DermHelpCentral

Melanoma: Work-up

This is a very helpful review:

Kauffmann RM, Chen SL. Workup and staging of malignant melanoma.

Surg Clin North Am. 2014 Oct;94(5):963-72

Abstract: Melanoma continues to be one of the fastest growing cancers in terms of incidence. The workup of melanoma focuses on risk factors based on the visual aspects of a skin lesion. Risk factors including sun exposure increase the risk of melanoma. Staging is based on depth of invasion, mitotic rate, and spread into lymph nodes and other sites. Once diagnosed, wide excision is indicated for the primary lesion, and sentinel node biopsy for all but the thinnest of melanomas. Routine imaging workup for most thinner melanomas should be minimized, and is questionable in the asymptomatic patients even with thicker melanomas.

Full article: Download Kauffmann2014

Cancer Facts: Melanoma (NIH)

Here are the U.S. melanoma statistics for the past 20 years.  (If you click on the link, you will see an instructive graph, also pictured below) The incidence of melanoma has increased almost 2 fold in two decades, but the number of people dying of melanoma per year has barely increased.  This indicates that the vast majority of people diagnosed with melanoma will do well in spite of many more melanomas being found.  Because of screening and looser standards, the number of people diagnosed with melanoma has markedly increased; but the annual number of melanoma deaths has been constant.  This is good news for the majority of people diagnosed with melanoma.

This graph shows a doubling of the number of annual melanoma cases in the U.S. since 1992, but no change in the number of deaths.  It means that in spite of the advances in therapy, the same number of people are dying.  It should give patient pause before choosing aggressive treatment protocols that have not been proven to improve outcome.

Sentinel Lymph Node Biopsy Decision Aid

The question of whether to undergo a SLN biopsy for melanoma is a difficult one.  It is clear that some experts recommend it while others don't.  Where does that leave a patient?  In England the National Institute for Clinical Excellence provides decision aids for many conditions. Here is a link to the SLN Decision Aid.  Please give it thought and discuss it with your dermatologist or surgeon.  The decision is really up to you.

Skin Cancer Screening: 2016 Recommendations

Image from Times article

Should you get screened for skin cancer?
By Nicholas St. Fleur
New York Times, July 26, 2016

In July 2016, the U. S. Prevention Services Force stated that there is no good evidence for the efficacy of skin cancer screening to prevent death or significant disability. This means that the benefits do not outweigh the potential harm of skin cancer screening.

Nonmelanoma skin cancer comprises 98% of skin cancer's and account for only about .1% of all cancer deaths. Melanoma accounts for about 10,000 cancer deaths a year.

If you have a personal or family history of melanoma, and if you have more than 100 moles you should probably consider being screened. But if not, you could safely pass. A large study in Germany found that skin cancer screening can potentially save one life per hundred thousand individuals screened. It is likely that much more harm could be done from over diagnosis and over treatment in a large screen and population.

Screening picks up small very slow growing or not even growing melanomas that are not destined to harm a patient. However, once they are discovered usually aggressive therapy is recommended and the patient is then labeled as a cancer survivor.

Most dermatologists recommend skin screening. In spite of the lack of evidence for its efficacy, it's good business practice for skin doctors. A skillful dermatologist can find something to treat with cryotherapy or a biopsy on most older caucasians, and this provides a good living for these doctors. It's a low risk screening and a high-value return for dermatologists.

The smart patient should avoid skin cancer screenings if they are not at risk. They should specifically avoid the free skin cancer screenings offered by many hospitals and aggressively promoted by the American Academy of Dermatology. They can just say no. If they have risk factors for skin cancer or are worried about specific lesions they can request a complete skin examination. This may be a good way of alleviating anxiety related to specific skin lesions.

The article in July 26, 2016 New York Times is a good overview. It can be accessed at: http://nyti.ms/2albmU/

Tanning "Parlor" Wars

F.D.A. Proposes Ban on Indoor Tanning for Minors to Fight Skin Cancer (This article appeared in the December 19^th 2015, NY Times)

“The Food and Drug Administration on Friday proposed barring everyone under 18 from using tanning beds, a sweeping move that medical experts say is a major step toward reducing the risk of skin cancer in the United States.”

The incidence of melanoma has been steadily rising over the past two decades. Importantly, as this article states, “death rates [from melanoma] have not gone up, however, a testament to earlier detection and better treatment.” This may not be a result of early detection and treatment, but because pathologists are calling lesions melanoma that would not have been labeled as such in the past (diagnostic drift) or because melanomas that are stimulated by artificial UVL behave less aggressively than melanomas that are caused in other ways.

Demonizing “tanning parlors” may well be attacking a soft target. Still, we agree that regulating the use of artificial tanning facilities, especially for minors (who appear at increased risk) is prudent. Thinking that this is based on good science, may be off the mark.

Sentinel Lymph Node Biopsy 2015

There has been controversy about whether to recommend SLN biopsy to patients, especially to those with intermediate thickness (1.2 - 3.5 mm) lesions.  A recent editorial in the British Journal of Dermatology addresses this.  It is couched in careful language since SLN biopsy is a religious ritual for many dermatologists, oncologists and surgeons.

"[While t]here is no evidence of harm associated with SNB (excepting surgical morbidity for those 80% of patients who did not require it, and the likely cost to the health service), neither is there convincing evidence of improved survival with biopsy-based management, even for those with intermediate- thickness melanoma what ever the claims of the proponents."

Download McGregor_et_al-2015-British_Journal_of_Dermatology

Review of article: Download Sentinel Lymph Node Biopsy - Overview

 

 

Melanoma Overview

In PubMed as of January 2015, there are 99,000 articles about melanoma.  Clearly, no one can master this literature.  There appears to be little consistency in the follow-up of patients with melanoma.  Some oncologists are very aggressive, but this does not appear to be backed by data.

AiM is a group that has put together a good website which provides some guidance.  Most of one's questions can be answered at their site.  [About AiM]

Melanoma - Mike Evans Video

This is a helpful Melanoma video from the Evans Health Lab.  it covers most of the bases very well.  Takes eight minutes to view.  Well worth your time.

Novel Melanoma Drug August 2014

F.D.A. Allows First Use of a Novel Cancer Drug   (September 4, 2014, NY Times)

The drug, which Merck will sell under the name Keytruda, was approved for patients with advanced melanoma who have exhausted other therapies.

Cancer researchers have been almost giddy in the last couple of years about the potential of drugs like Keytruda, which seem to solve a century-old mystery of how cancerous cells manage to evade the body’s immune system.

The answer is that tumors activate brakes on the immune system, preventing it from attacking them. Keytruda is the first drug approved that inhibits the action of one of those brakes, a protein known as PD-1, or programmed death receptor 1.

At precent, Keytruda is only approved for patients who failed to respond to other melanoma drugs, such as Yervoy, and it costs ~ $12,500 per month or about $150,000 per year.  Some patients will be eligible for clinical trials.

 

3Derm

is an innovtive company that has created a system for diagnosing skin lesions with a specal emphasis on melanoma. They have developed a handheld skin imager and intuitive cloud-based software to take, store, and send clinical quality 3D images from any user to a trained dermatologist. Their imager matches or exceeds industry standards in lighting, polarization, and magnification - ensuring that every image taken with a 3Derm device is diagnostically useful. The 3Derm web platform was built from the ground up to be HIPAA secure, and allows patients and dermatologists to connect easily with a modern interface. These innovations are designed to improve access to and frequency of standardized skin imaging - detecting skin cancer at the earlier, more treatable stages.  See 3Derm Website.