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NICE recently published its guidelines on the management of malignant melanoma,1 which caused more than 2,000 UK deaths in 2012, with over 13,000 new cases diagnosed.2
Rates of the disease are rising, partly because of the wider availability of low-cost foreign holidays and the enduring passion for sunbathing. The risk is increased in people who have Fitzpatrick type 1 skin and are exposed to intermittent high-intensity UV, rather than more chronic UV exposure.
However, people are now becoming more sun aware and as a result, are consulting more often with potential melanomas.
The NICE guidelines are focused on the assessment and management of melanoma at referral level. Although the guidance will be very useful, it does not examine the diagnosis of the condition in primary care.
With more patients presenting, it is essential that potential melanomas are referred quickly to the appropriate specialist.
At the same time, there is a need to avoid overwhelming secondary care resources with patients whose lesions are not suspicious, such as lentigo and seborrhoeic warts, which can be relatively easily recognised from history and appearance. Accurate assessment before referral to secondary care is the key to managing demand on limited resources.
Diagnostics
Dermoscopy is an essential first step in the diagnosis of melanoma and it would make sense, given the increasing incidence of the disease, to expand and promote this skill in clinicians working in primary care.
Similarly, it should be essential for all dermatologists to be competent in the use of the dermatoscope. More guidance on what constitutes competence would be useful, although the current guidelines do not address this aspect.
The guidelines also recommend photography, preferably dermatoscopic, for all lesions not requiring excision at first presentation, at baseline and again after three months.
Although sound in principle, I think this will pose problems as not all clinicians will have a dermatoscope. Those who do probably do not have a camera that fits the dermatoscope.
For those clinicians who have a dermatoscope and a suitable camera, there is then the question of setting up systems for storing the images in the clinical notes, so that they can be easily accessed. This can also pose problems.
Photography could be very useful in diagnosing melanoma, but the extra time required for it will also have to be factored into clinic timetables, which are inevitably constrained by demand and cost pressures.
Management and follow-up
The discussion of Spitzoid type lesions by the multidisciplinary team is recommended and treating Spitzoid lesions of uncertain malignant potential as melanoma is a sensible approach.
The guidelines also consider sentinel node biopsy as a staging tool, rather than a therapeutic measure, in melanomas that are >1mm thick. There are clear descriptions of the pros and cons of this procedure, which will be informative for patients and useful for clinicians.
Management of all stages of melanoma is discussed, with a recommendation for surgical margins of 0.5mm, 1mm and 2mm for stages 0, 1 and 2, respectively. For all patients with stage 3 melanoma, the guidelines recommend considering completion lymphadenectomy. Discussion of the treatment of stage 4 disease includes the use of vemurafenib for BRAF V600 mutation positive disease.
In patients at increased risk, a personalised follow-up regimen is recommended. All patients should have a full physical examination and be educated about self-examination. Vitamin D levels should be assessed and treated if low. Recommended follow-up procedures for the various stages of the disease are clearly explained.
Future research
The guidance also examines possible areas of research, such as the management of atypical Spitzoid lesions, the treatment of lentigo maligna and follow-up scanning of patients with high-risk stage 2 and 3 disease, where the evidence for such measures is debatable.
Overall, these are useful guidelines for clinicians managing melanoma, particularly in secondary care. They will help to standardise management and might provide a catalyst for further investment in diagnostic equipment, facilities and staff.
It would be excellent if in future, more guidance is produced concerning the diagnosis of melanoma in primary care, the stratification of risk and dermoscopy training. I also think research into the possible value of one-stop walk-in mole clinics would be useful.
- Dr Paul Charlson is a GP with a special interest in dermatology in Yorkshire and medical director of Skinqure Clinic
Competing interests: Dr Charlson is president of the British College of Aesthetic Medicine and medical director of Skinqure Clinic, which provides aesthetic treatments
References
1. NICE. Melanoma: assessment and management. NG14. London, NICE, July 2015.
2. Cancer Research UK. Cancer Statistics for the UK.
