New research indicates that advanced-stage melanoma patients should receive neoadjuvant immune checkpoint inhibitors followed by surgery.

This recommendation is emphasized in a recent editorial co-authored by Duke Department of Surgery resident Maggie O’Connor, MD, PhD, and Duke Cancer Institute melanoma experts April Salama, MD, and Georgia Beasley, MD, MHSc. Salama, a medical oncologist, and Beasley, a surgical oncologist, are both members of the DCI’s melanoma and advanced skin cancers group.

The editorial examined results from two clinical trials that compared neoadjuvant therapy – treatment administered before a main treatment like surgery – to therapies applied after a main treatment. Both trials showed a significant benefit for patients with stage 3 or 4 melanoma who received neoadjuvant care, particularly in event-free survival.

While these results are promising, real-world implementation of neoadjuvant therapy presents a challenge. Coordinating logistics among multiple service lines, as well as managing patient expectations, could make it difficult to put these therapies into practice.

“Neoadjuvant therapy has revolutionized the way we approach melanoma treatment and is an exciting next step,” O’Connor said. “However, with any treatment change comes new challenges and it is essential we focus on cohesive multidisciplinary work to set patient and provider expectations so we can provide this cutting-edge therapy.”

Multidisciplinary teamwork is also critical to the success of these treatments. Medical oncology and surgical oncology should work together to explain the risks of these therapies to patients while debunking the misconception that surgery or other forms of care are being delayed. Providers should also communicate the neoadjuvant treatment plan with pathology so future treatment and surveillance can be adjusted accordingly.

“Patients are understandingly wanting expeditious treatment of their melanoma,” Beasley said. “Now we know that some cancer cells are likely circulating around in the blood, and whole-body treatments before surgery offer the best chance of beating the cancer. The change in order of treatments, like any change, is not always easy, but the results are a game-changer for patients. “

While neoadjuvant therapy is more complex and requires more coordination amongst the medical team, this method of treatment results in marked improvements in disease control and could represent the new standard of care for certain melanoma patients.

“The development of effective immunotherapies for melanoma has been a major breakthrough and has changed the way we treat patients with resectable melanoma,” Salama said. “The complexity of the neoadjuvant approach highlights the importance of having a dedicated team of surgeons, medical oncologists and nurses to ensure the best possible outcome for patients.”