Use of an early-detection strategy to improve disease control in melanoma patients

Which medical disciplines diagnose and treat melanoma in Europe in 2019? A survey of experts from melanoma centres in 27 European countries

BACKGROUND AND OBJECTIVES

The incidence of melanoma is increasing. This places significant burden on societies to provide efficient cancer care. The European Cancer Organisation recently published the essential requirements for quality melanoma care. The present study is aimed for the first time to roughly estimate the extent to which these requirements have been met in Europe.

MATERIALS AND METHODS

A web-based survey of experts from melanoma centres in 27 European countries was conducted from 1 February to 1 August 2019. Data on diagnostic techniques, surgical and medical treatment, organization of cancer care and education were collected and correlated with national health and economic indicators and mortality-to-incidence ratio (MIR) as a surrogate for survival. Univariate linear regression analysis was performed to evaluate the correlations. SPSS software was used. Statistical significance was set at P < 0.05.

RESULTS

The MIR was lower in countries with a high health expenditure per capita and with a higher numbers of general practitioners (GPs) and surgeons (SURG) per million inhabitants. In these countries, GPs and dermatologists (DER) were involved in melanoma detection; high percentage of DER used dermatoscopy and were involved in the follow-up of all melanoma stages; both medical oncologists (ONC) and dermato-oncologists administered systemic treatments; and patients had better access to sentinel lymph node biopsy and were treated within multidisciplinary tumour boards.

CONCLUSION

Based on these first estimates, the greater involvement of GPs in melanoma detection; the greater involvement of highly trained DER in dermatoscopy, dermatosurgery, follow-up and the systemic treatment of melanoma; and the provision of ongoing dermato-oncology training for pathologists, SURG, DER and ONC are necessary to provide an optimal melanoma care pathway. A comprehensive analysis of the melanoma care pathway based on clinical melanoma registries will be needed to more accurately evaluate these first insights.

Screening and early detection of skin cancer

Skin cancer is the most common type of cancer in the United States. US incidence of malignant melanoma is increasing faster than any other type of cancer. To minimize increasing morbidity and mortality rates, it is imperative that appropriate screening and early detection of skin cancer become more widespread. All physicians who see patients clinically have the potential for detecting skin cancers. The scope of skin cancer as a health-care problem is discussed. Evidence for the effectiveness and necessity of skin cancer screening and early detection is presented. Costs of screening and detection are discussed in relation to impact on treatment costs and overall costs of skin cancer burden. Current methods and recommendations for skin cancer screening and detection are reviewed, especially with regard to individuals and populations that may require more specialized or intensive screening and follow-up. Newer approaches involving instrument-assisted screening and detection of skin cancer are under intense development, and these exciting emerging technologies are reviewed.

The UK Government two-week rule and its impact on melanoma prognosis: an evidence-based study

INTRODUCTION

In order to tackle increasing waiting lists the UK Government's 'two-week rule' was introduced for a number of cancers, including melanoma, in 2000. Whilst there is evidence that secondary prevention (i. e. early diagnosis) improves patient outcome, particularly in melanoma where early surgical excision is the only intervention to improve survival, there is as yet no evidence base for a 2-week limit. Any survival benefit from this Government target will not be demonstrable until long-term follow-up is available, realistically 10-year mortality figures in 2010.

PATIENTS AND METHODS

To investigate an evidence base for the two-week rule in melanoma, we performed a retrospective study on patients with suspected skin cancers referred to a rapid access Pigmented Lesion Clinic (PLC) over a 4-year period with long-term survival data, and compared them to a historical control group.

RESULTS

A total of 4399 patients attended the PLC from January 1993 to December 1996 and all were seen within 2 weeks. Ninety-six melanomas were diagnosed during this period with 96% treated within 2 weeks of GP referral, the majority (74%) excised on the day of PLC attendance. Melanoma patients (n = 78) diagnosed in the 2 years prior to the inception of the PLC waited 3-34 days for consultation and 4-74 days for treatment. Melanoma patients diagnosed in the PLC had significantly thinner tumours (Mann Whitney test, P < 0.001) and improved overall survival (chi(2) 18.1924; P < 0.001) compared with melanoma patients diagnosed before the inception of the clinic.

CONCLUSIONS

This is, to our knowledge, the first example that consultation within a 2-week time-frame of GP referral impacts patient survival and the first evidence base behind Government guidelines for this particular cancer.

Incidence, mortality and survival in cutaneous melanoma

Cutaneous melanoma remains a challenge despite increased levels of awareness, education and targeted health policies. Worldwide incidence rates for cutaneous melanoma have risen faster than those for any other malignancy in Caucasian populations over the last 30 years. Despite improving survival rates (defined as the ratio of those who survive the disease against incidence) over this period, mortality rates, generally, have continued to climb. Mortality from melanoma is greater than that caused by all other types of skin cancer, especially in men. In Britain the percentage of increase in the male age standardised mortality rate surpassed that of all other malignancies assessed (1993-2002) by Cancer Research UK. A literature-based study was conducted with review of publications identified through Medline and EMBase, 1980-December 2005, databases. We present a review of the current literature on incidence, mortality and survival rates of melanoma including a discussion on the aetiological factors, behaviour modification associated with public education campaigns and recent health policies and the effect these are having on melanoma figures. It is likely that any fall in mortality rates from melanoma in the near future will be secondary to early detection. Changes resulting from primary prevention are unlikely to be noticeable for several decades.