ABSTRACT
The advent of effective immunotherapy and targeted therapy has significantly improved outcomes in advanced-stage resectable melanoma. Currently, the mainstay of treatment of malignant melanoma is surgery followed by adjuvant systemic therapies. However, recent studies have shown a potential role for neoadjuvant therapy in the treatment of advanced-stage resectable melanoma. Mechanistically, neoadjuvant immunotherapy may yield a more robust response than adjuvant immunotherapy, as the primary tumor serves as an antigen in this setting rather than only micrometastatic disease after the index procedure. Additionally, targeted therapy has been shown to yield effective neoadjuvant cytoreduction, and oncolytic viruses may also increase the immunogenicity of primary tumors. Effective neoadjuvant therapy may serve to decrease tumor size and thus reduce the extent of required surgery and thus morbidity. It also allows for assessment of pathologic response, facilitating prognostication as well as tailoring future therapy. The current literature consistently supports that neoadjuvant therapy, even as little as one dose, is associated with improved outcomes and is well-tolerated. Some patients with a complete pathological response may even avoid surgery completely. These results challenge the current paradigm of a surgery-first approach and provide further evidence supporting neoadjuvant therapy in advanced-stage resectable melanoma. Further research into the optimal treatment schedule and dose timing is warranted, as is the continued investigation of novel therapies and combinations of therapies.
ABSTRACT
OBJECTIVE: The residency recruitment process has become increasingly challenging for both applicants and program directors, in part, due to the inflation in the number of applications per student. As a result, it has become more daunting for programs to design processes that evaluate applicants holistically. Furthermore, the existing methods used to evaluate and select applicants do not necessarily predict success in residency and may inadvertently lend to gender, racial, and ethnic bias. This narrative review aims to identify innovative tools used in residency recruitment that will allow programs and applicants to better determine concordance of interests and achieve value alignment while supporting improved, objective evaluation of an applicant's unique attributes and experiences. DESIGN: PubMed was used to conduct a narrative review of recruitment strategies in admission processes of undergraduate and graduate medical education between 1975 and June 2021, using the designated Medical Subject Heading (MeSH0 terms. Inclusion criteria were established surrounding innovative tools to better objectively screen, evaluate, or select applicants. Strategies relying primarily on traditional metrics (United States Medical Licensing Examination (USMLE) scores, Alpha Omega Alpha status, and clerkship grades) were excluded. RESULTS: Forty-two articles met specific inclusion criteria. Using these articles, a framework was created with two specific aims: (1) to allow applicants and programs to express or assess interest and (2) to foster objective review of unique applicant attributes, skills, experiences, and competencies that align with program mission and values. The following five innovative tools for recruitment were identified: preference signaling, secondary applications, standardized letters of recommendation, situational judgment testing, and surgical simulation. CONCLUSIONS: As the number of applications continues to rise, strategies must be implemented to allow applicants and institutions to achieve better alignment or "fit," while also giving balanced consideration to all of an applicant's unique characteristics. A more holistic approach to applicant selection is a necessary tool in order to increase diversity and inclusion within the field of surgery.
