DermHelpCentral

Interferon for Melanoma

The bottom line:  Interferon (IFN) is not very effective in the majority of patients. A year’s worth of IFN treatment can delay the time to recurrence, although half the time this delay will be less than one year. However, it is now known that the overall chance of recurrence and the overall survival time is not improved (contrary to some early studies that showed an increased survival time of about one year).

See full article about IFN on About.com.

 

Melanoma In-Situ

Melanoma In Situ is being diagnosed with increasing frequency.  Skill with dermoscopy is one reason, increaing awareness of the dangers of atypical dark lesions another, trends in dermatopathology a third.  There are a number of other theories.

Simply MIS is a Stage 0 lesion.  The link above is accurate and helpful.  Strictly speaking MIS is not cancer -- yet.  And no one knows whether these really progress to Stage I -- but the risks of waiting (for most people) outweigh the benefits.  The cure rate for MIS is 100% at ten years.

Blink Power

BLINK is a checklist devised by Dr. Peter Bourne, an Australian skin cancer expert, to help patients and doctors  more easily decide what skin lesions need to be biopsied and which ones can be observed.  This posting is intended to inform patients so that they can be real partners in the process.  The handout has been created by Yoon Cohen, a medical student who plans a career in dermatology.  Please contact her with questions, comments and suggestions.  Email Y.C.

See the BLINK pdf: Download BLINK Patient Handout

BLINK Checklist

B (Benign): Is the lesion immediately recognizable as a common benign lesion?

If the answer is ‘yes’, no further action is required.

If the answer is ‘no’, then proceed to the following:

L (Lonely): Is the lesion the only one of its type on that region of the body?

 ‘Yes’ scores 1

I (Irregular): Is the lesion dermatoscopically irregular? An asymmetrical pigmentation pattern and more than one color?

‘Yes’ scores 1

N (Nervous and/or Change): Is the patient nervous that lesion may be a skin cancer? Does the patient, or another observer, feel that the lesion is changing?

‘Yes’ scores 1

K (Known clues): Does the lesion have any dermatoscopic clues to malignancy?

‘Yes’ scores 1

If the lesion scores 2 or more out of 4, it is recommended to be biopsied.

Yoon Cohen, a 4th year medical student from Maine produced this document

Sentinel Node Biopsy for Melanoma

There is probably no more controversial area of melanoma management than sentinel node biopsy.  Patients are routinely offered this procedure as if it improves outcome; which it emphatically does not.

Marvin Kanzler has written an important essay on this topic.  He writes" "Physicians who actually diagnose melanoma are in an ideal position to discuss these facts with their patients, because they are completely free of financial conflicts of interest (the Medicare reimbursement for the SNB procedure is approximately $19,0004). ‘‘Discussion’’ versus ‘‘recommendation’’ is an important distinction. The decision ultimately should be made by the patient. The physician’s role is to provide the unbiased information necessary for the patient to make this important decision."

Dr. Kanzler's article is important.  We have placed this article on Google Docs for those who want "discussion" not a biased "recommendation."

See: SNB and Standard of Care for MM.

Melanoma Resource

  Melanoma Center (labeled as "Your Source for Melanoma information") is the brain child of Dr. John Kirkwood, a melanoma researcher who has published almost 300 peer-reviewed articles on melanoma.  There is so much false information on the web, that it is refreshing to find such a resource.  However, one must recognize that controversy exists as to the best treatment for melanoma.  The utility of sentinel node biopsy is still controversial.  In the U.S. is is used far more often than in Europe or Australia and it's difficult to prove that there is any long-term survival value.  It's primarily a prognostic tool and this needs to be made clear to the patient. The bottom line is that treatment in the U.S. tends to be more aggressive than elsewhere with little evidence for its value.  Still.  Melanoma Center is an important resource.

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Melanoma Survival Calculator

This calculator gives the melanoma survival and other outcome information projected over time. It reflects the current state of knowledge.  You may want to discuss the findings with your physician. 

Access Melanoma Calculator.

Melanoma and Oral Contraceptives

Women with melanoma (MM) are often advised to refrain from using oral contraceptives (OCPs).  The literature is difficult to interpret.  It appears that OCPs are not a risk factor for MM.  Here is a reference from reputable source:

A pooled analysis of 10 case–control studies of melanoma and oral contraceptive use  This is available free full text from the British Journal of Cancer.

A pooled analysis of 10 case-control studies of melanoma & oral contraceptive use.  Br J Cancer. 2002 Apr 8;86(7):1085-92.
Karagas MR, et. al.
Section of Biostatistics and Epidemiology, Department of Community and Family Medicine Dartmouth Medical School, 7927 Rubin 462M-3, One Medical Center Drive, Lebanon, New Hampshire, NH 03756-0001, USA. margaret.karagas@dartmouth.edu
Abstract
Data regarding the effects of oral contraceptive use on women's risk of melanoma have been difficult to resolve. We undertook a pooled analysis of all case-control studies of melanoma in women completed as of July 1994 for which electronic data were available on oral contraceptive use along with other melanoma risk factors such as hair colour, sun sensitivity, family history of melanoma and sun exposure. Using the original data from each investigation (a total of 2391 cases and 3199 controls), we combined the study-specific odds ratios and standard errors to obtain a pooled estimate that incorporates inter-study heterogeneity. Overall, we observed no excess risk associated with oral contraceptive use for 1 year or longer compared to never use or use for less than 1 year (pooled odds ratio (pOR)=0.86; 95% CI=0.74-1.01), and there was no evidence of heterogeneity between studies. We found no relation between melanoma incidence and duration of oral contraceptive use, age began, year of use, years since first use or last use, or specifically current oral contraceptive use. In aggregate, our findings do not suggest a major role of oral contraceptive use on women's risk of melanoma..

Melanoma: Targeted Therapy

This is a novel approach for patients with very advanced melanoma.  It is applicable to those patients who test positive for the B-RAF gene. 

Targeted therapy may prove helpful for melanoma and a number of other cancers.  The NY Times has a three part article on this promising new therapy.  It is a bit long and perhaps overly sensational, but it is a good introduction to this area.

Part 1.  Doggedly Testing a Melanoma Drug by Amy Harmon. 

Part 2.  After Long Fight, Drug Gives Sudden Reprieve by Amy Harmon. 

Part 3. A Drug Trial Cycle: Recovery, Relapse, Reinvention by Amy Harmon

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Melanoma on the Rise -- or is it being overdiagnosed?

An important article in the NY Times addresses a recent study on melanoma published from England.  It is important to read the Times piece and come to your own conclusions. Sadly, one of the American dermatologists who is quoted and who "pooh-poohs" the study is in the pay of sunscreen companies and a founder of the Skin Cancer Foundation which takes large sums from industry.

In recent years there has been a sharp rise in reported cases of malignant melanoma, the deadliest form of skin cancer. But a British study has found evidence that the epidemic may be due at least in part to “diagnostic drift,” a growing tendency to identify and treat benign lesions as malignant cancers. The findings may raise the temperature in an already-heated controversy.  Full Times article. 

Melanoma - Genetic Testing

It appears that routine genetic testing for persons at risk for melanoma is not, at present, the standard of care and may pose more uncertainties than help.  Things may change, but in 2009, this still appears to be valid.

Kefford RF, Mann GJ.  Is there a role for genetic testing in patients with melanoma?  Curr Opin Oncol. 2003 Mar;15(2):157-61.

Department of Medicine, Melanoma Genetics Research, Westmead Millennium Institute
for Cancer Research, University of Sydney at Westmead Hospital, Westmead, NSW,
2145, Australia. rick_kefford@wmi.usyd.edu.au

Autosomal dominant inheritance of mutations in the locus or the gene may confer a high risk of cutaneous melanoma development. The penetrance of mutations is influenced by UV exposure. Inherited variants in the melanocortin-1 receptor also confer increased risk of cutaneous melanoma. Features associated with increased genetic susceptibility to cutaneous melanoma include the presence of multiple affected first-degree relatives on one side of the family, multiple primary melanomas in the same individual, earlier age of onset, and the presence of multiple atypical nevi, but none of these factors reliably predicts for the presence of mutations. It is currently premature to offer predictive DNA testing  for melanoma outside of defined research protocols. This is because of (1). the low likelihood of finding mutations in known melanoma susceptibility genes, even in more than 60% of melanoma- prone kindreds; (2). the broad confidence limits on  current estimates of lifetime penetrance of mutations and the wide variation in this penetrance with locality; (3). a high "background" incidence of melanoma in non-mutation carriers in melanoma-prone families; (4). current uncertainties about the factors determining the functionality and phenotypic expression of the  trait among carriers of these mutations (penetrance), even if found; and (5). the lack of proved efficacy of melanoma prevention and surveillance strategies, even  for mutation carriers. Rather than singling out those deemed to be at high risk because of family history, all patients carrying risk factors for cutaneous melanoma should be subject to stringent programs of sun protection and skin surveillance.