ESMO E-Learning: The Neo-Adjuvant Melanoma Treatment Landscape 2023

The rationale for neoadjuvant treatment with immune checkpoint inhibitors, in patients with melanoma, is based on the concept that their administration, while the primary tumour is still present, will result in a more robust antitumour immune response compared with what can be seen in the adjuvant setting. Data from neoadjuvant phase II studies suggest improved recurrence-free survival with PD1 inhibitors compared to adjuvant treatment. However, overall survival data are still missing.

In this E-Learning module, the author, a world-renowned melanoma researcher, first provides an overview of adjuvant treatment for melanoma: highlighting that surgery, irradiation, and interferon are outdated, while dabrafenib/trametinib, nivolumab and pembrolizumab have shown consistent impact on major outcomes in patients with resected stage II/III​ melanoma. A careful risk/benefit assessment is crucial​. Immunotherapy combos are currently investigated in the adjuvant setting.

The author then continues with a set of slides that consider whether the neoadjuvant approach is superior to adjuvant immunotherapy. The evaluation of neoadjuvant treatment goes beyond PD1 inhibitors, with immunotherapy combos currently being investigated​. While there are several open questions regarding the neoadjuvant approach, the data so far support the paradigm shift of considering neoadjuvant treatment in clinical practice for patients at high risk for disease recurrence.  

Improved outcomes, such as recurrence-free survival, are reported among patients treated in the neoadjuvant versus the adjuvant setting. The author also elaborates on a type of pathologic response in relation to relapse rate and potential benefit from additional adjuvant treatment in these patients. The neoadjuvant setting is an emerging area of research interest, with several ongoing and planned clinical trials that explore the efficacy of novel agents or combinations.