9 Things to Know About Adjuvant Therapy For Melanoma
Your doctor just announced that you’re melanoma-free. Sweet relief, right? If your skin cancer was caught early, the only follow-up necessary is regular skin checks. But if you had stage III or IV melanoma that has a good chance of recurrence even after it’s been surgically removed, you may need a round of adjuvant therapy. What’s that? Think of it as an insurance policy—a precautionary melanoma treatment to kill off any cancer cells that may be hanging around, so they don’t stage a comeback. Read on for the specifics on this preventative treatment.
First, What’s a High-Risk Melanoma?
If your melanoma was more than 4 mm thick, or 2 mm with ulceration (a breakdown of the top layer of skin), or has spread to lymph nodes, you’re at a higher risk of a recurrence. “If you’ve got a little bit of spread, we know your risk of spread elsewhere is high,” says Sancy Leachman, M.D., Ph.D. director of the melanoma research program at the Knight Cancer Institute at Oregon Health & Science University in Beaverton. Removal of the primary melanoma and the nodes may be done, but the concern is that microscopic cancer cells will linger—and move. That’s where adjuvant therapy comes into play.
Who Is Eligible for Adjuvant Therapy?
Adjuvant therapy is given to those with resectable stage III melanoma. In layman’s terms, that means melanoma that has spread to the lymph nodes but can be fully removed with surgery. In some cases, it can be given for stage IV melanoma, too, says Allison Betof Warner, M.D., a medical oncologist at Memorial Sloan Kettering Cancer Center in New York City. “If somebody has just one or two sites of metastatic disease, and they can be surgically removed, then we can consider adjuvant therapy for a year after that surgery,” she says.
What Are My Options?
Several years back, there was only one FDA-approved drug for melanoma adjuvant therapy: the intravenous or injectable drug Interferon. It’s a synthetic version of a protein your body already produces that bolsters your immune cells to kill cancer. It has to be given in high doses, so it carries a risk of toxicity and unpleasant side effects. Now there are better-tolerated drug options, including checkpoint inhibitors (a type of immunotherapy) and targeted therapies, which home in on the specific genetic mutation causing your tumors to grow.
How Do Checkpoint Inhibitors Work?
Your T-cells (immune cells) have checkpoints that act as brakes to stop them from attacking healthy cells, but that means sneaky cancer cells can sneak by undetected. Checkpoint inhibitors release those brakes so your immune cells find and destroy cancer. These drugs are also known as PD-1 inhibitors, the specific checkpoint they act on. Those most commonly used for adjuvant therapy are Opdivo (nivolumab) and Yervoy (ipilmumab), taken for one year. The latter resulted in a longer recurrence-free period with fewer side effects, research in The New England Journal of Medicine showed.
So, What Are The Side Effects of Checkpoint Inhibitors?
You’re smart to ask this question of any med you might take. A bit of reassurance: The most common side effects of checkpoint inhibitors are fairly mild, including fatigue, skin rashes, nausea, joint pain, loss of appetite, constipation, or diarrhea, according to the American Cancer Society. In more severe cases though, your immune system can get too revved up by immunotherapy, resulting in inflammation and damage to other organs such as the lungs, liver, or kidneys.
How Does Targeted Therapy Work to Prevent Recurrence?
Your doctor may have tested your melanoma for DNA mutations, most commonly BRAF and MEK mutations. Certain drugs target proteins in these mutations, blocking molecules that allow the tumors to grow and spread. In recent years, targeted therapies—Tafinilar (dabrafenib), and (Mekinist (trametinib). Keytruda (pembrolizumab)—has been approved for adjuvant use but is not classified as targeted therapy, but as immunotherapy. In 2018, the FDA approved a combination of dabrafenib and trametinib. This power pairing yielded a 58% survival rate at three years versus 39% with the placebo, in a study in the New England Journal of Medicine.
What Are The Side Effects of Targeted Therapy?
Happily, compared to immunotherapy, the side effects stemming from targeted therapy tend to be short-lived. The majority of them are flu-like and include fever, chills, fatigue, nausea, and skin rashes. Your physician can help manage any issues you’re contending with by prescribing a short-term course of steroids, if necessary, so pipe up about any issues you’re experiencing (yep, however not-a-big deal they may seem).
What About Radiation as Adjuvant Therapy?
Radiation, which uses high-energy X-ray beams to destroy tumors, isn’t typically a go-to treatment for melanoma, but it can be used as an adjuvant treatment to kill off cancer cells in distant organs. In a study in The Lancet Oncology, researchers found that only 10.2% of participants who had a lymph node dissection (removal) for melanoma plus a course of radiation had a recurrence within 5 years compared to 40.6% who had undergone lymph node dissection alone.
So, What Happens After Adjuvant Therapy?
Once you’ve completed your treatment, you’ll need to be super diligent with doctor follow-ups. According to the Melanoma Research Alliance, you should check your own skin and lymph nodes monthly. Expect to see your doctor for an in-office exam every three to six months for the first two years after your adjuvant therapy, every three to 12 months for the next three years, and then once a year after that. The five-year survival rate for stage III melanoma is 63.6%, but experts say advances in treatments and adjuvant therapies should continue to increase that number over time.
- Adjuvant Therapy Overview: Cancers. (2020). “Adjuvant Therapy for Melanoma: Past, Current, and Future Developments.” ncbi.nlm.nih.gov/pmc/articles/PMC7409361/
- Defining a High-Risk Melanoma: Skin Cancer Foundation. (n.d.). “Melanoma Stages.” skincancer.org/skin-cancer-information/melanoma/the-stages-of-melanoma/
- Interferon as Adjuvant Therapy: Melanoma Research. (n.d.). “Interferon (Intron or Sylatron).” curemelanoma.org/patient-eng/melanoma-treatment/adjuvant-therapy/interferon-intron-a-or-sylatron/
- Combo Targeted Therapies for Adjuvant Therapy: New England Journal of Medicine. (2017). “Adjuvant Dabrafenib plus Trametinib in Stage III BRAF-Mutated Melanoma.” nejm.org/doi/full/10.1056/NEJMoa1708539