There is much in the literature regarding this issue and for those not familiar with the literature, it is worth reviewing. Bottomline- underlying autoimmune disease should NOT automatically be a contraindication to I/O therapy. However, as I am sure your practice is similar- there is no absolute right or wrong answer.
In our practice, decision to recommend I/O therapy to someone with underlying autoimmune dz (such as RA, colitis, psoriasis, etc) will vary depending on multiple factors to be considered based on each INDIVIDUAL patient. For example:
-is the underlying autoimmune issue well controlled?
-are they on immunosuppressive medications currently? what line of therapy (1st line, 5th line…)
-is there a specialist involved that would be willing to co-manage with oncology?
-is the patient reliable to report any new or worsening symptoms? do they have family/caregiver support?
-do they have additional comorbidities that would further increase risk
-Importantly- what is tumor burden- and have they had prior melanoma therapies?
Really, the decision comes down to is risk/benefit. If a patient has significant tumor burden and prognosis is poor- and they WILL die from their melanoma without intervention, then the benefits of trying I/O would seem to outweigh risks. Then there is the flip side to that as well.
We often see patients in consultation regarding safety of I/O therapy in such a patient. If the primary oncologist does not have enough of a comfort level with making such a decision, we will often weight in, and we are happy to co-manage or provide consultations regarding symptom management. There is not right answer here, as I am sure you know.
What I hate to hear about, is a patient being denied treatment to potentially life-prolonging or life-saving therapy due to lack of comfort or knowledge by a provider.
I would be very interested to hear how others address.
PS- my answer above relates to metastatic diasease. The adjuvant setting is a whole different discussion!!