Revised standards of care for stage III melanoma

University of Colorado Cancer Center (CU) members Martin McCarter, MD, Camille Stewart, MD, Karl Lewis, MD, William Robinson, MD, Ana Gleisner, MD, PhD, and Rene Gonzalez, MD, along with residents of CU Robert Torphy School of Medicine, MD, PhD, reviewed their patient data to determine if immunotherapy alone would provide better outcomes than CLND.

During the few years before immunotherapy became available, several surgical trials were performed asking whether self-dissection of the regional node would improve overall survival for patients.McCarter, professor of surgical oncology at CU School of Medicine.

And the answer is back: no, it doesn’t improve survivability. That’s been the norm forever, because we don’t have other effective therapies, but once the final trials are done, we know that CLND doesn’t help, it doesn’t improve ability survivability. Further trials demonstrated that immunotherapy can improve survival in metastatic melanoma.“.

For the study, Torphy, working with McCarter and other researchers, looked at the data of 90 patients who had undergone a lymph node biopsy (a procedure to determine if a skin melanoma has occurred) microscopic spread) only for stage III melanoma but not undergoing CLND.

Of those patients, 56 received immunotherapy and 34 did not. People treated with immunotherapy have better distant metastasis-free survival, which means their cancer is less likely to come back.

As melanoma treatments have evolved, so may the standard of care“, McCarter said.

This study looked at patients who had sentinel lymph node biopsies, so we know the patient had a positive metastatic melanoma to their regional node.

Those people have historically often gone ahead and performed complete lymph node surgery, but recently, people have begun to skip dissection of that lymph node, which does not improve survival, and instead instead switching directly to immunotherapy, which improved survival in other clinical trials.

We’ve demonstrated that this is acceptable, that we don’t do more harm to patients by doing it, and that people who continue on immunotherapy seem to benefit from it.” .

Forgoing CLND is part of a recent cancer treatment movement called de-escalation, which offers patients only the surgery they really need to treat their immediate disease.

It’s especially important when it comes to lymph node surgery, says McCarter, because in addition to the risks inherent to all surgeries, CLND carries a 20% to 30% risk of permanent lymphedema, a swelling of tissue harmful due to the accumulation of many proteins. Fluid is normally drained through the body’s lymphatic system.

If you can avoid that complication and not affect the patient’s survival, that will be beneficial“, McCarter said. That’s what we guess happened outside of solid clinical trial evidence, and that’s what we can show.

We know that we often over-treat our patients, and this fits with a pattern of finding ways to reduce unnecessary therapies already in place in breast and other cancers. ”

Change course

The CU researchers hope the study begins to move the needles for oncologists, which CLND often does, although previous studies have shown that additional surgery does not improve survival.

Previous clinical trials with the use of adjuvant immunotherapy for melanoma required CLNDMcCarter said. This study used actual data from our stage III melanoma patients who received immunotherapy without prior CLND.

It took years to change people’s practice patterns. I still talk to the community surgeons who treat melanoma, asking me, ‘Should I do these node dissections?’ even though this data has been around for 5 to 10 years now“, McCarter continued.

They fear giving up what they used to do and they fear that they are harming their patients or not giving them the best chance, when in fact our understanding of cancer biology has evolved. We now have an effective immunotherapy that overcomes some of the limitations of surgery while improving outcomes“.

Source: Medindia

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