One of the most common and effective ways to treat melanoma is with surgery. And for some early stage cases, that’s enough. In other cases, however, additional therapy after surgery is recommended to help improve the outcome and reduce the risk of recurrence.
Adjuvant therapy refers to those treatments administered after surgery designed to improve outcomes and decrease the risk of recurrence. Those the FDA has approved for melanoma include:
According to the NCCN guidelines, adjuvant treatment outside of a clinical trial is not recommended for patients with stage I disease.
In 2021, the FDA approved pembrolizumab (Keytruda) for treatment of patients with Stage IIB or IIC melanoma after surgery. NCCN guidelines were updated to reflect this approval and add this option as a recommendation.
NCCN guidelines recommend adjuvant treatment with immunotherapy or targeted therapy for some stage III and stage IV disease that can be primarily treated with surgery.
Dr. Cecilia Larocca, a dermatologist at the Dana-Farber Cancer Institute says immunotherapy has helped changed the landscape of melanoma treatment.
“When immunotherapy came on the market it was such an exciting time for everyone involved in the care of melanoma, the main reason being is it went from this scary, unmanageable cancer with no treatments to one that could potentially have an incredibly long-lasting result with patients absolutely never having to worry about their melanoma, aside from having us do regular skin checks,” Dr. Larocca said in a previous conversation.
Targeted therapy is also making an impact.
“So when it comes to melanoma and targeted therapy, one of the main things that your oncologist will do is evaluate whether or not it has a particular mutation called BRAF. If your cancer has a BRAF mutation, there is a particular target therapy that you might be available to use,” Dr. Larocca said. “This combination therapy is now working its way earlier into the treatment paradigm for melanoma, both in the adjuvant setting – meaning treating patients who are at high risk for recurrence but don’t actively have cancer – as well as treating patients who actively have metastatic disease.”
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The decision to undergo adjuvant therapy should be made with your doctor taking into consideration the follow items, according to the NCCN:
The patient should have a detailed conversation with their medical team to discuss the pros and cons for additional therapy.
Promising adjuvant treatments for melanoma are on the horizon, too. Clinical trials underway include:
These studies haven’t matured, so it may be three or more years before official results are in, but experts are hopeful.
“We’re part of that study. It’s a good study,” says Dr. Jeffrey Weber, an oncologist and melanoma specialist at NYU Langone’s Perlmutter Cancer Center. “It’s a well-powered, thousand-patient randomized study. And in a couple of years, or maybe three years when it matures, we’ll know whether the combo is better than just (nivolumab), as adjuvant therapy.”
Dr. Weber points to a phase II study of patients with previously untreated stage III/IV melanoma testing the combo of bempegaldesleukinand nivolumab. “It had a 30 percent rate of complete responses, which is unheard of,” says Dr. Weber. “There’s almost no therapy that gives you a 30 percent complete response rate in any sphere of melanoma. So, that looked pretty promising.”
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Dr. Webber says one concern when it comes to adjuvant therapies, however, is the potential for overtreatment of patients.
“This is a big issue,” he said. “Do you treat adjuvantly and overtreat half the patients? And treat four patients to benefit one or five, to benefit one? Or do you wait and only treat the half of patients who need it? And allow two-thirds of them to progress and presumably die of melanoma? I’ve always been trained to be aggressive. I admit that it’s an expensive proposition to treat every patient with adjuvant NIVO for a year. ”
He says cost is a major concern as well.
“Bottom line is, pharmacoeconomics is a big deal,” Dr. Weber said. “You can’t ignore it. There is only so much money. This is a very rich country, by the way. But even this country has only so much money. So the more drugs you put together, the higher the charges. Eventually, we’re going to run out of money and we’re going to have to ration. Unfortunately, I couldn’t condone rationing the use of PD-1 antibodies by not treating people in the adjuvant mode when they’re at a high enough risk. We desperately need biomarkers to predict who’s going to relapse.”
The biggest tool against melanoma and other skin cancers is prevention. In a previous interview with SurvivorNet, Dr. Dendy Engelman from MDCS Dermatology in New York shared the top five things you can do to avoid skin cancer:
If your melanoma has progressed to a stage two or three, the cancer will likely need to be removed surgically in the hospital.
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