Early diagnosis is key to curing melanoma
Melanoma is curable if diagnosed early. treatment is successful in around 80% of patients with an early diagnosis and their cancer does not recur but, if diagnosed late, there are few treatment options.1
Better knowledge of the biology of melanoma is driving the use of new therapeutic agents in clinical trials, offering hope to patients. However, at present, adjuvant treatments and effective chemotherapy for metastatic disease are lacking. The imperative, therefore, is to diagnose melanoma early.
The incidence of melanoma, moreover, continues to increase. A recent study in Yorkshire found that between 1 January 1993 and 31 December 2003 the incidence of invasive melanoma had risen, from 5.4 to 9.7 per 100,000 in males and from 7.5 to 13.1 per 100,000 in females.1 There is good evidence that this rise is due to intermittent sun exposure and sunburn in fair-skinned people who are holidaying in the sun in increasing numbers.2,3 Melanomas occur most commonly on the back in men and on the leg in women. Those most at risk have fair skin and large numbers of moles.
To help meet the challenge, the Royal College of Physicians and the British Association of Dermatology have collaborated to produce guidelines that aim to raise awareness of melanoma among healthcare professionals and to provide a practical photographic aid to identifying early predictors of this type of cancer.4
Most melanomas are superficial spreading melanomas, which evolve comparatively slowly in many instances. In the early phases of the disease the cancer cells proliferate radially in the skin before the genetic changes are sufficient to cause the tumour to invade the dermis. If recognised early, in the radial growth phase, excision is likely to result in cure.
The guidelines illustrate benign moles and typical normal changes as well as other skin lesions that resemble melanomas. A flat mole, which progressively changes in colour, shape and size, is likely to be an early melanoma, and when first noticed by the patient the changes may be relatively subtle. Nodular melanomas grow rather faster and present as pigmented palpable lesions, often with redness. Occasionally, nodular melanomas are amelanotic, when they appear as friable, rather vascular nodules; urgent referral, within two weeks, is crucial for this type of lesion.
The guidelines also illustrate less common variants: the lentigo maligna melanoma, which tends to occur on the face, and the acral lentiginous melanoma, which develops on the sole of the foot or under the nail.
Examining any adult patient gives GPs and other members of the primary healthcare team the chance to screen for melanomas. However, chest examination provides a particularly good opportunity to examine areas of skin that cannot easily be seen by the patient. Good light is essential, and a magnifying lens may also be useful.
Any patient with a suspicious lesion should be referred to a dermatologist within two weeks. NICE guidance recommends that if a GP working in the community who belongs to a local melanoma multidisciplinary team takes a biopsy of a lesion, which is reported as a melanoma, the patient should be referred urgently to a specialist who is a member of the hospital's local skin cancer or specialist skin cancer multidisciplinary team.5
When the patient is concerned, but the mole appears innocuous, it is reasonable to take a photograph of the lesion and review in six weeks. Patients often notice subtle changes that are less obvious to the healthcare professional, and when there is a clear history of change in shape, size or colour, referral is recommended.Further information
Diagnosing melanoma is not easy, and certainly not easily described. Images are therefore crucial. The guidelines, with their high quality images, can be found on the RCP's website: www.rcplondon.ac.ukAuthor
Professor Julia Newton-Bishop
Professor of Dermatology, St James's University Hospital, Leeds