Neoadjuvant therapy in melanoma: the fast track to critical new answers.

AT Outcomes are poor for patients with melanoma who are candidates for neoadjuvant therapy; that is, those who have locally or regionally advanced melanoma that is surgically operable. The 5-year tumor recurrence rate for these patients has been reported at approximately 68% to 89% after prior surgical management. The use of newer immunotherapies, targeted agents, and combinations has the potential to make a major impact in the management of these patients. We hope that neoadjuvant therapy can lead to improvements in outcomes in melanoma just as it has for other solid tumors, including cancers of the head and neck, breast, bladder, esophagus, and rectum. The benefits seen in these patients include improvements in survival, surgical resectability, local control, and organ preservation. The biggest advantage of neoadjuvant therapy is the ability to test tumor and blood samples both before and after the initiation of systemic therapy. This allows for a complete investigation of antitumor mechanisms of action, along with the conduct of biomarker studies. This may enable more selective application of therapeutic agents to these patients who are more likely to benefit. Such findings would improve the therapeutic index and cost effectiveness of these therapeutic agents. Secondly, neoadjuvant therapy allows us to avoid any delay in systemic therapy. This is a potential problem in the adjuvant setting because patients need to recover from surgery prior to initiation of therapy. Earlier systemic therapy means earlier targeting of distant micrometastases that could become the source of future disease relapse.