Cutaneous melanoma is a malignant tumour of the melanocytes. It is the major cause of deaths from skin cancer, and yet the visibility of cutaneous melanoma means it is curable if recognised and treated at an early stage.
The incidence of cutaneous melanoma has increased rapidly in all parts of the world in recent decades; over the past 20 years in Scotland it has risen from 3.5 to 10.6 per 100 000 population in men, and from 7.0 to 13.1 in women.1
SIGNÍs recently published guideline on cutaneous melanoma provides advice for all healthcare professionals who are involved in the management of melanoma patients throughout the care pathway.
Figure 1 (below) gives the key to evidence statements and grades of recommendations for the evidence considered by the guideline development group.
|Figure 1: Key to evidence statements and grades of recommendations|
Cutaneous melanoma diagnosed at an advanced stage can cause severe morbidity and carries a poor prognosis. Prevention of melanoma and minimising its consequences by early detection are important goals.
There is only indirect evidence that sun avoidance and other sun protection measures reduce the risk of cutaneous melanoma. Advice based on the Australian guideline on cutaneous melanoma (adapted to apply to the British climate) is given in Box 1 (below).2
|Box 1: Sun avoidance and sun protection measures|
Educating the public
Cutaneous melanoma is potentially preventable and so education of the general public is an important factor in reducing the incidence of the disease. Randomised controlled trials of interventions targeted at the public, schoolchildren and employees showed that leaflets and brochures increase short-term knowledge of sun awareness and prevention measures as well as assisting in the early detection of cutaneous melanoma.
A study in the west of Scotland indicated that a public education campaign and a rapid referral system to detect cutaneous melanoma at an early stage could result in sustained decreases in the rate of diagnosis of thick (>3.5 mm) cutaneous melanomas as well as mortality in women, but not in men.3
Risk factors for cutaneous melanoma are given in Box 2 (below).4 A cross sectional study found that a patientÍs self-assessment of risk correlated poorly with that of a dermatologist and that although patients counted the numbers of moles in agreement with physicians they could not accurately distinguish atypical moles.5,6
|Box 2: Risk factors for cutaneous melanoma|
Once identified, surveillance of individuals at higher risk can lead to earlier diagnosis of thin lesions. The cost-effectiveness of this is unclear.6
Systematic review of mass screening for skin cancers including cutaneous melanoma identified observational data to suggest that screening might be effective.4 The available evidence is not sufficient to recommend whether screening of individuals at higher risk of cutaneous melanoma should or should not be implemented.
Healthcare workers and the public should be aware of the risk factors for cutaneous melanoma (grade B recommendation).
Interventions to increase the awareness of risk factors for cutaneous melanoma are worthwhile.
Individuals identified at higher risk should be advised about appropriate methods of sun protection. They should be educated about the diagnostic features of cutaneous melanoma and encouraged to examine their own skin for the presence of suspicious pigmented lesions (grade C recommendation).
Most cutaneous melanomas are visible to the patient, members of their family and health professionals. It is essential to promote awareness of the signs suggestive of cutaneous melanoma in all these groups to encourage patients with thin lesions to present early. In men, the most common site for cutaneous melanoma is the trunk, while in women it is the leg.
There are four types of cutaneous melanoma, which are subdivided according to their clinical features and pathology.
Superficial spreading melanoma
Superficial spreading melanoma is the most common, presenting as an asymmetrical pigmented lesion with irregular edges and within which the pigmentation may vary.
The patient may notice a change in size or sensation, crusting, bleeding or even inflammation. It may have been present for anything from a few months to several years.
Nodular melanoma is the next most common type. It usually has a shorter presentation and a greater likelihood of bleeding or crusting.
Lentigo maligna melanoma
Lentigo maligna melanoma usually appears on sun-damaged skin on the face or neck of older patients.
Acral lentiginous melanoma
Acral lentiginous melanoma is the least common type, occurring in skin on the palms, soles of the feet and around or under the nails.
Clinicians should be familiar with the seven-point checklist or the ABCDE checklist (Boxes 3 and 4 below) for assessing lesions (grade D recommendation). 7
|Box 3: The seven-point checklist|
|Lesions with any of the major features or three of the minor features should give rise to suspicion of cutaneous melanoma|
|Box 4: The ABCDE checklist|
A Asymmetry in axes
B Irregular Border
C At least two different Colours in the lesion
D Diameter >6mm
E Elevation of the lesion above the skin surface
|Any of the features indicate a suspicious lesion, the level of suspicion increasing with the number of features present|
Health professionals are encouraged to examine the skin to identify suspicious lesions during the course of other clinical examinations.Any lesions found should then be carefully examined in good light and under magnification if needed.
The diagnosis of cutaneous melanoma is difficult and the accuracy of diagnosis may vary according to the level of experience of the clinician. The earlier a cutaneous melanoma is recognised, the better the chance of achieving a cure.
A GP who detects a suspicious pigmented lesion should refer the patient to a specialist dermatologist, indicating the degree of urgency in the referral letter. The specialist should ensure that such patients are seen as soon as possible.A dedicated pigmented lesion clinic can ensure rapid access to expert medical opinion and treatment.
The guideline suggests that biopsy of a highly suspicious lesion should be arranged by urgent referral to the appropriate specialty, which will inevitably depend on local circumstances and arrangements.
When a suspicious lesion is excised for biopsy, the whole lesion should be removed with a 2 cm margin and a cuff of underlying fat.8 There may be situations in which this is not possible because of the site of the lesion, in which case a full thickness biopsy taken from the most suspicious part of it should be obtained.A superficial shave biopsy is inappropriate.
A management flow chart has been included in the guideline, to outline the directions that a patient presenting with a suspicious lesion should follow (Figure 2, below).
Figure 2: Melanoma management flow chart, from SIGN 72, Cutaneous Melanoma
|© Scottish Intercollegiate Guidelines Network, 2003|
A GP may be asked to prescribe the contraceptive pill or hormone replacement therapy for a woman who has been treated for cutaneous melanoma. Similarly, women wishing to become pregnant may seek advice.
Oral contraceptive preparations
Meta-analysis provides no evidence that taking the oral contraceptive pill is a risk factor for cutaneous melanoma.9 Evidence from five large studies shows that there is no adverse effect on prognosis in women who take oral contraceptive preparations, after surgery for stage I and stage II cutaneous melanoma.
Women who have had a cutaneous melanoma treated should select contraception in the same way as those who have not had cutaneous melanoma (good practice point).
Hormone replacement therapy
A number of case controlled studies show no association between the use of hormone replacement therapy and risk of cutaneous melanoma.
Women who have had stage I or stage II cutaneous melanoma and who wish to take HRT should be advised and treated in the same way as those who have not had a cutaneous melanoma (good practice point).
During pregnancy, the melanocyte activity in the skin alters and pigmentary changes tend to occur. This has led to concern that pregnancy may be deleterious for women with cutaneous melanoma. No data are available to indicate that cutaneous melanoma during or around the time of pregnancy adversely affects outcome.
The prognosis mainly depends on tumour thickness. In women who have had localised disease of 31mm thickness, there is a significant risk of recurrence. GPs should counsel against embarking on a pregnancy for the first 2 years after surgery, as the likelihood of recurrence is highest during this time.
There are no good data on prognosis in women who have been diagnosed and treated for cutaneous melanoma during a previous pregnancy and who wish to become pregnant again. One paper reports no greater recurrence rate in patients with stage I and stage II disease.10
Frequency and duration of follow up
There is no consistent agreement on how often and when to follow up patients who have been treated for cutaneous melanoma. Currently, all patients with invasive cutaneous melanoma who are at risk of recurrence are followed up for a period, and those with stage III tumours are followed up for a prolonged period.
In general, thinner tumours are followed up less frequently than thicker tumours. The guideline gives indications of timing and rate of recurrence of cutaneous melanoma that should help in planning follow up of a particular individual.
Patients who have had cutaneous melanoma in situ have no risk of recurrence and do not require follow up (grade D recommendation).11
Most patients will require some degree of psychological and emotional support to help them come to terms with their disease, its treatment and implications. No evidence was found which explored these aspects of care when determining the intervals and duration of follow up.
Providing information for patients not only expands their knowledge of cutaneous melanoma, but also improves their ability to cope while reducing their levels of emotional distress.12,13 Patients should receive appropriate and targeted information throughout their care (grade C recommendation).
The guideline contains an example of a patient information leaflet, which can be adapted for local use by health professionals in primary care and dermatology departments. Sources of further information for patients and professionals are also listed.
SIGN facilitated a number of focus groups with patients who had been treated for a stage I or II cutaneous melanoma. These groups gathered data on the information that patients require at each stage of their journey of care.
The guideline therefore lists the types of questions that patients are likely to ask at each stage of care, from pre-diagnosis through to palliative care. These questions will be of immense value to clinicians in general practice and secondary care when caring for patients with cutaneous melanoma.
Literature searches were initially conducted in Medline, Embase, Cinahl, Cancerlit and the Cochrane Library using the year range 1993-2001. The literature search was updated with new material during the course of the guideline development process.
A final search was performed in March 2003. Key internet websites such as the National Guidelines Clearinghouse were also used. The searches were extended back to 1970 in areas where evidence was scarce; they were also supplemented by the reference lists of relevant papers and group membersÍ own files. The Medline version of the main search strategies can be found on the SIGN website: www.sign.ac.uk.
The guideline contains valuable information for GPs and other healthcare professionals on the management of patients, from those who present with a suspicious pigmented lesion to the detailed aspects of care of a cutaneous melanoma patient.
- The Scottish Melanoma Group. Incidence of and survival from malignant melanoma in Scotland; an epidemiological study. Lancet 2002; 360 (9333): 587-91
- Australian Cancer Network/National Health and Medical Research Council. Clinical Practice Guidelines. The management of cutaneous melanoma. Sydney: NHMRC, 1999.
- MacKie RM, Hole D. Audit of public education campaign to encourage earlier detection of malignant melanoma. Br Med J 1992; 304: 1012-15.
- Helfand M, Mahon S, Eden K. Screening for Skin Cancer. Systematic Evidence Review No.2 AHRQ Publication No. AHRQ01-S002. Rockville, MD: Agency for Healthcare Research and Quality, April 2001.
- Melia J, Harland C, Moss S, Eiser JR, Pendry L. Feasibility of targeted early detection for melanoma: a population based screening study. Br J Cancer 2000; 82: 1605-9.
- Mackie RM, McHenry P, Hole D. Accelerated detection with prospective surveillance for cutaneous malignant melanoma in high risk groups. Lancet 1993; 341: 1618-20.
- Healsmith MF, Bourke JF, Osborne JE, Graham- Brown RA. An evaluation of the revised sevenpoint checklist for the early diagnosis of cutaneous malignant melanoma. Br J Dermatol 1994; 130: 48-50.
- Calonje E. ACP best practice no 162. The histological reporting of melanoma. Association of Clinical Pathologists. J Clin Pathol 2000; 53: 587-90.
- Gefeller O, Hassan K, Wille L. Cutaneous malignant melanoma in women and the role of oral contraceptives. Br J Dermatol 1998; 138: 122-4.
- Shiu MH, Schottenfeld D, Maclean B, Fortner JG. Adverse effect of pregnancy on melanoma: a reappraisal. Cancer 1976; 37: 181-7.
- Dicker TJ,Kavanagh GM,Herd RM,Ahmad T et al. A rational approach to melanoma follow-up in patients with primary cutaneous melanoma. Scottish Melanoma Group. Br J Dermatol 1999; 140: 249-54.
- Brandberg Y, Bergenmar M, Bolund C, Michelson H et al. Information to patients with malignant melanoma: a randomised group study. Patient Educ Couns 1994; 23: 97-105.
- Butow PN, Coates AS, Dunn SM. Psychosocial predictors of survival in metastatic melanoma. J Clin Oncol 1999; 17: 2256-63.