Adjuvant systemic therapy for melanoma - Analysis of factors leading to the timely initiation of treatment

Early-stage melanoma is associated with high rates of recurrence. Checkpoint inhibitors have dramatically improved outcomes for metastatic melanoma over the past decade and now they are available in the adjuvant setting for stage IIB-IIID disease.1–3 For BRAF V600 mutant, fully resected stage 3 disease, there is the alternative option of adjuvant BRAF/MEK inhibitors, dabrafenib/trametinib.4 Nivolumab is licensed for fully resected stage IV disease. Adjuvant treatment should commence within 12 weeks of surgery to reflect trial data.3 To characterise melanoma patients treated with adjuvant therapy in Barts Health NHS trust, assess time to initiating adjuvant therapy and recurrence rates. Data was collected retrospectively on all melanoma patients who started adjuvant treatment at Barts NHS Trust from 2018 to June 2023. Data was collected on demographics, cancer stage, type of adjuvant treatment, toxicity, survival, and recurrence. 87 patients received adjuvant treatment. The median age was 65 years (range). 50 (57%) pts received pembrolizumab; 27 (31%) pts dabrafenib/trametinib and 10 (11%) pts nivolumab; 33 (38%) patients harboured a BRAF V600 mutation. 18% (6/33) opted for immunotherapy and 82% (27/33) opted for targeted therapy. Relapse rates were higher than estimations provided by the American Joint Committee on Cancer (ACJ) (Table 1).5 Of these patients, 27 (31%) exceeded the 12-week target for commencing adjuvant treatment post-surgery. Reasons for delays included delays in scan scheduling/reporting (11[38%]) and pathology reporting (3 [11%]), late referral to medical oncology (1 [4%]), lack of chemo unit availability (4 [15%]), late referral to correct multidisciplinary team meeting (5 [19%]) and patients too unwell to start treatment (9 [33%). Our results show higher-than-expected relapse rates in patients receiving adjuvant treatment for melanoma. Additionally, 31% of patients did not commence treatment within the 12-week recommended timeframe. Recommendations on how to improve on this will be presented at the regional specialist skin MDT. Medical oncologists will aim to see all new patients within 8 weeks of surgery and chemotherapy booking requests will be made pre-emptively. We plan to re-audit in 12 months once these changes have been implemented.