A New Era in Holistic Care: Bridging the Gap Between Dermatologists and Oncologists for the Treatment of Malignant Melanoma

S. Muthiah; D. Tang; B. Nasr; S. Verykiou

Disclosures

The British Journal of Dermatology. 2018;178(1):1-4. 

Melanoma is the most aggressive skin cancer with incidence rates rising by 360% in the last 30 years and projected to increase by a further 7% between 2014 and 2035.[1] Patients are referred to dermatology to make the diagnosis, excise the primary tumour and offer clinical surveillance. However, when melanoma spreads beyond loco-surgical regional control, patient care is then transferred to a multidisciplinary team (MDT) including oncologists, plastic surgeons, dermatologists, radiologists and histopathologists.

At any point during the patient's journey, from diagnosis through to treatment of metastatic melanoma, dermatological input is required. The recent emergence of targeted treatments, immunotherapies and combination regimes has revolutionized clinical outcomes for patients with metastatic disease; however, as seen in most systemic cancer treatments, this has also unveiled a plethora of cutaneous side-effects.[2–7] These cutaneous toxicities have garnered considerable attention, due to frequent occurrence, visibility and impact on the physical and psychological health of patients with melanoma, resulting in dose reduction or cessation of treatment.[8–10] The rapid expansion of melanoma treatments and the increasing number of cutaneous side-effects that accompany such treatments has left dermatologists and oncologists feeling ill-equipped to recognize and manage the wide spectrum of complications alone. Instead, oncologists and dermatologists should work alongside each other to allow prompt diagnosis, reporting and treatment of dermatology-related treatment side-effects for improved patient outcomes.

This need for collaborative efforts between oncologists and dermatologists is not just limited to the management of malignant melanoma and has long been required to deliver the highest standard of cancer care. For example, epidermal growth factor (EGFR) inhibitors, used to treat solid organ cancers, cause skin changes such as folliculitis, pulpitis and xerosis, which can significantly impact on the patient's quality of life, leading to compliance issues and in some instances, treatment refusal.[3,9,10] A French study that surveyed 67 oncologists, radiologists, gastroenterologists and gastrointestinal oncologists, demonstrated that the cutaneous effects of EGFR inhibitors are largely managed by the treating oncologists and that dermatology referral is mainly considered if the side-effects are persistent or there was exacerbation of skin lesions that lasted more than 2 weeks. Furthermore, less than half the respondents would refer to a dermatologist if they needed help in diagnosing cutaneous side-effects, if the patient had important physical or psychological impact as a result of their skin rash or if there was evidence of suspected or confirmed secondary skin infection. The authors concluded that this was likely due to the lack of MDT consultations within public hospitals, the long waiting lists for dermatology appointments, and that perhaps, the oncologists are best placed to manage cutaneous toxicities. However, this study identified the difficulties nondermatologists encountered when diagnosing and grading skin toxicities. Although oncologists were uniform in their management for milder skin lesions, discrepancies arose when asked about the management of patients with more complex dermatological toxicities.[9,10] These results were echoed by two other surveys published in Germany and the U.S.A., which highlighted disparity in the management of cutaneous toxicities with few dermatological consultations[11,12] and how such discrepancies could be improved by partnerships between dermatologists and oncologists to ensure skin toxicities are accurately identified and promptly managed to improve treatment compliance, duration and ultimately patients' quality of life.[11,12]

In North America, active awareness of the unique set of dermatology-related problems that patients with cancer can present with has driven the set-up of cutaneous oncology clinics by specialist dermatologists to provide input on chemotherapy-related skin rashes, hair and nail disorders and paraneoplastic dermatoses. Several European countries have also adopted the concept of dermato-oncologists – skin specialists trained to diagnose and manage all aspects of the care of patients with any form of skin cancer. However, in the U.K., dermato-oncology services are largely accessed through select tertiary referral centres with limited availability in peripheral hospitals. One example is the transplant skin clinic where dermatologists offer patients with solid organ transplants routine monitoring for squamous cell carcinomas, and input for other treatment-related skin diseases. However, with limited services available in peripheral hospitals, dermatological input for patients with skin cancer remains largely fragmented with no dermatological continuity of care.[13]

For patients with melanoma, the combined expertise of oncologists and dermatologists is necessary for post-treatment surveillance to identify evidence of disease recurrence, to detect further primary melanomas and to provide important support and education to patients.[14] To this day, there are no evidence-based guidelines or international consensus as to which surveillance strategies are most effective following surgical excision of melanoma. This has led to significant variations in follow-up surveillance of patients with melanoma.[15] In the first prospective study of its kind, Garbe et al. evaluated follow-up strategies in 2008 patients according to German guidelines and demonstrated that 70% of all recurrences were detected during scheduled follow-up assessments.[16] Evidence has also demonstrated that earlier detection of recurrent melanoma led to better overall survival for patients, better quality of life as well as reducing direct costs for health services and indirect costs to patients caused by their inability to function in their usual role due to the result of having melanoma.[16,17]

Due to the rapidly increasing incidence of melanoma, NHS costs for all skin cancers are expected to climb from £106–112 million in 2008 to over £180 million in 2020,[18] placing an increasing burden on an already stretched national health service. Given this, the ability to identify and create robust, evidence-based surveillance programmes with emphasis on efficient prognostication and personalized treatment options for patients with melanoma must be the focus of future work, and in close collaboration with colleagues in oncology to aid better outcomes in patients with melanoma. Despite American Joint Committee on Cancer (AJCC) stage I melanomas representing the thinnest tumours with the lowest associated mortality risk of ~ 14% over 10 years,[19] these tumours make up more than 90% of all melanomas diagnosed in the U.K.,[1] each requiring follow-up of between 1 and 5 years. With low rates of metastases of tumours at an early physiological stage of development, more stratified follow-up strategies in this group would potentially allow the greatest benefit for health economics, with some evidence suggesting that patients at the lowest risk of disease recurrence may not need intensive clinician follow-up as is generally recommended.[20] Current practice is to treat all patients with surgical excision and surveillance until metastasis ensues. However, with still no consistently beneficial treatments for metastatic melanoma, there is a push towards informing the clinical decisions at the outset. Collaborative translational research between dermatology and oncology is therefore crucial to inform the development of novel prognostic biomarkers for more stratified follow-up strategies in early AJCC stage melanomas, including the need for closer clinical or radiological surveillance and investigation in high-risk patients or, equally, to aid patient discharge decisions in low-risk disease, thus impacting positively on health economics. Moreover, collaborative research in dermato-oncology may pave the way to the discovery and development of more efficient targeted therapies for melanoma and novel companion biomarkers to stratify patients for adjuvant treatment, particularly in early-stage disease prior to the development of metastasis. In addition, dermatologists may offer support to oncologists in the context of clinical trials through recruitment of patients with early-stage melanomas and provide input for dermatological side-effects of such novel systemic therapies.

Overall, collaborative efforts between oncologists and dermatologists beyond the clinical setting remain essential. Through their active involvement in melanoma research, their expertise provides an optimal means to develop a greater understanding of the biology of melanoma, ultimately informing and improving clinical practice. Research placements for clinicians early on in speciality training will allow interaction and promote collaborations with researchers both in the U.K. and abroad, thereby bridging the gap between conception of cutting-edge dermato-oncology research to translation into clinical practice. Combining the expertise of both specialities will ultimately ensure the development of more efficacious and well-tolerated treatments in addition to the conception of robust, high-quality evidence-based guidelines for treatment and follow-up of patients with skin cancers (Figure 1).

Figure 1.

Improving care for melanoma patients through collaboration between dermatologists and oncologists.

Worldwide, patients with melanoma are generally reviewed by their dermatologist or oncologist separately, or are referred specifically to a dermatologist with a specialist interest in cutaneous oncology. However, improved clinical care could be achieved by providing patients with melanoma, and perhaps all patients with cancer, the opportunity to see their dermatologists and oncologists in joint clinics, during and after treatment. Such a holistic approach would mean that the dermatologists would be there to offer support to the oncologists at each step of the patient's journey, through offering expertise in dermoscopy when reviewing skin lesions, enabling cutaneous metastatic deposits to be identified and biopsied early, provide prompt management of skin complications and aid in post-melanoma surveillance. This would undoubtedly enable patients to feel that all aspects of their care are being addressed, while reducing waiting times, further clinic appointments and healthcare costs. In addition, with rising melanoma incidence rates and a drive towards integrated, holistic patient care, it is undeniable that the need for research into understanding tumour biology to support the development of efficacious therapeutic strategies to limit tumour dissemination is of paramount importance. Emphasis on a multidisciplinary approach with the unified expertise of dermatologists, oncologists and researchers alike will ensure the translation of scientifically robust and clinically relevant research and the seamless care for patients from diagnosis to treatment. This is an exciting time for dermatologists and oncologists to work together through the whole pathway of melanoma management; from research into the biology of melanomas, developing targeted therapies to managing these patients in the clinic setting. Such collaborations will undoubtedly provide patients with the best possible care during their cancer journey.

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