17 Mar Efficiency of Melanoma High-risk Clinics in Detecting New Skin Cancers
MedicalResearch.com Interview with:
Anne Cust | PhD, Professor of Cancer Epidemiology
The University of Sydney
Faculty of Medicine and Health
Sydney School of Public Health
MedicalResearch.com: What is the background for this study? Are the screeners specially trained, use full body photographs, dermoscopy etc?
Response: The Melanoma High-risk Clinic Study was developed to optimise the early detection of new melanomas in people at high risk of developing melanoma. A previous single-centre study observed fewer excisions and healthcare costs, thinner melanomas and better quality of life when surveillance of high risk patients was conducted in a melanoma dermatology clinic with a structured surveillance protocol involving 6-monthly full body examinations aided by total body photography (TBP) and sequential digital dermoscopy imaging (SDDI). The initial pilot study was performed in a single tertiary referral specialist centre using trained dermatologists who routinely used the diagnostic interventions.
Our objective was to examine longer-term sustainability and expansion of the program to multiple practices including a primary care skin cancer clinic setting. The hypothesis was that the outcomes would be similar if using the same protocol and diagnostic tools. The participating doctors were trained to follow the protocol, which included instruction on how to respond and interpret changing lesions, but not in use of dermoscopy or skin examinations, which were routinely and consistently used in all clinics prior to the study commencing. There were 593 participants assessed as very high risk of melanoma who participated in the Melanoma High-risk Clinic Study from 2012-2018. Nearly all of the participants had had a previous melanoma and had additional melanoma risk factors. 57% were male and the median age at study entry was 58 years.
MedicalResearch.com: What are the main findings?
Response: Over a median 2.8 years follow-up, 1,513 lesions were removed from participants during follow-up including 171 (11%) new melanomas, 690 (46%) non-melanoma skin cancers (NMSC), 410 (27%) benign (harmless) melanocytic lesions and 234 (16%) benign (harmless) non-melanocytic lesions. Of the 593 participants, 19% had 1 or more new melanomas excised during the median 2.8 years follow-up surveillance period, 36% had 1 or more non-melanoma skin cancers, 36% had 1 or more benign melanocytic lesions and 24% had 1 or more benign non-melanocytic lesions. The patient risk to develop a new melanoma was 9% annually in the first two years and increased over time particularly for those with multiple primary melanomas. Two-thirds (67%) of melanomas in our study were found because of changes on photography (total body photography or sequential digital dermoscopy imaging). The new melanomas were nearly all detected at an early stage – only 7 of 171 were more than 1mm in thickness at diagnosis. The overall benign to malignant excision ratio of 0.8:1.0 and benign melanocytic to melanoma ratio of 2.4:1.0 in this study were better than what is commonly accepted in clinical practice. Our results showed similar outcomes across centres, indicating that the diagnostic tools and structured surveillance protocol were more important than the clinical specialty.
MedicalResearch.com: What should readers take away from your report?
Response: We have shown the sustainability and replication of favourable early-detection and excision results from the Melanoma High-risk Clinics in multiple settings including a primary care skin cancer clinic. Photography was very helpful for detecting melanomas at an early stage and for reducing the number of benign (harmless) lesions removed. The results indicate that cost-effectiveness may be higher than previously estimated and provide impetus to scale up the program.
MedicalResearch.com: What recmmendations do you have for future research as a result of this work?
Response: Further research is needed to evaluate if people at average risk of melanoma (not just those at high-risk) would benefit from a structured surveillance program. Use of risk prediction tools such as those available at https://www.melanomarisk.org.au/ may help to accurately select people at high risk and tailor surveillance intervals according to personal risk. Advanced diagnostic photographic tools and high-quality, low-cost dermatoscopes provide an opportunity for primary care doctors and even patients to equip themselves with this technology. Incorporating artificial intelligence to enhance melanoma diagnosis may further change this paradigm of skin surveillance.
Financial support was provided by the National Health and Medical Research Council and Cancer Institute NSW.
Two of the authors on the paper list disclosures related to advisory roles for pharmaceutical and/or diagnostic companies.
Guitera P, Menzies SW, Coates E, et al. Efficiency of Detecting New Primary Melanoma Among Individuals Treated in a High-risk Clinic for Skin Surveillance. JAMA Dermatol. Published online March 17, 2021. doi:10.1001/jamadermatol.2020.5651
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