Home' Australian Pharmacist : February 2013 Contents 62
Australian Pharmacist February 2013 I ©Pharmaceutical Society of Australia Ltd.
EVIDENCE IN PATIENT CARE
1. In Australia, melanoma is:
a) the most prevalent cancer.
b) the 2nd most prevalent cancer.
c) the 3rd most prevalent cancer.
d) the 4th most prevalent cancer.
2. Melanoma is LESS COMMON in:
a) the elderly.
b) people with darker skin.
c) people who burn without tanning.
d) people with previous non-melanoma
3. The BRAF oncogene is present in:
a) 30% of melanomas.
b) 40% of melanomas.
c) 50% of melanomas.
d) 60% of melanomas.
4. The initial dose of vemurafenib
a) 960 mg twice daily.
b) 720 mg twice daily.
c) 480 mg twice daily.
d) 240 mg twice daily.
5. Which one of the following agents
targets the BRAF onogene?
Vemurafenib (Zelboraf) and dabrafenib
are orally administered drugs that target
the BRAF oncogene, which is present
in approximately 50% of melanomas.
This oncogene stimulates proliferation
of the cancer and inhibits apoptosis.
Approximately 50% of patients treated
with these medications achieve remission
in all sites of disease, including those with
brain metastases.28,31 However, the average
duration of response is only six months
with a median extension in overall survival
of just under four months.30 Vemurafenib is
indicated for the treatment of unresectable
metastatic melanoma positive for the BRAF
mutation. It is given twice daily on an empty
stomach (one hour before or two hours
after food) at a dose of 960 mg, with the
ongoing dose dependent on the emergence
of toxicity. Treatment should continue until
disease progression or the development of
intolerable toxicity. Adverse effects include
rash, alopecia, pruritus, hyperkeratosis, dry
skin, erythema, arthralgia, fatigue, nausea
and diarrhoea. Approximately 40% of
patients are likely to require dose reduction
due to toxicity.31 Cases of squamous cell
carcinoma (SCC) have been reported in
patients taking vemurafenib, usually early
in treatment. Age > 65 years and prior skin
cancer appear to be risk factors. Treatment
can continue in patients who develop SCCs,
which can simply be excised. Vemurafenib is
not currently PBS approved.
The purpose of follow up is to detect
recurrences early so that treatment can
be undertaken as quickly as possible. The
incidence of new, invasive melanomas
is approximately 2–8%, but subsequent
melanomas are commonly thinner and
have a better prognosis.5 Those at low risk of
recurrence (e.g. thin melanoma <1 mm) may
only need to be seen annually, while a patient
with a thick melanoma (> 4 mm) may need
to be seen every 4–6 months for the first 2–3
years and less frequently thereafter.6
Early detection is critical in maximising
survival from melanoma. Surgery is the
primary form of treatment, and the prognosis
is good if detected and treated early. While
the advances in survival demonstrated with
ipilimumab, vemurafenib and dabrafenib
appear to be small, the outcomes with
chemotherapy are poor.6 Therefore these
medications hopefully represent the
beginning of a series of advances that
will improve survival time in people with
The short case at the beginning of the article
illustrates an opportunity for the pharmacist
to provide advice on appropriate strategies
to prevent melanoma, including the use
of physical methods of UV protection,
complemented by the use of an appropriate
sunscreen. Since the customer has
mentioned that she has a number of moles,
it might be appropriate for the pharmacist to
ask her if she has her skin checked regularly
and provide suitable advice and information
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