Choosing Therapy after Surgical Removal of Melanoma (Adjuvant Therapy)
Dear OncoLink "Ask The Experts,"
I have been diagnosed with melanoma, stage IIIA. After a 4.5 mm lesion was removed, I had a sentinel node biopsy which came back "barely" positive. Two weeks later, I had a complete lymph node dissection of the left groin. ALL came back negative - Hooray!
Now I am faced with the interferon vs. vaccine vs. nothing decision. I am having a terrible time deciding what I should do next. Help!?
Keith T. Flaherty, MD, Assistant Professor of Medicine (Hematology/Oncology), responds:
Deciding whether or not to pursue medical therapy following the surgical removal of melanoma ("adjuvant therapy") is a complex and individual choice. There are three important factors that strongly influence this issue: the thickness of the primary melanoma, the presence or absence of microscopic ulceration, and the involvement of lymph nodes. (See interpreting your pathology report) Generally, surgery to assess the potential involvement of lymph nodes is only recommended if the primary melanoma is at least 1 mm in thickness, or if there is evidence of microscopic ulceration.
Adjuvant therapy is considered potentially appropriate only if the primary melanoma is at least 2 mm in thickness (thinner in the presence of microscopic ulceration), or if there is evidence of melanoma in the lymph nodes. Even the presence of melanoma in lymph nodes is not straightforward, as the presence of a few melanoma cells in a single sentinel lymph node may be no more worrisome than no evidence of melanoma cells at all. In the end, the features described above and the potential need for adjuvant therapy should all be discussed with a medical oncologist to determine the most appropriate course.
The only FDA-approved therapy to prevent recurrence of melanoma following surgical removal is one year of interferon-alpha. This therapy can clearly delay a potential recurrence of melanoma. However, it is less clear whether people who take interferon live longer than those who do not. While there is no doubt that interferon impacts the risk of melanoma recurrence to some degree, the treatment is associated with severe side effects in most who take it. Therefore, the decision to take interferon or not requires careful consideration of the potential benefits and risks for each individual.
A major focus of melanoma research is to develop more effective and tolerable adjuvant therapies. While several types of therapies are being investigated, the largest numbers of clinical trials in this area are evaluating melanoma vaccines. In general, vaccines have been associated with very infrequent and mild side effects. However, no vaccine has demonstrated an ability to either delay the recurrence of melanoma or contribute to longer survival. Therefore, trials with vaccines or other novel therapies must be considered experimental. The availability of clinical trials with novel adjuvant melanoma therapies varies over time, and may require travel to a cancer center that is participating in these trials. A medical oncologist will be able to determine if an available trial is appropriate.