Melanoma care is shifting to risk-based screening and treatment before surgery | Fall Clinical Derm 2026

Broad skin cancer screening may not be the best use of clinicians' time, and more patients with melanoma are getting immunotherapy before surgery, according to Laura Ferris, M.D., Ph.D., professor and chair of the department of dermatology at the University of North Carolina.

"Screen smarter, not harder," Ferris said during a session at the Fall Clinical Dermatology Conference on Oct. 9.

Screening that targets risk

Ferris shared that Germany has offered state-funded skin cancer screening since 2008. Adults 35 and older are covered for a skin exam every two years, and about a third take part.

A study published in July 2026 in JAMA Dermatology compared melanoma death rates in Germany with those in nine neighboring countries without such programs from 2009 to 2022. Death rates fell everywhere, by 1.8% a year in Germany and 2.2% a year in the other countries. The difference wasn’t that significant.

Ferris said one likely reason is that the program does not focus on people at high risk.

“Thirty-five is pretty young to start for screening for skin cancer,” she said.

A second study, from Emory University, looked at more than 1,000 patients who came in for a routine skin check with no specific concern. Ferris said clinicians had to examine about 33 of these patients to find one skin cancer. Among patients 50 or younger, it took 181. The number dropped sharply for older patients and for those who had skin cancer before. The authors suggested sorting patients by age, skin type and skin cancer history to get more out of each exam.

Immunotherapy is moving earlier

Patients whose stage IIB or IIC melanoma has been removed are now candidates for a year of PD-1 inhibitor therapy after surgery. Keytruda (pembrolizumab) and Opdivo (nivolumab) are both approved for this use. In trials, each lowered the risk that the cancer would return or spread compared with placebo.

Follow-up scans after surgery may add less than expected. For instance, Ferris slides for her presentation included interim results from TRIM, a phase 3 trial in Sweden of patients with stage IIB to III melanoma that had been removed. Adding routine whole-body CT or PET-CT scans to physical exams did not improve survival, with three-year survival of 88.2% and 87.7% in the two groups. The trial continues toward its five-year goal.

For patients whose melanoma has already reached nearby lymph nodes, Ferris said clinicians should be thinking about starting treatment before surgery.

In the SWOG S1801 trial of 313 patients with stage III or IV melanoma that could be removed, every patient had surgery and 18 doses of pembrolizumab. The only difference was timing: one group got three doses before surgery and 15 after, while the other had surgery first. At two years, 72% of patients treated before surgery were alive without their cancer returning or worsening, compared with 49% of those who had surgery first. Serious side effects were similar between the groups.

In the NADINA trial of 423 patients with stage III melanoma that could be removed, patients in one group got two doses of nivolumab plus low-dose Yervoy (ipilimumab) before surgery. Those whose removed tumor had less than 10% living cancer cells, which was 59% of patients, needed no further treatment. Patients in the surgery-first group went on to 12 cycles of nivolumab. Event-free survival was best in the group treated before surgery, Ferris said.

A vaccine with limits

Ferris also addressed a personalized mRNA vaccine, intismeran autogene, that has drawn wide media attention. Each vaccine contains up to 34 targets drawn from a patient's own tumor and is given with pembrolizumab.

In a phase 2b trial in patients with removed stage IIIB or later melanoma, published in September in the Journal of Clinical Oncology, 72.4% of patients on the combination were free of recurrence at four years, compared with 49.1% on pembrolizumab alone. Fewer patients on the combination died (6.5% vs. 14%), but the trial was not large enough to show a significant difference in overall survival. The phase 3 INTerpath-001 trial, which enrolled patients with stage IIB or later disease, met its main goal of recurrence-free survival, according to topline results Merck and Moderna announced in August. Full results have not been published.

Ferris said patients are already asking for the vaccine, but it has been studied only in people with removed stage IIB or later melanoma who enrolled within 13 weeks of surgery. "It's not for everybody, but it's exciting," she said.

New options after PD-1 therapy

For advanced melanoma that keeps growing despite PD-1 therapy, Ferris pointed to two newer treatments. The FDA granted accelerated approval in August to Tudriqev (vusolimogene oderparepvec), a modified herpes virus injected into tumors and given with nivolumab. In the IGNYTE trial, about one-third of patients responded. Responses lasted a median of more than 35 months, according to the data behind the FDA approval. The drug was initially rejected before its approval, Ferris noted.

She also highlighted Amtagvi (lifileucel), which uses a patient's own tumor-fighting immune cells. The cells are removed, grown in large numbers and given back. Because a company makes the product, it can be given at many hospitals, not only those with their own cell therapy labs. About 30% of patients responded, she said.

Gene tests to guide biopsies

Ferris also reviewed gene expression tests that help decide whether patients with thin melanomas need a sentinel lymph node biopsy, a surgery to check whether cancer has spread.

The National Comprehensive Cancer Network (NCCN) guidelines now say clinicians may consider such testing for select patients with T1b and T2a melanomas, based on the MERLIN_001 study of SkylineDx's Merlin test. The guidelines say testing should not replace a discussion with a surgical oncologist. It can support shared decision-making when a patient or clinician would skip the biopsy if the true risk of a positive node were below 10%. In a separate study of 912 patients called DECIDE, which used Castle Biosciences' DecisionDx-Melanoma test, 2.6% of patients the test rated as low risk and who still had the biopsy turned out to have cancer in the node. Ferris disclosed that she has consulted for Castle Biosciences.

“Risk-based screening is probably the best way that we can serve our patients,” Ferris said, adding that care across specialties is key.