Patient self-checks are critical for picking up melanoma recurrence

Recurrences of early stage (stage II) melanoma are more often detected by patients and their physicians checking the skin than by routine imaging tests, a study published online by the Journal of the American College of Surgeons has found | OnMedica

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Melanoma has a 95% cure rate if caught and treated early, and studies suggest the recurrence rate for melanoma is as high as 50%.

For this study researchers at Thomas Jefferson University and the University of North Carolina analysed data on 581 patients with stage II melanoma and at least one year of follow-up. Of those, 171 patients with early stage melanoma developed a recurrence (29.4%). Male sex, ulceration, and stage were significant predictors of recurrence.

A total of 40% of recurrences were picked up by patients – either they noticed a suspicious change on their skin or experienced a symptom such as coughing blood or seizures. A further, 30% of recurrent melanomas were identified by scheduled physician examination and 26% by surveillance imaging.

Regional nodes were the most common site of recurrence (30%), followed by lung (27%), and in-transit metastases (18%).

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Sun protection for preventing basal cell and squamous cell skin cancers

Sanchez, G. et al. Cochrane Skin Group. Published online:  25 September 2016

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Keratinocyte cancer (BCC and cSCC of the skin) is the most commonly identified type of skin cancer. The main risk is exposure to ultraviolet radiation, which is a component of sunlight. Prevention has become an important way to manage this cancer, so it is important to assess the effectiveness of methods used to prevent keratinocyte cancer in the general population. In this review, we assessed the effects of using topical sunscreen and physical barrier methods (such as sun-protective clothing, hats, sunglasses, and the active search for shade when outdoors) compared with no specific precautionary interventions aimed at preventing the development of BCC and cSCC in adults and children.

We searched the medical literature up to May 2016 for randomised controlled trials that evaluated preventive strategies. We found only one study suitable for inclusion. This study compared the daily application of sunscreen (with or without beta-carotene, which is a precursor of vitamin A) compared with the occasional use of sunscreen (with or without beta-carotene) in the general population, without restriction by gender or age. The study was undertaken in Australia, where 1621 participants, 55% of them with fair skin, were monitored for 4.5 years for new cases of BCC or cSCC assessed by histopathology (which is a method used to detect cancerous cells under the microscope).

We found no difference between the number of people who developed BCC or cSCC in the two groups over the time period of the trial. So, there did not seem to be a difference in applying sunscreen daily compared with using it occasionally.

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Drinking filter coffee could reduce the risk of malignant melanoma – results from the (NOWAC) Study.

Lukic, M. et al. BMC Cancer. 2016 16:562

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Background: Coffee contains biologically-active substances that suppress carcinogenesis in vivo, and coffee consumption has been associated with a lower risk of malignant melanoma. We studied the impact of total coffee consumption and of different brewing methods on the incidence of malignant melanoma in a prospective cohort of Norwegian women.

Methods: We had baseline information on total coffee consumption and consumption of filtered, instant, and boiled coffee from self-administered questionnaires for 104,080 women in the Norwegian Women and Cancer (NOWAC) Study. We also had follow-up information collected 6–8 years after baseline. Multiple imputation was used to deal with missing data, and multivariable Cox regression models were used to calculate hazard ratios (HR) for malignant melanoma by consumption category of total, filtered, instant, and boiled coffee.

Results: During 1.7 million person-years of follow-up, 762 cases of malignant melanoma were diagnosed. Compared to light consumers of filtered coffee (≤1 cup/day), we found a statistically significant inverse association with low-moderate consumption (>1–3 cups/day, HR = 0.80; 95 % confidence interval [CI] 0.66–0.98) and high-moderate consumption of filtered coffee (>3–5 cups/day, HR = 0.77; 95 % CI 0.61–0.97) and melanoma risk (p trend = 0.02). We did not find a statistically significant association between total, instant, or boiled coffee consumption and the risk of malignant melanoma in any of the consumption categories.

Conclusions: The data from the NOWAC Study indicate that a moderate intake of filtered coffee could reduce the risk of malignant melanoma.

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Early Detection of New Melanomas by Patients With Melanoma and Their Partners Using a Structured Skin Self-examination Skills Training Intervention

Robinson, J.K. JAMA Dermatology. Published online: 29 June 2016

Importance:  More than 1 million patients with melanoma in the United States are at risk to develop a second primary melanoma. Early detection of melanoma improves survival. Patients with melanoma may be able to self-manage care with their skin-check partners (“partners”) and alert the physician when a concerning lesion is identified, thus providing an important adjunct to yearly skin examinations by a physician.

Objective:  To evaluate the effect of a structured skin self-examination (SSE) intervention for patients with melanoma and their partners (“dyads”) on SSE performance and the detection of new melanomas by the dyad or the physician.

Design, Setting, and Participants:  Randomized clinical trial with 24-month follow-up assessments. Patients with stage 0 to IIB melanoma and their skin-check partners participated from June 6, 2011, to April 24, 2015.

Interventions:  Dyads of patients and their partners were randomly assigned to receive the skills training intervention or customary care (control group).

Main Outcomes and Measures:  The main outcome was frequency of SSE performance. The secondary outcome was detection of a new or recurrent melanoma by the dyad or physician. The tertiary outcome was the number of unscheduled physician appointments for concerning lesions.

Results:  The study cohort comprised 494 participants. The patient population was 51.2% (253 of 494) female and had a mean (SD) age of 55 (10) years. Patients in the intervention arms had significantly increased SSEs with their partners at 4, 12, and 24 months (P < .001 for all) compared with the control group (mean differences, 1.57 [95% CI, 1.29-1.85], 0.72 [95% CI, 0.39-1.06], and 0.94 [95% CI, 0.58-1.30], respectively). Patients in the intervention arms identified new melanomas more than those in the control group (χ21 = 28.77, P < .01 [n = 51 melanomas in situ] and χ21 = 6.43, P < .05 [n = 18 invasive melanomas]) and did not increase physician visits.

Conclusions and Relevance:  Patients with melanoma and their partners reliably performed SSE after participating in a structured skills training program lasting approximately 30 minutes, with reinforcement every 4 months by the study dermatologist. Accurate SSE by those at risk to develop melanoma may enhance early detection and relieve some of the burden on health services to provide continuing follow-up to a growing population of eligible patients.

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A combined approach to treating metastatic melanoma

ScienceDaily. Published online: 30 May 2016.

Image shows photomicrograph (magnification X400) of fine needle aspiration from breast in metastatic malignant melanoma.

Oncologists at the Fred Hutchinson Cancer Research Center have successfully treated a patient with metastatic melanoma by combining two different types of immunotherapy. Cassian Yee and colleagues describe their approach in a paper, “Combined IL-21-primed polyclonal CTL plus CTLA4 blockade controls refractory metastatic melanoma in a patient,” that will be published online May 30 in The Journal of Experimental Medicine.

The researchers tested their idea on a 53-year-old patient with multiple metastases who had previously shown little response to either T cell transfers or ipilimumab treatment. The patient now received an infusion of his own antitumor T cells that had been treated with an immune signaling protein, called interleukin-21, that promotes T cell survival. Immediately afterward, the patient received a dose of ipilimumab. Within weeks, the patient’s tumors began to shrink, and they eventually disappeared completely. Yee and colleagues report that, over five years later, the patient remains disease free.

The researchers found that their combined approach boosted the number of antitumor T cells circulating in the patient’s blood in both the short and long term. Moreover, the enhanced immune response induced by this treatment allowed the patient to develop new types of T cells that attacked the melanoma in additional ways, a phenomenon known as epitope spreading.

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Study of patients with melanoma finds most have few moles

Gellar. A. C. et al. JAMA Dermatology. Published online March 02, 2016

Image shows a scanning electron micrograph of a skin cancer cell derived from a cell culture grown from a human melanoma cell line.

Importance: Nevi are among the strongest risk factors for melanoma. However, little is known about the association of many total nevi (TN) or atypical nevi (AN) with tumor thickness.

Objectives: To examine the association between age and the number of TN and AN and to explore whether there was a relationship between TN or AN and tumor thickness, controlling for multiple variables.

Design, Setting, and Participants: Survey of patients with melanoma at 2 academic sites and an affiliated Veteran Affairs medical center. Participants included 566 patients surveyed within 3 months of diagnosis. Patients were surveyed in the melanoma clinics from May 17, 2006, through March 31, 2009, within 3 months of diagnostic biopsy. The dates of the analysis were April 1, 2015, to August 1, 2015.

Main Outcomes and Measures: Counts of TN and AN were performed at the first visit after diagnosis and were categorized as 0 to 20, 20 to 50, or more than 50 for TN and as 0, 1 to 5, or more than 5 for AN. Tumor thickness was categorized as 2.00 mm or less or as 2.01 mm or greater. All analyses were stratified by patient age (<60 or ≥60 years). Logistic regression was used to test associations, controlling for age, sex, anatomic location of melanoma, institution, histologic subtype, marital status, performance of skin self-examination, number of health care visits in the past year, mode of melanoma discovery, and receipt of skin examination by a physician.

Results: The study population included 566 patients. Their mean (SD) age was 56.7 (15.9) years, and 39.0% (n = 221) were female. Of 566 patients, the number of TN was classified as 0 to 20 (66.4% [n = 376]), 20 to 50 (20.5% [n = 116]), or more than 50 (13.1% [n = 74]). Atypical nevus counts were 0 (73.3% [n = 415]), 1 to 5 (14.5% [n = 82]), or more than 5 (12.2% [n = 69]). For those younger than 60 years, the presence of more than 50 TN was associated with a sharply reduced risk of thick melanoma (odds ratio, 0.32; 95% CI, 0.12-0.81), and the presence of more than 5 AN compared with no AN was associated with thicker melanoma (odds ratio, 2.43; 95% CI, 1.02-5.75).

Conclusions and Relevance:  Most patients with melanoma had few nevi and no AN. In younger patients (<60 years), thick melanomas were commonly found in those with fewer TN but more AN, suggesting that physicians and patients should not rely on the total nevus count as a sole reason to perform skin examinations or to determine a patient’s at-risk status. Younger patients should be educated on the increased risk of thicker melanomas that is associated with having more AN.

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NICE guidance: sunlight exposure risks and benefits

NICE has published new guidance Sunlight exposure: risks and benefits (NG34).

This guideline covers how to communicate the risks and benefits of natural sunlight exposure (specifically, the ultraviolet rays UVA and UVB) to help people understand why they may need to modify their behaviour to reduce their risk of skin cancer and vitamin D deficiency.

NICE has also updated its public health guidance Skin cancer prevention (PH32). The guideline covers the provision of shade as part of the design of new buildings.

Related video: Cancer Research UK: Sun Smart Sun Burn video