Identifying Patients for Neoadjuvant Melanoma Therapy

Jeffrey S. Weber, MD, PhD: Let’s turn to Jason. There’s been a lot of attention given to neoadjuvant approaches with immunotherapy in not just melanoma but also other cancers. Whom do you consider for neoadjuvant immunotherapy, and how often do you see these patients?

Jason J. Luke, MD, FACP: That’s a good question, and I appreciate everything that everybody else has mentioned so far. I think there’s neoadjuvant, and there’s neoadjuvant. What I mean by that is, in the old days, we had patients who had disease who were probably not really resectable. We had a hope that by giving some intervention initially, we can shrink it enough where we can do surgery. Those patients are not that common, but they do happen, and all of us have seen them in clinical practice. That actually contrasts somewhat with the whole concept of neoadjuvant as we’ve been discussing in the field over the last couple of years. We’re just trying to identify patients who actually are resectable, but where we could intervene in a therapeutic approach, either for research consideration or potential therapeutic implications prior to the surgery. Those are 2 different things.

The extent to which these are common patients is suspect. At our center, because we have had an interest in this for quite an extended period of time, we see a fair number of these. We have had institutional investigator-initiated trials where we’ve put on 20 to 30 patients per year. But again, recognize that there’s a long-standing practice of all patients with cutaneous malignancies being referred to UPMC Hillman Cancer Center as the hub in western Pennsylvania, owing to the work of John Kirkwood for decades now.

In clinical practice in general, this isn’t a particularly common presentation. I will note, however, that the results initially—and others will to speak to them—are quite impressive for intervening. That being said, it’s still a research question, and we really guide all the patients toward research protocols. We would necessarily take a patient through neoadjuvant therapy if they were resectable, if they weren’t going to go on a protocol. That’s an important differentiator. For community practitioners, they should be cognizant that there actually is a cooperative group trial now that’s a SWOG clinical trial, trying to look at the impact of neoadjuvant therapy relative to adjuvant. I strongly recommend people consider that if they actually do see some of these patients.

Jeffrey S. Weber, MD, PhD: When you see these folks, do you test them for BRAF or PD-L1? Does it matter to you?

Jason J. Luke, MD, FACP: We tend to test them for BRAF but not really for PD-L1. For BRAF, in the setting where they have palpable disease, our expectation is that their risk is going to be quite high for recurrence, and it seems very reasonable to get that data up front. That data don’t always inform what we do. Most of the trials we’ve been pursuing in the neoadjuvant space are immunotherapy trials. We sometimes get the PD-L1, but that’s more in the context of research, not to guide standard practice.

Transcript Edited for Clarity