The Absolute Effect / Oncology Evidence / Evidence Index
DREAMseq (ECOG-ACRIN EA6134)
In BRAF V600-mutant metastatic melanoma, is immunotherapy-first sequencing superior to BRAF/MEK-targeted therapy-first sequencing?
Registry: NCT02224781 · Evidence reviewed 9 November 2026 · Aliases and follow-up publications consolidated.
Phase III randomized sequencing trial; n=265; stopped early for efficacy.Primary-source evidence summaryStudy design, population and eligibility
Phase III randomized sequencing trial; n=265; stopped early for efficacy.
Treatment-naive metastatic BRAF V600-mutant melanoma eligible for both strategies.
Treatment and comparator
Intervention: Nivolumab/ipilimumab first, BRAF/MEK therapy at progression.
Comparator: Dabrafenib/trametinib first, immunotherapy at progression.
Endpoints
2-y OS primary.
Key efficacy and clinical outcomes
2-y OS 71.8% immunotherapy-first vs 51.5% targeted-first (p=.010); first-line ORR 46% vs 43%.
Source-reported outcome visualization
Values are reproduced from the cited report; bars are scaled within this figure. Treatment sequencing in BRAF V600-mutant metastatic melanoma
Median survival and hazard ratios are not fixed-time event risks; NNT is not inferred from them.
Toxicity and treatment burden
Grade ≥3 toxicities similar overall; profiles differ by regimen.
Absolute effect and NNT/NNH
Applies to patients fit for both strategies; symptomatic rapid progression may warrant individualization; early stopping/crossover limitations.
NNT/NNH is not calculated unless a directly reported, comparable fixed-time risk difference supports it. Median survival and hazard ratios alone do not provide an NNT.
Critical interpretation and limitations
Applies to patients fit for both strategies; symptomatic rapid progression may warrant individualization; early stopping/crossover limitations.
This page is an evidence summary, not a substitute for multidisciplinary assessment or patient-specific decision-making.
Current-practice context
Review date: 9 November 2026. Primary publication and selected follow-up sources were reviewed. Full disease-specific guideline, regulatory-label and sequencing audit remains pending; verify current local recommendations and biomarker eligibility before clinical application.