Dr. Pavlick on the Benefit of Neoadjuvant Immunotherapy in Resectable Melanoma

Anna C. Pavlick, DO, professor of medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, founding director, the Cutaneous Oncology Program, Weill Cornell Medicine and New York-Presbyterian, discusses the potential benefit of neoadjuvant immunotherapy prior to surgical resection, according to results from the phase 2 SWOG S1801 trial (NCT03698019).

The randomized trial assessed the administration of pembrolizumab (Keytruda) in the neoadjuvant setting, as well as in the adjuvant setting for patients with clinically detectable and resectable stage IIIB/IV melanoma.

Eligible patients enrolled on the trial were assigned to either the neoadjuvant or adjuvant treatment arm. Patients on the adjuvant treatment arm underwent surgery followed by 18 cycles of pembrolizumab. Patients on the neoadjuvant arm received 3 cycles of pembrolizumab, followed by surgery, and then 15 additional cycles of pembrolizumab. Additionally, patients receiving neoadjuvant pembrolizumab were required to undergo surgery regardless of response to the treatment.

Overall, data from this trial revealed that there is a clear increased survival benefit in patients receiving neoadjuvant immunotherapy prior to resection compared with adjuvant pembrolizumab, Pavlick continues. This result was observed across all subgroups. Moreover, the effect of immunotherapy on resected tumors was also able to be analyzed, and patients who fell short of achieving a complete response still displayed encouraging long-term survival, Pavlick states. These results led to a practice change within the treatment paradigm, Pavlick notes.

Prior to this trial, the standard approach involved immediate resection followed by treatment with preventive therapy, Pavlick adds. Now, clinicians should consider administering preoperative immunotherapy in addition to postoperative regimens, she says.

Although these results were paradigm-shifting, there is still a need for further adjuvant therapy in patients who have already achieved complete responses. Future research on the continued administration of adjuvant therapy after up-front immunotherapy and surgical resection will benefit this patient population, Pavlick concludes.