Management of melanoma with a multidisciplinary melanoma clinic model

Melanoma patterns of care in Ontario: A call for a strategic alignment of multidisciplinary care

BACKGROUND AND OBJECTIVES

Variability in melanoma management has prompted concerns about equitable and timely treatment. We investigated patterns of melanoma diagnosis and treatment using population-level data.

METHODS

Patients with invasive cutaneous melanoma were identified retrospectively from the Ontario Cancer Registry (2003-2012) and deterministically linked with administrative databases to identify incidence, disease characteristics, geographic origin, and multimodal treatment within a year of diagnosis. Melanoma treatment was categorized as inadequate or adequate based on multidisciplinary clinical algorithms. Multivariable logistic regression was used to model factors associated with treatment adequacy.

RESULTS

From 2003 to 2012, 22 918 patients with invasive melanoma were identified with annual age/sex standardized incidence rates of 11.7-14.3/100 000 for females and 13.4-15.9/100 000 for males. Melanoma occurred at median age of 62 and primarily on extremities (43.9%). Within 1 year after diagnosis, 86.7% of patients received surgery as primary therapy. A total of 2312 (10.6%) patients received inadequate or no treatment after diagnosis. Receiving adequate treatment was associated with consultation with dermatology (OR 1.92, CI 1.71-2.14), plastic surgery (OR 4.80, CI 4.32-5.34), or general surgery (OR 2.15, CI 1.94-2.38).

CONCLUSIONS

Significant variation exists in melanoma management and nearly one in nine patients is inadequately treated. Referral to sub-specialized providers is critical for ensuring appropriate care.

Dermatopathology and Social Media: A Survey of 131 Medical Professionals From 29 Countries

CONTEXT

- Use of social media in the medical profession is an increasingly prevalent and sometimes controversial practice. Many doctors believe social media is the future and embrace it as an educational and collaborative tool. Others maintain reservations concerning issues such as patient confidentiality, and legal and ethical risks.

OBJECTIVE

- To explore the utility of social media as an educational and collaborative tool in dermatopathology.

DESIGN

- We constructed 2 identical surveys containing questions pertaining to the responders' demographics and opinions regarding the use of social media for dermatopathology. The surveys were available on Twitter and Facebook for a period of 10 days.

RESULTS

- The survey was completed by 131 medical professionals from 29 different countries: the majority (81%, 106 of 131) were 25 to 45 years of age. Most replied that they access Facebook or Twitter several times a day (68%, 89 of 131) for both professional and social purposes (77%, 101 of 131). The majority agreed that social media provides useful and relevant information, but stated limitations they would like addressed.

CONCLUSIONS

- Social media is a powerful tool with the ability to instantaneously share dermatopathology with medical professionals across the world. This study reveals the opinions and characteristics of the population of medical professionals currently using social media for education and collaboration in dermatopathology.

Pathology Review of Thin Melanoma and Melanoma in Situ in a Multidisciplinary Melanoma Clinic: Impact on Treatment Decisions

Purpose

Patients with thin melanoma (≤ 1.0 mm) and melanoma in situ (MIS) represent the majority of newly diagnosed melanoma. We estimated the impact of expert review of outside pathology material on the staging and thus treatment decisions affecting patients referred to a multidisciplinary clinic with early-stage melanoma.

Patients and Methods

We studied patients with a diagnosis of thin melanoma or MIS referred to H. Lee Moffitt Cancer Center from 2006 to 2009. After comparing the referring laboratory and in-house dermatopathologic interpretations, we calculated any differences in diagnosis and tumor staging and the potential impact of differences in diagnosis and staging on prognosis and surgical treatment using the National Comprehensive Cancer Network clinical guidelines.

Results

The overall pathologic discordance rate in diagnosis was 4% (15 of 420 patients; 95% CI, 2% to 6%). The overall change in tumor staging rate was 24% (97 of 405 patients; 95% CI, 20% to 28%). Pathology review led to changes in surgical excision margins in 12% of patients (52 of 420 patients; 95% CI, 9% to 16%) and in the decision about whether to perform a sentinel lymph node biopsy in 16% of patients (67 of 420 patients; 95% CI, 13% to 20%). Key pathologic factors, particularly mitotic rate, were frequently missing from outside pathology reports.

Conclusion

Our data suggest that review of thin melanoma or MIS by an expert dermatopathologist results in frequent, clinically meaningful alterations in diagnosis, staging, prognosis, and surgical treatment. Referral of these patients to a multidisciplinary melanoma clinic is appropriate, and management of such patients should include review of the biopsy whenever feasible.

Melanoma early detection

Recognizing early forms of melanoma may have significant impact on decreasing mortality from this malignancy. As a result, multiple efforts have focused on developing new and improving current early detection strategies. These include educating patients about the importance of performing skin self-examination, increasing rates of complete skin examinations by physicians in the context of routine care, initiating mass screening campaigns, creating specialized skin cancer clinics, and developing better diagnostic tools through advances in technology. In this article, the current state of these efforts is reviewed.

Merkel cell carcinoma: critical review with guidelines for multidisciplinary management

Merkel cell carcinoma (MCC) is a relatively rare cutaneous malignancy that occurs predominantly in the older white population. The incidence of MCC appears to have tripled during the past 20 years; an increase that is likely to continue because of the growing number of older Americans. The pathogenesis of MCC remains largely unknown. However, ultraviolet radiation and immunosuppression are likely to play a significant pathogenetic role. Many questions currently remain unanswered regarding the biologic behavior and optimal treatment of MCC. Large, prospective, randomized studies are not available and are unlikely to be performed because of the rarity of the disease. The objective of this review was to provide a comprehensive reference for MCC based on a critical evaluation of the current data. The authors investigated the importance of sentinel lymph node biopsy as a staging tool for MCC to assess the status of the regional lymph node basin and to determine the need for additional therapy to the lymph node basin. In an attempt to standardize prospective data collection with the intention to define prognostic indicators, the authors also present histopathologic profiles for primary MCC and sentinel lymph nodes. The controversies regarding the appropriate surgical approach to primary MCC, the use of adjuvant radiation therapy, and the effectiveness of adjuvant chemotherapy were examined critically. Finally, the authors have provided treatment guidelines based on the available evidence and their multidisciplinary experience.

Early melanoma diagnosis: a success story that leaves room for improvement

PURPOSE OF REVIEW

Early diagnosis has the greatest potential for short-term impact on melanoma mortality. We highlight recent trends in early melanoma detection and address the related challenges and opportunities.

RECENT FINDINGS

Significant strides have been made in the early diagnosis of melanoma. Success has been achieved through improved awareness of early signs of melanoma and identification of high-risk cohorts. Detection pressure, however, may also be resulting in the diagnosis of indolent disease, leading to unnecessary morbidity and cost. A looming imbalance of supply and demand for melanoma detection services is anticipated with the aging of the baby boom generation. Prioritization of other preventive services and a growing emphasis on cosmetic dermatology are anticipated to exacerbate this imbalance. While a paucity of hard data have precluded adoption of formal screening recommendations for melanoma, general consensus supports opportunistic screening and identification of high-risk individuals who may benefit from specialized surveillance with dermoscopy and whole-body photography. Research is needed to distinguish biologically indolent and aggressive melanoma, to develop and test evolving technologies to aid diagnosis, and to assess the utility of specific public health strategies for melanoma detection.

SUMMARY

Significant strides have been made in early melanoma detection, but multiple challenges remain.

Influence of provider and practice characteristics on melanoma care

BACKGROUND

Melanoma care is becoming increasingly multidisciplinary, requiring coordination of many types of providers. The purpose of this study is to describe the structure of melanoma care in North Carolina by examining services provided by different providers and the overall coordination of care.

METHODS

Self-administered surveys were developed to collect demographic and practice information, assess patient volume and services provided, and explore referral patterns. Surveys were administered to all dermatologists and a subset of surgeons practicing in North Carolina.

RESULTS

The response rate was 60% (263/438). Melanoma patient volume, referral patterns, use of nodal staging, and access to clinical trials were each related to provider characteristics, specialty, affiliations with cancer care organizations, and practice setting.

CONCLUSIONS

Many types of providers contribute significantly to the care of melanoma patients. Coordination between providers is variable. This study provides indirect evidence that multidisciplinary melanoma programs increase patient access to comprehensive melanoma care.

High-risk surgically resected pediatric melanoma and adjuvant interferon therapy

BACKGROUND

Pediatric patients with high-risk surgically resected melanoma are at risk for relapse, yet little is known about these young patients and how they tolerate high-dose interferon therapy.

PROCEDURE

We reviewed medical records of patients (< or =18 years) with high-risk melanoma referred to the University of Michigan Pediatric Hematology-Oncology service between January 1989 and July 2003.

RESULTS

Fourteen patients were identified with high-risk resected melanoma. The median age at diagnosis was 8.5 years. The median time to establish diagnosis was 9 months. Primary lesions were diagnosed as unequivocal melanoma, atypical epithelioid melanocytic proliferations, or atypical Spitz tumor with indeterminate malignant potential. Twelve patients had a positive sentinel lymph node (SLN) biopsy or a palpable regional lymph node and underwent regional lymph node dissection (LND). Two patients with unequivocal melanoma with Breslow depth >4 mm had negative SLN biopsies. Twelve patients received adjuvant high-dose interferon. The following toxicities were observed: constitutional symptoms, gastrointestinal symptoms, depression or neuropsychiatric symptoms, myelosuppression, elevated AST or ALT, hypothyroidism, and hypertension. Grade 3 or 4 toxicities were uncommon with exception of neutropenia, resulting in modification of therapy in one patient. All patients are alive and free of disease at follow-up (median 24.5 months).

CONCLUSIONS

Invasive melanoma can occur in very young children. Despite early signs of malignancy, there is often a delay in diagnosis. Histologically, diagnosis may be difficult because of overlap with Spitz nevi. Pediatric patients tolerated adjuvant high-dose interferon well and may be less likely than adults to require therapy modification secondary to toxicities.

Vulvar Melanoma: Review of Diagnosis, Staging, and Therapy

OBJECTIVES

To update, assimilate, and bridge the contemporary literature on vulvar and cutaneous melanoma regarding diagnosis, staging, and therapy to provide a useful clinical reference for managing and counseling for affected patients.

MATERIALS AND METHODS

A computerized search for reports in the literature up to June 2003 was carried out using PubMed and MEDLINE databases. Multidisciplinary involvement was used in evaluating the available data and formulating conclusions.

RESULTS

More than 300 reports were reviewed. Diagnosis, staging, and therapy aspects of vulvar melanoma are summarized.

CONCLUSIONS

Vulvar melanoma represents a subtype of cutaneous melanoma, with similar prognostic and staging factors. The most recent American Joint Committee on Cancer staging system for cutaneous melanoma is applicable to vulvar melanoma. Sentinel lymph node biopsy is reliable for staging the regional lymph node basin for vulvar melanoma. Standardized documentation of clinical and histopathologic parameters is needed to standardize grouping of cases for future comparison studies.

The potential impact on melanoma mortality of reducing rates of suboptimal excision margins

We estimated the potential benefit of reducing rates of inadequate excision margins in the treatment of localized invasive melanoma. A computer-simulated Markov decision analytic model was created to follow until death a hypothetical cohort of 55 y old Caucasians, newly diagnosed in a community setting with localized invasive melanoma. We considered two scenarios: usual care, and a hypothetical intervention. Markov states included well without local recurrence, local recurrence, cured, and dead. Published population-based data were used for rates of optimal excision margins, local recurrence, and mortality. Two outcome measures were employed: melanoma-related mortality and life expectancy. Major assumptions included: local recurrence occurs within 10 y of diagnosis, and patients revert to general population mortality rates 10 y following melanoma excision or subsequent local recurrence. For usual care, the model estimated 8.17% melanoma-related mortality. Modeling intervention with 100% optimal excision margins reduced this rate to 6.15%, a 25% relative reduction in mortality. This increased average life expectancy by 0.437 y, which equates to approximately 11 additional years in the 4% who would not experience a local recurrence due to improved excision margins. Increasing the percentage of optimal excision margins to 80% would still yield substantial improvement, with 6.83% melanoma-related mortality, saving 0.29 life-years compared with baseline. Results were insensitive to moderate changes in the parameter values. Suboptimal excision margins may account for approximately one-fourth of all melanoma-related mortality for localized invasive melanoma. If intervention can achieve even modest adherence to optimal excision margins, it might substantially reduce mortality.