | To describe treatment patterns among patients prescribed with TT versus IO in both the populations. | throughout the study period, approximately 6 years (i.e., 01 January 2014 to 30 August 2020 for population 1 and 01 January 2014 to 31 May 2020 for population 2 | 
| Proportion of patients switching from IO 1L therapy to TT 2L therapy | To describe treatment patterns among patients prescribed with TT versus IO in both the populations. | throughout the study period, approximately 6 years (i.e., 01 January 2014 to 30 August 2020 for population 1 and 01 January 2014 to 31 May 2020 for population 2 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of patients who discontinued treatment in 1L | To evaluate discontinuation of 1L treatment among patients receiving TT or IO. | throughout the study period, approximately 6 years (i.e., 01 January 2014 to 30 August 2020 for population 1 and 01 January 2014 to 31 May 2020 for population 2 | 
| Reasons for discontinuation of treatment in 1L | To evaluate discontinuation of 1L treatment among patients receiving TT or IO. | throughout the study period, approximately 6 years (i.e., 01 January 2014 to 30 August 2020 for population 1 and 01 January 2014 to 31 May 2020 for population 2 | 
| Time from initiation of 1L therapy to death for any reason | To estimate OS from initiation of 1L treatment among patients receiving TT or IO. | throughout the study period, approximately 6 years (i.e., 01 January 2014 to 30 August 2020 for population 1 and 01 January 2014 to 31 May 2020 for population 2 | 
| Time from initiation of 1L therapy to recurrence (for population 1) | To estimate Recurrence Free Survival (RFS) (for population 1) from initiation of 1L treatment among patients receiving TT or IO. | throughout the study period, approximately 6 years (i.e., 01 January 2014 to 30 August 2020) | 
| Time from initiation of 1L therapy to progression or death (for population 2) | To estimate Progression Free Survival (PFS) (for population 2) from initiation of 1L treatment among patients receiving TT or IO. | throughout the study period, approximately 6 years (i.e., 01 January 2014 to 31 May 2020) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Adjuvant melanoma,, advanced melanoma,, treatment patterns and outcomes