WCCS 2016
The timeline of adjuvant and neoadjuvant therapy for melanoma
Dr Jean Jacques Grob - Hôpital de la Timone, Marseille, France
This meeting is organised by the EADO which is the European Association of Dermato Oncology and I was the President of this association in the previous years then Claus Garbe overtook the presidency. So we have founded this association fifteen years ago.
What were you discussing at this conference?
My talk was about the possibility that we have to use new drugs which have been tested so far in very advanced stages of metastatic melanoma, so the targeted therapies, BRAF and MEK inhibitors, and the immunotherapies, whether we could use them in earlier stage, early in the disease. That is covering the adjuvant therapy after the nodal surgery usually. So a neoadjuvant strategy before the nodal surgery but you could also think about intervention which could be even earlier, I mean at the time of the primary melanoma before the sentinel node. It could be that at the end of the story the treatment would not start with surgery at all. Surgery has a long history of two centuries but once you know the mechanism of the tumours, once you can intervene with immune strategies for instance, you can imagine that you can reset the disease before surgery or even avoid surgery.
So to go to this step, not tomorrow morning of course, one condition is to really understand the different steps of the disease from a biological point of view. From this point of view the neoadjuvant trials are very interesting because they permit a very interesting translational research to understand what each treatment is really doing on a molecular point of view, on an immune point of view. So there are a substantial number of trials dealing with neoadjuvant interventions with immunotherapy, with targeted therapy, in nodal diseases but you could also imagine much earlier neoadjuvant strategies.
What subtypes would they be most suited to?
One important point is that if you consider the patients who die from a melanoma there is a large proportion of these patients who started their disease by stage 2a or 2b AJCC disease. That means that a large number of patients who die do not start their disease with a 3a or 3b disease so it’s very important to focus also in this population that we considered as low risk patients. As a group they are low risk but as they are very numerous they represent a major component in the deaths from melanoma. That’s the reason why we should not focus only on 3b and 3c patients but also go back to earlier disease because among this high number of patients many or some will end up with metastatic disease. That means that we need prognostic markers, much better ones than the ones we have now like Breslow, that kind of thing, we need probably biomarkers. At the time when we move primary melanoma we should have an assessment of immunological factors, genetic factors, molecular profile of the tumour and this could help us to define the potential bombs from the rest of the tumours.
Is more research on biomarkers needed?
I don’t think we will have very fast operational biomarkers because not a single marker can classify a patient, probably a biomarker has to be a panel of markers. So I do not expect that we will be able to classify the primary melanoma into really high risk and low risk in the near future. That’s the reason why maybe we have to find a low tox procedure, low tox treatments, that we can use in a lot of patients without taking too much risk. Hopefully within this whole group there will be those diseases which, by the natural history of melanoma, would kill the patient and maybe we could prevent it.
Any final thoughts?
We should not stay on the vision we had of melanoma ten years ago. So many things have changed that really the place of the sentinel node, the role of surgery, what should we do on primary melanoma, all these questions become completely open. Again, we may expect to get rid of the surgery and treat patients just from the very beginning with medical drugs, at least it’s possible.
