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Optimising treatment for Australian melanoma patients can save taxpayers millions of dollars annually

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To the Editor: Patients with BRAF-mutated metastatic melanoma benefit greatly from the novel BRAF inhibitor dabrafenib and the checkpoint inhibitor ipilimumab, recently listed under the Australian Pharmaceutical Benefits Scheme (PBS). Dabrafenib results in rapid responses; but the cancer later adapts, and patients relapse rapidly. Conversely, ipilimumab slowly reactivates anticancer immunity, meaningfully improving long-term survival (up to around 20% at 5 years).

The costs of these drugs are substantial. Dabrafenib costs A$8759 per month, and median duration of therapy is 9.4 months.1 The Australian price of ipilimumab is confidential, but potentially up to A$190 000 per patient, depending on weight. The 2014 year-to-September PBS cost of ipilimumab was $68 456 890 (data from https://www.medicareaustralia.gov.au/statistics/pbs_item.shtml).

Current PBS approval mandates that dabrafenib may only be used as first-line therapy. Commencing treatment with dabrafenib then switching to ipilimumab when the disease progresses may inadvertently deliver worse outcomes than using the slower but longer acting immunotherapy followed by the potent but impermanent BRAF inhibitor.2,3

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