Focus Shifts to Toxicity Management Gaps as Melanoma Survival Improves: Igor Puzanov, MD, MSCI

In part 2 of an interview with The American Journal of Managed Care^® ahead of the 2026 American Society of Clinical Oncology (ASCO) Annual Meeting, Igor Puzanov, MD, MSCI, senior vice president of clinical investigation at Roswell Park Comprehensive Cancer Center, addressed 2 interconnected challenges in modern melanoma care: the long-term consequences of immune-related toxicities from checkpoint inhibitor therapy and the persistent gap between published management guidelines and real-world clinical practice.

On the question of systemic costs, Puzanov noted that while the full economic burden is not yet precisely quantified, it is substantial. Effective management requires a multidisciplinary infrastructure, remote patient monitoring, and dedicated survivorship programs. He highlighted that patients exposed to immune checkpoint inhibitors face roughly 2.34 times the risk of coronary artery disease and vascular complications compared with unexposed patients.

To address survivorship comprehensively, Puzanov and colleagues published a white paper in The Journal for ImmunoTherapy of Cancer aimed at convening experts to define what data must be captured, what follow-up is required, and how to build the economic case for funding long-term survivorship care. Puzanov's own clinical guidance to survivors mirrors cardiovascular risk-reduction strategies: blood pressure below 120/70 mm Hg, low-density lipoprotein cholesterol below 70 mg/dL, and weight management with regular exercise and a diet rich in fiber and fermented foods to support the microbiome.

He acknowledged that these are informed clinical opinions rather than data-driven protocols, underscoring the need for large survivor registries and analytic partnerships to generate that evidence.

“Obviously, these are just opinions; it's not data-driven advice,” Puzanov said. “For that, we need to create databases of survivors and look at these databases, probably with the help of large data sets and large kinds of data analytic groups…[to] look into that in more detail and then deploy systems and measures to ameliorate these long-term toxicities.”

Regarding guideline implementation, Puzanov noted that the gap is large and personally frustrating. He was involved in developing the first US-based toxicity management framework for immune checkpoint inhibitors with the Society for Immunotherapy of Cancer group and has distributed it widely to the emergency departments he works with. Despite this, clinicians frequently fail to recognize immune-related adverse events at all, and when they do, many do not apply the Common Terminology Criteria for Adverse Events grading system. Puzanov described this as a critical misstep, since treatment decisions hinge on whether a toxicity is grade 1, 2, 3, or 4.

“When I was in training 20-plus years ago, we actually carried books in our pockets, and I think we actually used them more than people do now, when everything is electronic,” he said.