This guide is designed as an aid to help you understand neoadjuvant and adjuvant treatments. It can be used to help you discuss your options with your medical team, as they will know your individual case. They can let you know about the benefits of treatment and any side effects to help you decide if this treatment is right for you.
Neoadjuvant therapy is any treatment that is given before the complete surgical removal (resection) of a melanoma.
The main aim of neoadjuvant therapy is to make surgery to remove the melanoma easier. Neoadjuvant therapy can shrink the size of the melanoma and therefore it should be easier to remove all of it.
Neoadjuvant therapy may also mean that some people don’t need adjuvant therapy (after surgery to remove the melanoma), depending on if the doctors think that all the melanoma cells have been removed by neoadjuvant treatment and surgery.
Neoadjuvant immunotherapy treatment is generally given once every 3 weeks for 2 or 3 doses before surgery. For more information on immunotherapy treatment and possible side effects see the immunotherapy section further down this page.
Adjuvant therapy refers to any extra treatment that is given after the complete surgical removal of a cancer (a melanoma in this case). The aim of the surgery is to cure you. However, even if your surgery was successful at removing all visible melanoma, invisible cancer cells sometimes remain. These are too small to be detected by scans or blood tests. We think this is why some melanomas come back after surgery. The reason for offering adjuvant treatment is to try to kill these cancer cells and increase the chance of cure after surgery. Adjuvant therapy usually lasts for 1 year but could be less if you have had neoadjuvant treatment before your surgery.
In order to decide whether adjuvant therapy is right for you, it is important you understand how likely it is your melanoma will come back. Your doctor will be able to give you an idea of the risk of your melanoma returning when they know what stage your melanoma is. They can then help you understand the benefit you might get from adjuvant therapy. They use information from clinical trials involving patients with melanoma who were treated with adjuvant therapy. They will look carefully at what happened to patients whose melanoma was similar to yours, and who were given the same treatment. This will help your doctor estimate how much adjuvant therapy might reduce the risk of your melanoma returning.
Some patients will be cured of their melanoma by surgery alone (or neoadjuvant treatment and surgery). Unfortunately, there are no specific tests that will tell us exactly who will go on to have further problems from their melanoma. This means that there is a chance you may be receiving the adjuvant therapy unnecessarily. On the other hand, adjuvant therapy is also not a guarantee of success. Some patients will have both surgery (with or without neoadjuvant treatment) and adjuvant therapy and their melanoma will still come back. However, adjuvant therapy can reduce the risk of your melanoma coming back (recurrence) after surgery.
As with all drug treatments, some people will experience side effects with adjuvant therapy, but these do not affect everyone. Many people are able to live normally whilst having treatment. However, it is important to be aware of possible side effects in advance and discuss with your doctor what these might be. People who already have underlying health conditions might be more at risk, and your doctor will take this into account when discussing adjuvant treatment with you.
Some people want to do everything possible to reduce the chance that their cancer will return, even if this means putting up with the risk of side effects. Other people prefer not to risk extra side effects if there is likely to be little benefit from treatment. Ask your doctor what they recommend for you, and why. These decisions can be very difficult, and your doctor can help you decide whether or not the benefits of adjuvant therapy outweigh the risks for you.
Some patients who have had surgery for Stage 2B or 2C melanoma may be offered adjuvant immunotherapy to reduce their chance of further problems from the melanoma. Pembrolizumab is currently the only treatment approved for stage 2B or 2C melanoma, however, there are ongoing clinical trials looking at other treatments.
If you have been diagnosed with stage 3A, 3B, 3C or 3D melanoma you may be offered adjuvant immunotherapy treatment (pembrolizumab or nivolumab), or BRAF-targeted therapy (dabrafenib and trametinib) if you have a faulty BRAF gene.
If you have completely resected stage 4 melanoma you may be offered adjuvant immunotherapy treatment.
Please see the section below for information on these 2 different treatments.
Any discussion about adjuvant treatment will require very careful discussion with your Oncologist about your risk from melanoma, the potential benefit from treatment and possible side-effects of treatment.
NB: Please note that adjuvant treatment may not be recommended for all patients with Stage 3A melanoma. This is because patients with a sentinel node metastasis of 1 mm or less were excluded from trials due to the minimal benefit expected in this patient group. Your medical team should be able to help you with any questions you have about this.
If you have already received adjuvant therapy with pembrolizumab for stage 2 melanoma and you then develop stage 3 melanoma, there is no current evidence to support the use of repeated adjuvant treatment after any further curative-intent surgery. If you go on to develop stage 4 (metastatic) melanoma, further immunotherapy treatment may be discussed with you.
Targeted treatments for stage 3 melanoma can be offered if your melanoma contains a BRAF mutation. Approximately half of melanomas carry this mutation and may be referred to as BRAF-mutant, or BRAF-positive. Melanomas that do not carry the mutation are referred to as BRAF wild-type or BRAF-negative. This test will be performed on melanoma tissue from your surgery. If you have a BRAF-mutant melanoma you may be offered BRAF targeted treatments. These are given as capsules and tablets and the drugs ‘target’ the abnormal or faulty BRAF protein. This oral treatment is of no benefit in BRAF-negative melanoma.
BRAF-targeted treatment is taken twice a day by mouth at home for up to 1 year. The number of capsules and tablets you have to take depends on the dose of treatment. Side effects of BRAF-targeted treatments may include high temperatures, skin rashes, diarrhoea, tiredness and, rarely, changes in the way your heart or liver works. A full list of possible side effects, and the chances of these happening, will be given to you if you are offered targeted treatment. Side effects from targeted treatment can be managed in several ways. These approaches include pausing your treatment temporarily, reducing the dose you are receiving, or in severe cases, stopping treatment altogether. You will be supported by your medical team and will need to make contact with them if you feel unwell in between your appointments.
Dr Elaine Vickers, Cancer Science Communicator, explains BRAF and MEK targeted therapies.
Immunotherapy uses our immune system to fight cancer. It works by helping the immune system recognise and attack cancer cells. These drugs are usually given as a hospital out-patient via a drip into your vein, usually via a cannula in the back of your hand every three, four, or six weeks depending on which treatment you are offered. Immunotherapy treatment is given for up to 1 year and is suitable for patients with BRAF-positive or BRAF-negative melanoma. Many patients who receive immunotherapy experience minimal side effects. However a small proportion may experience toxicity from treatment, which can include skin rashes, irreversible changes in how well your thyroid gland works, diarrhoea and inflammation in the lungs, kidneys or liver. A full list of possible side effects, and the chances of these happening, will be given to you if you are offered immunotherapy treatment. You will be supported on treatment by your medical team and will need to make contact with them if you feel unwell in between your appointments
Dr Elaine Vickers, Cancer Science Communicator, explains immunotherapy treatment for melanoma.
The potential benefits and risks for adjuvant treatment vary by stage. Please select your melanoma stage from the links below to see the correct information.
