SEOM clinical guideline for the management of cutaneous melanoma (2020)

Melanoma affects about 6000 patients a year in Spain. A group of medical oncologists from Spanish Society of Medical Oncology (SEOM) and Spanish Multidisciplinary Melanoma Group (GEM) has designed these guidelines to homogenize the management of these patients. The diagnosis must be histological and determination of BRAF status has to be performed in patients with stage ≥ III. Stage I–III resectable melanomas will be treated surgically. In patients with stage III melanoma, adjuvant treatment with immunotherapy or targeted therapy is also recommended. Patients with unresectable or metastatic melanoma will receive treatment with immunotherapy or targeted therapy, the optimal sequence of these treatments remains unclear. Brain metastases require a separate consideration, since, in addition to systemic treatment, they may require local treatment. Patients must be followed up closely to receive or change treatment as soon as their previous clinical condition changes, since multiple therapeutic options are available.

An update on access to novel treatment for metastatic melanoma in Europe - A 2024 survey of the European melanoma registry and the European association of dermato-oncology

Advances in cancer treatments have significantly improved their effectiveness, yet access to first-line therapies remains limited. A 2017 survey revealed that over 25 % of metastatic melanoma patients in Europe lacked access to recommended therapies. To address this, the European Association of Dermato-Oncology and the European Melanoma Registry conducted a follow-up study on the registration and reimbursement of first-line treatments.A web-based survey using LimeSurvey was distributed to melanoma experts across 27 European countries from February to April 2022 and updated from February to April 2024. The questionnaire covered the percentage of patients receiving recommended treatments, as well as treatment authorization and reimbursement dates for systemic and adjuvant therapies.There has been significant improvement in the registration and reimbursement of BRAFi/MEKi, anti-PD1, and anti-PD1/anti-CTLA4 therapies, increasing from 48 %, 63 %, and 37 % in 2017 to 96 %, 96 %, and 78 % in 2024, respectively. Despite these gains, restrictions persist. Anti-PD1/anti-CTLA4 combination immunotherapy is still not available without restrictions in 48 % of the surveyed countries. The nivolumab/relatlimab combination is licensed only for PDL-1-negative melanoma and reimbursed in seven countries of Europe. Tebentafusp is reimbursed in 15 countries and talimogene laherpervec in 5. In 2024, adjuvant treatments for stage III melanoma are reimbursed in 22 countries for dabrafenib/trametinib and 24 of 27 for anti-PD1 antibodies. Pembrolizumab and nivolumab are reimbursed in 15 and 8 countries, respectively, for stage IIB/IIC disease.While there have been improvements in the reimbursement of metastatic melanoma treatments in Europe, challenges and discrepancies remain. Further efforts at European and global levels are needed to harmonize and enhance access to cancer medicines.

Abstract P1-10-10: An integrative intervention to change breast cancer patients' lifestyle: A medical challenge. A randomize controlled trial

Background. Physical exercise increases breast cancer (BC) patients' survival. However, only about two thirds of them follow the American Guidelines of Exercise to cancer survivors. The aim of this study was to examine the effect of an exercise intervention in breast cancer patients' lifestyle.

Methods. A randomized clinical trial evaluated an intervention (EXE) vs. a control (CON) group in early stage BC patients who recently finished the chemo and radio (neo) adjuvant. Intervention consists on exercise group classes combining aerobic and resistance activities designed specially for the necessities of these patients. Intensity was increasing gradually and intervention was controlled by a qualified in oncologic exercise specialist. CON group maintained their lifestyle without changes. Leisure-time exercise levels (LTEL), quality of life (QoL), grip strength index (GSI), physical capacity (VO2max) and fatigue, were assessed at baseline and after 3 months in both groups. Women who had been participated in the intervention group were followed up after six months to know if lifestyle levels were maintained.

ANCOVA and Pearson Test were used to analyze the continuous variables of baseline and final data and ANOVA test was used to analyze the follow-up data. A 95% of CI was calculated and p < 0.05 was determined as statistically significant.

Results 89 women, aged 49.06±8.75, completed the study, 44 in EXE group and 45 in CON group. Adherence rate was on average of 89%. Main results are presented in the Table.

Main ResultsMEASUREEXE GroupEXE GroupEXE GroupCON GroupCON Group BLFFUBLFQoL*+107.53±17.99112.88±17.74110.96±14.40104.94±17.65103.11±19.26LTEL*+18.73±20.5345.11±14.6134.56±19.5116.02±8.5215.04±4.75GSI*+2.07±1.082.60±0.832.48±0.582.03±0.722.12±0.69VO2max*+26.99±4.3532.58±4.9632.11±7.1027.73±4.8227.08±3.73Fatigue *+130.09±19.68135.94±18.20138.24±17.49124.83±24.66124.00±24.20BL=baseline; F= Final; FU= Follow-Up. *Significant differences between EXE and CON. + Significant differences between BL and FU.

There was a significant improvement in LTEL (p=0.0001) and in QoL (p=0.0001) comparing EXE vs. CON group. In addition, results showed a correlation between this two variables in EXE group (r=0.22; p=0.013). These significant improvements, as well as the mentioned correlation, were maintained in the 6-months follow-up assessment in EXE group.

Significant differences between groups were observed in GSI (p=0.004), and in VO2max levels (p=0.001). EXE group showed a significant improvement in fatigue levels compared with CON group (p=0.0001). All these significant improvements were maintained in the 6-months follow-up assessment in EXE group, as well as previous variables.

Conclusion. These results suggest that an exercise intervention increases LTEL correlated to a better QoL, improving patients' lifestyle that could be long lasting. These changes may ameliorate psychological and physical BC treatments side effects, such as fatigue, in patients with early breast cancer that has recently finished adjuvant treatments.

Citation Format: Casla S, López-Tarruella S, Jerez Y, Marquez-Rodas I, Barakat R, Martín M. An integrative intervention to change breast cancer patients' lifestyle: A medical challenge. A randomize controlled trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-10.

Abstract P4-20-01: Implications of financial modeling in breast cancer clinical research from 1990 to 2010

SUMMARY: Over the past two decades significant progress has been made in breast cancer treatment resulting in a substantial improvement in patients' outcome. But we have to think about who promotes all this research and the consequences of the type of fundingThis project aims to evaluate the implication of finance in clinical research and the variance according to the type of funding.

OBJETIVES: To evaluate the financial evolvement of breast cancer clinical trials in the past two decades, regarding the phase of development design of the studies, the collaboration between Academy (Acad) and Industry (Ind), the sample size, the study results and the statistical analyses conducted.

METHODS: A systematic review was performed using MEDLINE to identify breast cancer randomized clinical trials published between January1990 and December2010. Studies that involved chemotherapy, endocrine and/or targeted therapies, wherethe primary endpoint was considered adequate to support a drug approval in oncology according to the FDA and EMA (U.S. Food and Drug Administration and European Medicines Agency, respectively), were included.

RESULTS:Data were evaluated 2,211 and 472 met selection criteria comprised in the methodology During the first decade the Acad was the main breast cancer research promoter being replaced by the Inv. throughout the second decade (p <0.0001). Thirty nine percent of the studies evaluated were phase III (39% Acad, 61% Ind), 15% were phase II (30% Acad, 70% Ind) and the remaining 47% were not classified by authors (65% Acad 35% Ind). As for the primary endpoint, 25% of the phase III trials evaluated progression free survival, 15% overall response rate, 1% time to progression and only 5% examined overall survival. Sixty five percent of the trials were national (60% Acad 40% Ind) and 35% international (25% Acad 75% Ind). Single-center studies accounted for 11% of the trial (65% Acad 35% Ind). Most of the national trials were developed by the US. Fifty four percent of the studies were conducted by research groups (67% supported by Ind. and 33% Acad.). The Ind sponsored 26% of the studies in the first decade and 50% during the second. The median number of patients enrolled by research groups was 892 in contrast with 409 included by other organizations. The primary endpoint was achieved in 19% of the Acad trials and 21% of the Ind trials. Only 53% of the studies declared intention to treat based analysis in their statistical workout.

RESULTS  ACADEMY(%)INDUSTRY (%)PPROMOTION OF THE STUDY1990-2000121(26)68(14)0,0001 2001-2010105(22)178(38)0,0001STUDY DESIGNUNICENTRIC TRIALS34(7)18(4)0,007 MULTICENTRIC TRIALS191(40)228(48)  NATIONAL TRIALS183(39)122(26)0,0001 INTERNATIONAL TRIALS42(9)124(26)  COOPERATIVE GROUP95(20)160(34)  NOT COOPERATIVE GROUP130(28)86(18) STATISTICAL ANALYSISINTENT OF TREAT86(18)163(35)  NOT DECLARATED140(30)83(18) 

CONCLUSIONS:There is a significant tendency towards the promotion of research by the pharmaceutical industries during the last two decades, leading a change in the clinical trials design and the endpoints.

Citation Format: Jerez Y, Lopez-Tarruella S, Marquez-Rodas I, Perez S, Ocaña A, Echavarria I, Lobo M, Gallego I, Torres G, Ortega L, Garcia G, Palomero I, Gonzalez Del Val R, Massarrah T, Esteban M, Del Monte-Millan M, Martin M. Implications of financial modeling in breast cancer clinical research from 1990 to 2010 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-20-01.

Prognostic significance of sentinel node biopsy status in cutaneous melanoma: a 21-years prospective study from a single institution

AIM

To analyze the accuracy of the sentinel lymphatic node biopsy (SLNB) and to investigate predictive factors for sentinel node (SN) status and prognostic factors for recurrence-free survival (RFS) and disease-specific survival (DSS) in patients with melanoma.

MATERIAL AND METHODS

Between June 1997 and June 2017, 440 consecutive patients, who underwent SLNB by a single surgical team, were prospectively included. Descriptive and survival analysis were performed.

RESULTS

119 of 440 patients (26%) had positive SN. SLNB's false-negative rate was 6.3%. Breslow thickness, Clark´s level, ulceration and histological subtype were statistically significant predictive factors of SN metastases. In a multivariate analysis, positive SN (HR = 2.21, p = 0.01), deeper Breslow thickness (HR = 2.05, p = 0.013), male gender (RR = 2.05, p = 0.02), and higher Clark's level (HR = 2.30, p = 0.043) were significantly associated with decreased RFS; and positive SN (HR = 2.58, p < 0.001), deeper Breslow thickness (HR = 2.57, p = 0.006) and male gender (HR = 1.93, p = 0.006) were associated with lower DSS.

CONCLUSION

SLNB is a reliable and reproducible procedure with high sensitivity (93.7%). Positive SN metastases, Breslow thickness and male gender were statistically associated with poorer outcomes. Male gender was an independent prognostic factor of tumor thickness or SN status.

Nomogram for predicting survival after first-line anti-PD-1-based immunotherapy in unresectable stage IV melanoma: a multicenter international study

BACKGROUND

The introduction of anti-programmed cell death protein 1 (PD-1) immunotherapy has revolutionized the treatment landscape for melanoma, enhancing both response rates and survival outcomes in patients with advanced stages of the disease. Despite these remarkable advances, a noteworthy subset of patients (40%-60%) does not derive advantage from this therapeutic approach. This study aims to identify key predictive factors and create a user-friendly predictive nomogram for stage IV melanoma patients receiving first-line anti-PD-1-based immunotherapy, improving treatment decisions.

MATERIALS AND METHODS

In this retrospective study, we included patients with unresectable stage IV melanoma who received first-line treatment with either anti-PD-1 monotherapy or anti-PD-1 plus anti-cytotoxic T-lymphocyte associated protein 4 between 2014 and 2018. We documented clinicopathological features and blood markers upon therapy initiation. By employing the random survival forest model and backward variable selection of the Cox model, we identified variables associated with progression-free survival (PFS) after the first-line anti-PD-1-based treatment. We developed and validated a predictive nomogram for PFS utilizing the identified variables. We assessed calibration and discrimination performance metrics as part of the evaluation process.

RESULTS

The study involved 719 patients, divided into a training cohort of 405 (56%) patients and a validation cohort of 314 (44%) patients. We combined findings from the random survival forest and the Cox model to create a nomogram that incorporates the following factors: lactate dehydrogenase (LDH), S100, melanoma subtype, neutrophil-to-lymphocyte ratio (NLR), body mass index, type of immune checkpoint inhibitor, and presence of liver or brain metastasis. The resultant model had a C-index of 0.67 in the training cohort and 0.66 in the validation cohort. Performance remained in different patient subgroups. Calibration analysis revealed a favorable correlation between predicted and actual PFS rates.

CONCLUSIONS

We developed and validated a predictive nomogram for long-term PFS in patients with unresectable stage IV melanoma undergoing first-line anti-PD-1-based immunotherapy.

Adjuvant immunotherapy in the modern management of resectable melanoma: current status and outlook to 2028

BACKGROUND

Therapeutic advances have reshaped the treatment landscape for patients with resectable melanoma, particularly for those with stage IIB/C and stage III disease. In this article, we discuss the current status and future outlook of adjuvant immunotherapy for melanoma in Europe.

RESULTS

Adjuvant immunotherapy offers significant benefits in terms of recurrence-free survival and distant metastasis-free survival. Uncertainties regarding overall survival (OS) benefits, however, remain. Trials such as Keynote-054, which are expected to provide crucial OS information, have delayed their final analyses until 2027. Additionally, real-world studies have raised questions about the correlation between recurrence-free survival/distant metastasis-free survival improvements observed in clinical trials and OS outcomes in routine clinical practice. These uncertainties have led to ongoing debates about the cost-effectiveness of adjuvant therapies, with disparities in reimbursement policies across Europe reflecting these concerns.

CONCLUSION

Looking ahead to 2028, adjuvant immunotherapy will remain a key option of comprehensive melanoma care, particularly for patients with stage IIB/C and stage III with micrometastatic disease, where neoadjuvant immunotherapy is not feasible.