This is a very relevant issue, especially in the adjuvant setting. This came up for us recently when a 34 year old woman with Stage IV melanoma resected to NED (no evidence of disease) was going to start adjuvant ipilimumab. She was recently married and asked about having children. In discussion with her PCP, she was referred to a fertility specialist who felt immunotherapy itself would not impact her ovarian reserve, but her advancing age could as she awaits completion of therapy and then more time to ensure she does not recur. For that reason, embryo cryopreservation could be considered. One of our concerns was that development of hypophysitis from I/O therapy may make in vitro fertilization difficult, but that was not felt to be a major concern as gonadroptropins would be used in this setting.

Here is another related question – what are your recommendations about pregnancy for females with a history of Stage III or Stage IV melanoma resected to NED?

Great question Lisa! Our approach to this issue follows Krista’s guidelines with each particular patient’s situation evaluated independently weighing the risks and benefits. Several years ago we would have avoided I/O therapy in patients with autoimmune conditions, but that practice has now changed as more information has come out showing that it can be offered to some patients.

We do not routinely give premedication for ICI’s. If a patient develops an infusion reaction, they will receive premedication thereafter.

Thank you Kathleen and Lisa for your feedback.
Kathleen, we are going to start maintenance dosing with infliximab which is a great suggestion. Lisa, I had not thought about approaching the company for assistance. I will look into that. We have sent stool for C diff, shigella, salmonella and camplyobacter all of which were negative. Interestingly, she is now being treated for serratia bacteremia with cipro so it will interesting to see if that helps.

I do not recall seeing that, but will pay more attention to concomitant meds with our patients on BRAF/MEK inhibitors.

I have not had increased reports of vivid dreams while on ICI’s, but perhaps this is a milder form of neurotoxicity (reported in 1-3% of patients on these agents)?? As you note, this is very common with high dose IL-2 and can worsen if therapy is not held. Anyone else have ICI patients reporting vivid dreams?

Krista,
This is an excellent point. It is difficult to watch patients and families struggle with the financial concerns of cancer therapy when they have such a bigger battle to wage against their disease. I have had good experiences with the drug companies’ financial assistance programs, but the process takes time and resources to make it happen.