A Call to Arms: Surgeons Must Play an Important and Early Role in the Management of Patients with Advanced Melanoma

Excerpt

As systemic therapies continue to decrease recurrences and improve survival in patients with advanced melanoma, the management of patients with metastatic disease has evolved into a much more multidisciplinary approach. While a significant focus of recent literature has been on the success of novel systemic agents, incorporating surgery into the care of the patient with advanced melanoma is both increasing in frequency and dramatically impacting survival. Two articles published in this issue of Annals of Surgical Oncology demonstrate the role of surgery as an important component of the multidisciplinary approach to patients with both regional and distant metastatic disease.1,2 In the analysis by Nelson et al.1 the 5-year melanoma-specific survival (MSS) of stage IV patients who underwent surgery and received either immunotherapy or BRAF-targeted therapies was 45.5%. In a matched-pair analysis of patients undergoing upfront surgery compared with patients undergoing modern systemic therapy alone, 5-year MSS was even better for the upfront metastasectomy group (58.8% compared with 38.9% in the systemic therapy-only group). Furthermore, the study reported from the University of Pennsylvania group demonstrated that survival for patients with clinical stage III disease is markedly improved since the approval of immunotherapy.2 On cursory review, the juxtaposition of these two studies would imply that the credit should be applied to systemic therapy; however, it is important to consider that effective systemic therapy often permits the surgeon to consider a more aggressive approach. The introduction of neoadjuvant therapeutic paradigms makes this increasingly true. …