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Original Investigation
March 2017

Systemic Therapy for Previously Untreated Advanced BRAF-Mutated MelanomaA Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

Author Affiliations
  • 1Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton , Ontario, Canada
  • 2Department of Oncology, McMaster University, Hamilton, Ontario, Canada
  • 3Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare-Hamilton, Hamilton, Ontario, Canada
JAMA Oncol. 2017;3(3):366-373. doi:10.1001/jamaoncol.2016.4877
Key Points

Question  What is the relative efficacy and safety of systemic therapies for advanced, treatment-naive, BRAF-mutated melanoma?

Findings  In this systematic review and network meta-analysis, BRAF/MEK and programmed cell death protein 1 (PD-1) inhibition were associated with improved overall survival benefit compared with all treatments except cytotoxic T-lymphocyte–associated antigen 4/granulocyte macrophage colony–stimulating factor. There was no significant difference in overall survival between BRAF/MEK and PD-1; BRAF/MEK conferred a significant advantage over all other treatments for progression-free survival; chemotherapy and PD-1 were associated with lowest risk of serious adverse events, with no significant difference in risk between treatments.

Meaning  The favorable efficacy and safety profile of PD-1 inhibitors supports using this option as first-line therapy.

Abstract

Importance  Multiple effective first-line systemic treatment options are available for patients with advanced BRAF-mutated melanoma. A lack of head-to-head randomized clinical trials (RCTs) comparing targeted and immunotherapies leaves uncertainty regarding optimal first-line treatment.

Objective  To estimate the relative efficacy and safety of systemic therapies for advanced, treatment-naive, BRAF-mutated melanoma.

Data Sources  We searched MEDLINE, Embase, and the Cochrane Central Registry of Controlled Trials for phase 2 or 3 RCTs published up until April 29, 2016.

Study Selection  We included RCTs in which at least 1 intervention was a targeted (BRAF or MEK) or an immune checkpoint (cytotoxic T-lymphocyte–associated antigen 4 [CTLA-4] or programmed cell death 1 [PD-1]) inhibitor.

Data Extraction and Synthesis  Two reviewers performed study selection, data abstraction, and risk of bias assessment. We performed a Bayesian network meta-analysis using a fixed-effect model to combine direct comparisons with indirect evidence. We estimated hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS), and odds ratios (OR) for objective response rate (ORR) and serious adverse events.

Results  Sixteen eligible articles reporting 15 RCTs involving 6662 patients assigned to 1 of 10 treatment strategies were included. Both BRAF/MEK and PD-1 were associated with improved OS benefit compared with all other treatments except CTLA-4/granulocyte macrophage colony-stimulating factor. There was no significant difference in OS between BRAF/MEK and PD-1 (HR, 1.02; 95% credible interval [CrI], 0.72-1.45). The network meta-analysis showed a significant advantage of BRAF/MEK compared with all other treatment strategies for PFS. BRAF/MEK was associated with higher ORR (OR, 2.00; 95% CrI, 1.64-2.45) compared with BRAF alone, with both being superior in achieving ORR compared with other treatments. Chemotherapy and PD-1 were associated with lowest risk of serious adverse events. There was no significant difference in the risk of serious adverse events between chemotherapy and PD-1 (OR, 1.00; 95% CrI, 0.74-1.34).

Conclusions and Relevance  Compared with other treatments, BRAF/MEK and PD-1 inhibition significantly improved OS. The favorable safety profile of PD-1 inhibitors supports using this option as first-line therapy in circumstances where rapid response is not a priority.

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