At High Risk for Melanoma? Get With a Program

Dermoscopy is needed, say experts

Nick Mulcahy

January 20, 2011

January 20, 2011 — Individuals at high risk for melanoma should participate in a regular follow-up program at a melanoma center or qualified institution, according to a Spanish study published online January 17 in the Archives of Dermatology.

In a retrospective study conducted at the melanoma clinic at the Hospital Clinic of Barcelona in Spain, patients at high risk for melanoma participating in a follow-up program were more likely to have their melanomas detected at an earlier stage and to have a good prognosis than patients simply referred to the clinic.

"The results are valuable, but not surprising," said Janice Mehnert, MD, from the Cancer Institute of New Jersey in New Brunswick, who was not involved with the study.

"The findings make a lot of sense," she added in an interview with Medscape Medical News, "If you know what you are looking for, chances are better that you will find it."

The study "confirms" what other studies have shown, said Steven Q. Wang, MD, from Memorial Sloan-Kettering Cancer Center at Basking Ridge, New Jersey, another independent commentator. "What's so special about this study is that it looks at clinical, dermoscopic, and histologic information," Dr. Wang told Medscape Medical News.

In this Spanish study, the investigators, led by Gabriel Salerni, MD, retrospectively reviewed data from 201 melanoma patients in their melanoma clinic and divided patients into 2 groups: those who received a diagnosis while being followed, repeatedly, in the clinic program for high-risk patients (n = 40) and those diagnosed after a referral to the clinic because of suspicious skin lesions (n = 161).

The goal of the study was to see if the status of patients' melanomas differed, depending on the kind of monitoring and care they received before the diagnosis.

In the study, high-risk patients were defined as "fair-skinned persons, persons who tan with difficulty, blond or red-haired persons, and persons with blue eyes." They are also individuals with "the presence of many pigmented lesions, including freckles and clinically typical or atypical nevi; intermittent sun exposure and severe sunburns, especially during childhood; and exposure to artificial UV-A radiation"; as well as a personal or family history of melanoma.

Program-Detected Melanomas Are Less Far Along

The investigators found that 70% of melanomas diagnosed in patients in the follow-up program had not spread beyond the initial site and were thus in situ, compared with 27.9% of those in the referral group.

Also, the measure of tumor thickness, the Breslow index, was significantly lower in the follow-up group than in the referral group, with a mean of 0.55 vs 1.72 mm (P < .001).

The follow-up cancers were, for the most part, diagnosed at earlier stages: 70% were diagnosed at stage 0 and 30% were diagnosed at stage IA. In the referral group, diagnoses were as follows: 27.9% at stage 0, 37.6% at stage IA, 12.7% at stage IB, 10.9% at stage II, 8.5% at stage III, and 2.4% at stage IV.

In terms of dermoscopic findings, the referral group had a higher total dermoscopy score (6.42 vs 5.00), which is a general indication that their lesions had progressed further, suggest the authors.

The study highlights the shortcomings of the ABCD clinical acronym designed to provide "simple parameters" for the detection of suspicious skin lesions that are in need of evaluation by a skin cancer specialist, the authors note. Under this system, primary care physicians and dermatologists look out for asymmetry (A), irregular borders (B), multiple colors (C), and a diameter greater than 6 mm (D).

Dr. Salerni and colleagues report that most of the melanomas diagnosed in the follow-up group did not match some of the clinical or dermoscopic features characteristic of melanoma, and only 12% met all 4 of the ABCD criteria.

In contrast, 63.6% of the melanomas detected in the referral group met the criteria.

The findings are a reminder to clinicians to be aware of patients at high risk for melanoma and in need of referral, especially because there is no uniform guidance about screening, said Dr. Mehnert. The US Preventative Services Task Force, for instance, does not have any guidelines because of a lack of sufficient data to support the efficacy of screening, she noted.

Benefit of a Melanoma Clinic

Digital dermoscopy monitoring devices are part of the reason that high-risk individuals should be seen in specialty clinics. They allow for the "follow-up of melanocytic lesions to detect changes over time," write the authors. Dermoscopy also increases the sensitivity of the diagnosis of melanoma from 60% to 90%, they write.

Memorial Sloan-Kettering uses total-body photography and total-body exam, as well as dermoscopy, with high-risk patients, including those with previous lesions at risk for recurrence, noted Dr. Wang. "Most melanoma clinics are using these strategies. If not, they should be," he said.

Patients at high risk for melanoma are most likely best off at clinics, suggested Dr. Mehnert, because dermoscopy is not universally used by community-based dermatologists in the United States.

The authors have disclosed no relevant financial relationships.

Arch Dermatol. Published online January 17, 2011. Abstract

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