Current Challenges in Access to Melanoma Care: A Multidisciplinary Perspective

Resource Management Challenges in Rural Dermatological Care: A Mapping Review

Skin cancer prevalence in the United States is rapidly on the rise, particularly in rural communities where individuals are subjected to heavy sunlight exposure through occupations such as agricultural work and construction. These geographic regions are often lacking in dermatologic specialty care, thus increasing the disease burden of skin conditions in primary care settings. Access barriers to specialized dermatology care are exacerbated by prolonged wait times to schedule an appointment, travel demands, and a relative paucity of dermatology providers in rural areas as compared to urban areas. In rural communities, the high burden of skin diseases, the logistical challenges, and the shortage of dermatologists lead to increased reliance on primary care physicians (PCPs) for dermatological care. This review aims to identify barriers to dermatology care in rural communities, understand challenges faced by PCPs related to dermatological management, and explore modalities that are currently being used to streamline clinical workflows for PCPs. Dermatology training for PCPs consists primarily of pre-clinical exposure to the field, and it has been reported that there is a relative lack of opportunity for training to further enhance postgraduate dermatology knowledge. Recent studies demonstrate that novel educational and infrastructural support to primary care clinics has had substantial positive impacts on the ability of primary caregivers to provide accurate, cost-effective dermatologic care in addressing skin conditions, as well as increasing diagnostic confidence. Regular skin examinations, dermoscopy, and digital transformation of images are also shown to improve detection and diagnostic accuracy. Interventions like the use of smartphones, teledermatology, and dermoscopy show potential for improving care but must be thoroughly evaluated for effectiveness before widespread adoption in primary care settings.

The Impact of Medicaid Expansion on Stage at Diagnosis of Melanoma Patients: A Retrospective Study

BACKGROUND

This study addresses the lack of research on Medicaid expansion's impact on melanoma staging, treatment utilization, and outcomes by evaluating its effects under the Affordable Care Act (ACA), particularly focusing on staging at diagnosis, treatment use, and 3-year mortality outcomes. The objective is to determine whether Medicaid expansion led to earlier melanoma diagnosis and improved survival rates among non-elderly adults (ages 40-64) by analyzing data from the National Cancer Database (NCDB).

METHODS

A total of 12,667 patients, aged 40-64, diagnosed with melanoma from 2010 to 2020 were identified using the NCDB. Difference-in-difference (DID) analysis was performed to analyze tumor staging at presentation between Medicaid expansion states and non-Medicaid expansion states both prior to the expansion and after the expansion.

RESULTS

Of the total patients, 2307 were from the pre-expansion time period residing in Medicaid expansion states (MES) and 1804 in non-Medicaid expansion states. In the post-expansion time period there were 5571 residing in the MES and 2985 in the non-MES. DID analysis revealed a decrease in stage IV melanoma at diagnosis (DID -0.222, p < 0.001) between MES and non-MES before and after Medicaid expansion. After expansion, in stage IV, the occurrence of primary surgery was 0.42 in non-MES and 0.44 (difference 0.02); DID analysis was not statistically significant. The use of immunotherapy in MES was significantly higher than in non-MES after expansion (p < 0.001), although DID analysis did not reveal a statistically significant difference. DID analysis showed a statistically significant decrease in 3-year mortality (DID -0.05, p = 0.001) between MES and non-MES before and after Medicaid expansion.

CONCLUSIONS

This study revealed the positive impact of the ACA's Medicaid expansion on melanoma stage at presentation, highlighting the importance of public health policies in reducing disparities in mortality rates and early-stage diagnoses. Future research should explore additional barriers to care and evaluate the long-term outcomes of Medicaid expansion to optimize cancer care for vulnerable populations.

Recent Advancements in Cell-Based Therapies in Melanoma

Malignant melanoma outcomes have drastically changed in recent years due to the introduction of immune checkpoint inhibitors (ICIs). However, many patients still experience intolerable side effects, therapy resistance, and disease progression on ICI therapy. Therefore, there remains a need for novel therapeutics that address this gap in treatment options. Cell-based therapies have gained wide attention as a therapeutic option that could address this gap in treatment options for advanced melanoma. These therapies work by extracting certain cell types produced in the human body such as T-cells, modifying them based on a specific target, and transfusing them back into the patient. In the realm of cancer therapy, cell-based therapies utilize immune cells to target tumor cells while sparing healthy cells. Recently, the Food and Drug Administration (FDA) has approved the usage of lifileucel, a tumor-infiltrating lymphocyte (TIL) therapy, in advanced melanoma. This came following recent results from the C-144-01 study (NCT02360579), which demonstrated the efficacy and safety of TILs in metastatic melanoma patients who otherwise failed on standard ICI/targeted therapy. Thus, the results of this trial as well as the recent FDA approval have proven the viability of utilizing cell-based therapies to fill the gap in treatment options for patients with advanced melanoma. This review aims to provide a comprehensive overview of major cell-based therapies that have been utilized in melanoma by delineating results of the most recent multi-center phase II/ III clinical trials that evaluate the efficacy and safety of major cell-based therapies in melanoma. Additionally, we provide a summary of current limitations in each cell-based therapeutic option as well as a future direction of how to further extrapolate these cell-based therapies in advanced melanoma.

A Unique Case of High-Grade Dedifferentiated Melanoma Without a Known Primary Site

Melanoma is a malignant neoplasm that arises in melanocytes, pigment-producing cells present primarily in the skin. However, not all malignant melanomas originate from the skin, and the other sites of origin include the uveal (eye) or mucosa (rectal or oral); it can have different patterns of mutations. While targeted therapies and immunotherapies have transformed the treatment of this disease in the metastatic setting, resistance mechanisms can still pose challenges for patients and their healthcare providers. We present a case of a male patient with metastatic melanoma and discuss its clinical presentation, diagnostic workup, treatment options, and outcomes. By exploring the complexities of this multifaceted disease process, clinicians and researchers can gain valuable insights into potential areas for improved management strategies. Ultimately, we should aim to deepen our understanding of melanoma and work towards better patient outcomes.

Immunohistochemistry for Diagnosing Melanoma in Older Adults

Importance

Pathologic assessment to diagnose skin biopsies, especially for cutaneous melanoma, can be challenging, and immunohistochemistry (IHC) staining has the potential to aid decision-making. Currently, the temporal trends regarding the use of IHC for the examination of skin biopsies on a national level have not been described.

Objective

To illustrate trends in the use of IHC for the examination of skin biopsies in melanoma diagnoses.

Design, Setting, and Participants

A retrospective cross-sectional study was conducted to examine incident cases of melanoma diagnosed between January 2000 and December 2017. The analysis used the SEER-Medicare linked database, incorporating data from 17 population-based registries. The study focused on incident cases of in situ or malignant melanoma of the skin diagnosed in patients 65 years or older. Data were analyzed between August 2022 and November 2023.

Main Outcomes and Measures

The main outcomes encompassed the identification of claims for IHC within the month of melanoma diagnoses and extending up to 14 days into the month following diagnosis. The SEER data on patients with melanoma comprised demographic, tumor, and area-level characteristics.

Results

The final sample comprised 132 547 melanoma tumors in 116 117 distinct patients. Of the 132 547 melanoma diagnoses meeting inclusion criteria from 2000 to 2017, 43 396 cases had accompanying IHC claims (33%). Among these cases, 28 298 (65%) were diagnosed in male patients, 19 019 (44%) were diagnosed in patients aged 65 years to 74 years, 16 444 (38%) in patients aged 75 years to 84 years, and 7933 (18%) in patients aged 85 years and older. In 2000, 11% of melanoma cases had claims for IHC at or near the time of diagnosis. This proportion increased yearly, with 51% of melanoma cases having associated IHC claims in 2017. Increasing IHC use is observed for all stages of melanoma, including in situ melanoma. Claims for IHC in melanomas increased in all 17 SEER registries but at different rates. In 2017, the use of IHC for melanoma diagnosis ranged from 39% to 68% across registries.

Conclusions and Relevance

Considering the dramatically rising and variable use of IHC in diagnosing melanoma by pathologists demonstrated in this retrospective cross-sectional study, further investigation is warranted to understand the clinical utility and discern when IHC most improves diagnostic accuracy or helps patients.

Long non-coding RNA as a potential diagnostic and prognostic biomarker in melanoma: A systematic review and meta-analysis

Recently, long noncoding RNAs (lncRNAs) have been applied as biomarkers for melanoma patients. In this systematic review and meta-analysis, we investigated the diagnostic and prognostic value of lncRNAs. We used the keywords 'lncRNA' and 'melanoma' to search databases for studies published before June 14th, 2023. The specificity, sensitivity and AUC were utilized to assess diagnostic accuracy and the prognostic value was assessed using overall survival, progression-free survival and disease-free survival hazard ratios. After screening 1191 articles, we included seven studies in the diagnostic evaluation section and 17 studies in the prognosis evaluation section. The Reitsma bivariate model estimated a cumulative sensitivity of 0.724 (95% CI: 0.659-0.781, p < 0.001) and specificity of 0.812 (95% CI: 0.752-0.859, p < 0.001). The pooled AUC was 0.780 (95% CI: 0.749-0.811, p < 0.0001). The HR for overall survival was 2.723 (95% CI: 2.259-3.283, p < 0.0001). Two studies reported an HR for overall survival less than one, with an HR of 0.348 (95% CI: 0.200-0.607, p < 0.0002). The HR for progression-free survival was 2.913 (95% CI: 2.050-4.138, p < 0.0001). Four studies reported an HR less than one, with an HR of 0.457 (95% CI: 0.256-0.817). The HR for disease-free survival was 2.760 (95% CI: 2.009-3.792, p < 0.0001). In conclusion, the expression of lncRNAs in melanoma patients affects survival and prognosis. LncRNAs can also be employed as diagnostic biomarkers.

Association between surgical delay and outcomes among patients with invasive cutaneous melanoma

BACKGROUND

The relationship between surgical delay and outcomes for patients with cutaneous melanoma is understudied. The objectives of this study were to determine the impact of surgical delay on regional nodal involvement and mortality in patients with cutaneous melanoma.

METHODS

Retrospective study of patients diagnosed with clinically node-negative invasive cutaneous melanoma from 2004 to 2018. Outcomes included regional lymph node disease and overall survival. Multivariable logistic regression and Cox proportional-hazards models were constructed to adjust for pertinent clinical factors.

RESULTS

Of 423,001 patients, 21.8% experienced a surgical delay (≥45 days). These patients were more likely to have nodal involvement (OR1.09; P ​= ​0.01). Surgical delay (HR1.14; P ​< ​0.001), Black race (HR1.34; P ​= ​0.002), and Medicaid (HR1.92; P ​< ​0.001) were associated with lower survival. Patients treated at academic/research (HR0.87; P ​< ​0.001) or integrated network cancer programs (HR0.89; P ​= ​0.001) had improve survival.

CONCLUSIONS

Surgical delay was frequent and resulted in higher rates of lymph node involvement and decreased overall survival.

The Implications of a Dermatopathologist's Report on Melanoma Diagnosis and Treatment

An accurate and comprehensive histopathology report is essential for cutaneous melanoma management, providing critical information for accurate staging and risk estimation and determining the optimal surgical approach. In many institutions, a review of melanoma biopsy specimens by expert dermatopathologists is considered a necessary step. This study examined these reviews to determine the critical primary histopathology Breslow score in which a histopathology review would be most beneficial. Histopathology reports of patients referred to our institute between January 2011 and September 2019 were compared with our in-house review conducted by an expert dermatopathologist. The review focused on assessing fundamental histologic and clinical prognostic features. A total of 177 specimens underwent histopathology review. Significant changes in the Breslow index were identified in 103 cases (58.2%). Notably, in many of these cases (73.2%), the revised Breslow was higher than the initially reported score. Consequently, the T-stage was modified in 51 lesions (28.8%). Substantial discordance rates were observed in Tis (57%), T1b (59%), T3a (67%) and T4a (50%) classifications. The revised histopathology reports resulted in alterations to the surgical plan in 15.3% of the cases. These findings emphasize the importance of having all routine pathologies of pigmented lesions referred to a dedicated cancer center and reviewed by an experienced dermatopathologist. This recommendation is particularly crucial in instances where the histopathology review can potentially alter the diagnosis and treatment plan, such as in melanoma in situ and thinner melanomas measuring 0.6-2.2 mm in thickness. Our study highlights the significant impact of histopathology reviews in cutaneous melanoma cases. The observed changes in Breslow scores and subsequent modifications in T-stage classification underline the need for thorough evaluation by an expert dermatopathologist, especially in cases of melanoma in situ and thin melanomas. Incorporating such reviews into routine practice within dedicated cancer centers can improve diagnostic accuracy and guide appropriate treatment decisions, ultimately leading to better patient outcomes.

The Role of Biomarkers in the Diagnosis and Prognosis of Different Stages of Melanoma

Melanoma is a skin cancer arising from melanocytes, the cells responsible for synthesizing melanin pigment, which gives the skin its color. Early diagnosis and treatment of melanoma increase survival rates. Clinical examination and biopsy are the primary tools used to diagnose melanoma. However, distinguishing between pre-malignant melanocytic lesions and early invasive melanoma histopathologically remains challenging. Therefore, additional modalities such as a detailed clinical history, imaging, genetic testing, and biomarkers have been applied to diagnose melanoma. This review discusses the current trends in biomarker advancements over the last 10 years to assist in the early detection and diagnosis of melanoma. Biomarkers such as melanoma-associated antigens (MAAs), S100B, microRNAs (miRNAs), and circulating tumor cells (CTCs) have the potential to aid in the detection, diagnosis, and prognosis of melanoma. However, the application of biomarkers in the diagnosis of melanoma is still evolving.

Circulating tumor DNA-based molecular residual disease detection for treatment monitoring in advanced melanoma patients

BACKGROUND

Immune checkpoint inhibitors (ICIs) have substantially improved overall survival in patients with advanced melanoma; however, the lack of biomarkers to monitor treatment response and relapse remains an important clinical challenge. Thus, a reliable biomarker is needed that can risk-stratify patients for disease recurrence and predict response to treatment.

METHODS

A retrospective analysis using a personalized, tumor-informed circulating tumor DNA (ctDNA) assay on prospectively collected plasma samples (n = 555) from 69 patients with advanced melanoma was performed. Patients were divided into three cohorts: cohort A (N = 30), stage III patients receiving adjuvant ICI/observation; cohort B (N = 29), unresectable stage III/IV patients receiving ICI therapy; and cohort C (N = 10), stage III/IV patients on surveillance after planned completion of ICI therapy for metastatic disease.

RESULTS

In cohort A, compared to molecular residual disease (MRD)-negative patients, MRD-positivity was associated with significantly shorter distant metastasis-free survival (DMFS; hazard ratio [HR], 10.77; p = .01). Increasing ctDNA levels from the post-surgical or pre-treatment time point to after 6 weeks of ICI were predictive of shorter DMFS in cohort A (HR, 34.54; p < .0001) and shorter progression-free survival (PFS) in cohort B (HR, 22; p = .006). In cohort C, all ctDNA-negative patients remained progression-free for a median follow-up of 14.67 months, whereas ctDNA-positive patients experienced disease progression.

CONCLUSION

Personalized and tumor-informed longitudinal ctDNA monitoring is a valuable prognostic and predictive tool that may be used throughout the clinical course of patients with advanced melanoma.

Melanoma Treatments and Mortality Rate Trends in the US, 1975 to 2019

IMPORTANCE

Melanoma accounts for most of the deaths due to skin cancer. In the past decade, effective US Food and Drug Administration (FDA)-approved therapies for melanoma have emerged.

OBJECTIVE

To review changes in the long-term melanoma mortality rate (MMR) trends in the US and determine whether they have any temporal association with the FDA approval of new agents.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used population data from the Surveillance, Epidemiology, and End Results (SEER) database and retrospectively reviewed the age-adjusted MMR trends in adult patients (aged ≥18 years) from 1975 to 2019 in the US population. The timeline of the FDA approvals for melanoma treatment was also reviewed. Data were analyzed from March 15 to August 15, 2022.

EXPOSURES

Outcomes were assessed in association with FDA approval of drugs for the treatment of melanoma.

MAIN OUTCOMES AND MEASURES

Mortality rates are from the SEER database, reported per 100 000 population and age-adjusted to the 2000 US standard population. The annual percent change (APC) has been used to report long-term trends.

RESULTS

After the introduction of newer treatments in 2011 (most after 2013), a significant reduction in MMR was seen from 2013 to 2017 in the US for the first time in the past 40 years. Rates increased from 1975 to 1988 (APC, 1.65% [95% CI, 1.30%-2.00%]; P < .001). No statistically significant change in MMR was seen from 1988 to 2013 (APC, 0.01% [95% CI, -1.10% to 0.12%]; P = .85). The MMR decreased significantly from 2013 to 2017 (APC, -6.28% [95% CI, -8.52% to -3.97%]; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest a benefit associated with the availability of effective therapies in the past decade and further suggest that the use of new pharmacological therapies is associated with decreased MMR in the US population. These data are very encouraging and support the continued development of such therapies. Additionally, the accessibility of these treatments and the associated health care costs need to be addressed.

Modern views on skin biopsy in the diagnostic algorithm of dermatooncological diseases

Background. Malignant neoplasms of the skin are fairly common tumors in the world population and among the population of Ukraine. The main method of diagnosing skintumors is a biopsy, which allows establishing a diagnosis at an early stage and ensures the cure of most patients. Purpose. To evaluate modern recommendations for skin biopsy in the diagnosis of dermato-onсological diseases. Materials and methods. The search for sources of information was conducted using the MEDLINE/PubMed, EMBASE/ExcerptaMedica, CochraneLibrary, PubMed та Google Scholar databases using the following keywords: skin biopsy, skin tumors, diagnosis, melanoma. Among the identified sources, works without statistical analysis, descriptions of individual cases, articles without conclusions, and sources with duplicate results were excluded. The search depth was 10 years. Results. As a result of the conducted search, 57 publications were found that corresponded to the declared purpose. The most common methods are: puncture, shaving, excisional and incisional biopsy. Most guidelines recommend full-thickness excisional biopsy as the preferred procedure for the diagnosis of suspected melanoma. It is indicated that a statistically significant mortality rate was found in the puncture biopsy group. Most observations showed no significant differences in melanoma recurrence between excisional biopsy and puncture groups. Given the clinical diversity of melanoma, there is no uniformity in the types of biopsies performed to diagnose melanoma. The most inaccurate method turned out to be the punch biopsy method, which is associated with an increased risk of underdiagnosis of melanoma. Conclusions. A skin biopsy is a mandatory first step to establish a definitive diagnosis of a skin tumor. Excisional complete biopsy is the most justified in most cases of diagnosis. Rational biopsy technique remains an issue that needs further study.