Swapping Surgery for Adjuvant Therapy May Improve Outcomes in Patients With Stage 3 Melanoma

Adjuvant therapy in patients who did not undergo complete lymph node removal surgery for the treatment of stage 3 melanoma, a type of skin cancer, may provide better distant metastasis-free survival, according to recent data.

“I think this data provides some comfort to both physicians and patients that says it’s OK to skip that step and move onto the systemic therapy, which probably has more impact on the overall outcome,” Dr. Martin McCarter, a professor of surgery in the Division of Oncology at University of Colorado School of Medicine in Aurora, said in an interview with CURE®.

He explained that due to a lack of survival benefit, more patients with stage 3 melanoma have skipped surgery to remove the lymph nodes. Instead, providers and patients are turning to adjuvant systemic therapy, or additional treatment given after primary treatment to potentially lower the risk of the cancer coming back, which has been shown to improve survival.

“In contrast to the surgical removal of the melanoma involved in lymph nodes, the clinical trials with systemic therapies — either immunotherapy or targeted therapy for melanoma — did show a survival benefit in patients with metastatic disease,” he said.

Comparing Therapy With Observation

McCarter and researchers evaluated the outcomes of 90 patients with stage 3 melanoma who skipped surgical removal of affected lymph nodes, of whom 56 patients received adjuvant therapy, consisting of immunotherapy or targeted therapy and the rest underwent observation alone.

Disease recurrence was observed in 12 patients in the observation group and 11 patients in the adjuvant therapy group. And the most common first site of recurrence in patients was distant recurrence alone, which occurred in five patients from the observation group. In addition, eight patients in the adjuvant therapy group had nodal recurrence alone. The 24-month nodal recurrence rate was not significantly different in patients from the adjuvant therapy and observation groups (26% versus 20%, respectively) despite more adverse nodal features in patients from the adjuvant therapy group. There was also no significant difference in recurrence-free survival during this time (75% versus 61%).

Patients with stage 3b/c melanoma treated with adjuvant therapy had a longer distant metastasis-free survival at 24 months compared with those who underwent observation alone (86% versus 59%).

“That suggests that there are microscopic melanoma cells in places that we cannot see at the time of surgery, and that by targeting those cells either with immunotherapy or targeted therapy, we can reduce the chance of the melanoma showing up at distant sites outside of the regional lymph nodes,” McCarter explained.

The overall data demonstrated that patients treated with adjuvant therapy are having better outcomes than those who are undergoing surgery to remove the lymph nodes.

“I think if you put the two pieces of information together, the one saying that a regional lymph node dissection did improve survival and that the systemic therapy did improve survival, the data we discovered or uncovered supports that notion,” he said.

McCarter explained that having the option of skipping a procedure, such as lymph node removal, and moving to adjuvant therapy can be beneficial for some patients who are at high risk for recurrence.

“It avoids significant complications, but it also allows them to progress sooner to systemic therapy that might improve the long-term outcome,” he added.

A Potential Change in Standard of Care

Additionally, he said skipping this surgery and moving to adjuvant therapy may become the standard of care for patients in this setting. It is still currently an active area of investigation, in addition to newer therapies.

“With the newer therapies available, there’s a lot of changes evolving, and sometimes the practice of medicine gets ahead of the actual clinical trial data that we have to support it. This is one of those scenarios where logically it makes sense, scientifically it makes sense and now at least we have some data to support the direction that things are heading,” McCarter said. “I think that just gives everybody more comfort in doing the treatment the way that things have now evolved.”

He concluded that data such as these would not be possible without patients participating in clinical trials and encourages patients to continue to do so to advance cancer care.

“I thank all the patients that have participated in prior clinical trials because that is the way we change in advanced care. If patients did not participate in those kinds of trials, then care would stagnate. I think most of all, it’s important that patients are willing to continue to contribute to our knowledge base,” McCarter concluded.

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