Implementation of Neoadjuvant Immunotherapy in Stage III Melanoma: A Modified Delphi Consensus Study in a European-accredited cancer Centre in Ireland

Background The landscape of perioperative immune checkpoint inhibitor (ICI) therapy for stage III melanoma is rapidly evolving. We conducted a modified Delphi Consensus process to the define at an institutional level the optimal approach to implementation of a neoadjuvant ICI pathway for melanoma, addressing the themes of patient selection, perioperative therapy, response assessment and operative considerations, and follow-up. Methods We developed 28 consensus statements which were circulated to 24 senior members of an institutional melanoma multidisciplinary meeting (MDM) team at the OECI-accredited Beaumont RCSI Cancer Centre, Ireland. Members were invited to anonymously rate statements using a 5-point Likert score. Statements not reaching pre-determined consensus threshold from the initial round of Delphi process would be amended for subsequent rounds. Results Two modified Delphi rounds were conducted between May and June 2024, with round one results presented locally and a national meeting. Response rates for rounds one and two were 60% and 46%, respectively. In total, 23 statements of the 28 included (82%) met pre-determined criteria for consensus. Areas where lack of consensus was identified included the use of ICIs to down-stage unresectable disease, response-adapted approaches to adjuvant therapy and the optimal extent of nodal resection. Conclusion Our process identified important knowledge gaps regarding the multidisciplinary care of stage III melanoma. The statements generated will be used to develop a local pathway for the implementation of neoadjuvant immunotherapy in melanoma, with plans to further expand the Delphi process to other Irish institutions incorporating up to date published data to refine recommendations.