# Prognosis and Toxicity Stratified by Best Tumor Burden Change in Japanese Patients With Advanced Melanoma Treated With First‐Line Programmed Cell Death Protein 1 Monotherapy

## TL;DR

This study shows that tumor shrinkage, not just response categories, better predicts outcomes and side effects in Japanese melanoma patients treated with PD-1 inhibitors.

## Contribution

BTBC is proposed as a more accurate predictor of prognosis and toxicity than traditional response categories in melanoma treatment.

## Key findings

- BTBC < 0% was a significant indicator of favorable long-term prognosis.
- Greater tumor shrinkage correlated with increased toxicity (irAEs).
- BTBC ≥ 0% represented poor prognosis regardless of new lesions.

## Abstract

Immune checkpoint inhibitors (ICIs) have significantly improved outcomes in patients with advanced malignant melanoma (MM). However, more than half of patients receiving anti‐programmed cell death protein‐1 (PD‐1) antibody monotherapy still fail to respond, with response rates varying by race and melanoma subtype. Additionally, immune‐related adverse events (irAEs) remain a major concern. Although the best overall response based on Response Evaluation Criteria in Solid Tumors version 1.1 is commonly used in clinical trials to assess efficacy, its utility in predicting prognosis and toxicity in real‐world clinical settings remains unclear. This retrospective cohort study conducted at Shizuoka Cancer Center in Japan evaluated the association between best tumor burden change (BTBC) in target lesions and prognosis or toxicity among Japanese patients with stage IV MM who received PD‐1 monotherapy as first‐line treatment. A total of 115 patients were analyzed. Prognosis improved proportionally with reductions in tumor burden from baseline. No significant difference was observed in overall survival between the partial response group and the stable disease group (p = 0.833). However, BTBC < 0% was a significant indicator of a favorable long‐term prognosis (p < 0.001). The development of new lesions indicated poor prognosis; however, BTBC ≥ 0% represented poor prognosis regardless of new lesions. Regarding toxicity, the incidence of any‐grade irAEs was significantly higher in the BTBC < 0% group than in the BTBC ≥ 0% group (p < 0.001), suggesting that greater tumor shrinkage correlated with increased toxicity. These findings indicate that BTBC may serve as a more accurate predictor of prognosis and toxicity than best overall response in clinical practice. Incorporating BTBC into treatment planning and toxicity monitoring could improve management of stage IV MM, though future prospective studies are needed to establish standardized BTBC criteria.