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By Helen K. Kelley

Melanoma, typically a malignant tumor associated with skin cancer and the cause of the vast majority of skin cancer deaths, can also occur in the eye or any mucous membrane of the body. While the risk of melanoma increases with age, it is one of the most common cancers found in young adults, particularly young women.

Georgia is one of the states with the highest incidence of melanoma in the U.S. To learn more about why this number is rising and how doctors are treating the disease, Atlanta Medicine recently spoke with two physicians who are specialists in melanoma.

B. Scott Davidson, M.D.

Multidisciplinary approach to treatment; physicians should know signs
“I think a multidisciplinary team approach is crucial in the successful treatment of melanoma,” says B. Scott Davidson, M.D., a surgical oncologist with Northside Hospital Cancer Institute’s Melanoma and Sarcoma Program.

“It’s important to have close collaboration between surgical, medical and radiation oncologists who share their ideas about treating individual patients.”

He adds that since there are many variations in patient care, having input from a team of practitioners with different knowledge and skills can create a more effective treatment for each individual.

“There are a lot of components to treating melanoma, all of them important. It’s best to review those options during a multidisciplinary conference,” he says. “During these meetings, we form a game plan. We determine the best treatment options – immunotherapy, radiation and/or surgery – and the sequence of their delivery for the individual patient.”

Davidson adds that all physicians can play a role in the early detection of melanoma in their patients.
“It can be tricky to identify a melanoma just on gross examination. Certainly, any changing mole should be suspicious and the patient referred to a dermatologist for biopsy,” he says. “It’s good for every doctor to know the signs of skin cancer.”

He recommends following the guidelines set forth by The American Academy of Dermatology (AAD), known as the ABCDEs of melanoma:
• Asymmetry: Is one half of a mole unlike the other half?
• Border: Does a mole have an irregular, scalloped or poorly defined border?
• Color: It there more than one color in a mole, such as shades of tan and brown, black, white, red or blue?
• Diameter: Is a mole bigger than 6 mm (the size of a pencil eraser)? Melanomas are usually bigger than 6 mm when diagnosed, but they can be smaller.
• Evolving: Does a mole or another spot on the skin that look different from the rest? Is a mole or another spot changing in size, shape or color?

“The majority of melanoma occurs on sun-exposed areas, although there are certainly exceptions. And it is still a disease of all age groups,” Davidson adds. “The changing of a mole from benign to malignant probably calls into question the genetics that a person may harbor.”

Andrew Page, M.D.

Stimulating the immune system; rising numbers of skin cancer in younger people
According to Andrew Page, M.D., director of pancreas, liver and cancer surgery at Piedmont Hospital, the landscape in melanoma treatment has made phenomenal progress, particularly for patients with metastatic melanoma.

“Up until about seven years ago, the medications available to treat metastatic melanoma were not very good. Patient responses were not durable, and side-effects were not tolerable,” he says. “But starting in 2011, many groups began publishing remarkable outcomes for patients using novel treatments that were previously not available. Specifically, researchers had identified medications that target both the molecular pathogenesis of melanoma and the patient’s own immune system – and the results have revolutionized the treatment landscape for melanoma. Effectively, we now have medications to treat patients better with durable responses, without as severe toxic side effects.”

Newer drugs like Opdivo (nivolumab), used in the past couple of years for patients who have advanced (stage IV) melanoma, are now approved for people with stage III disease.

“In the past, if a person had comorbidities, the treatment itself – Interleukin-2 – could have killed them,” Page says. “But today, we have immunotherapeutic agents like Opdivo that are used, with some success, to treat advanced-stage melanoma. That’s amazing progress.”

Page warns that even though treatment of the disease is improving, the incidence of melanoma continues to rise.

“We have medications that work so much better today, yet melanoma is on the rise, about 90,000 incidences in the U.S. annually. While certainly many factors contribute to melanoma, young people, even children, are still getting too much sun exposure,” he says. “I’m seeing younger patients coming in with melanoma. Almost every single one of my young female patients admits to using tanning beds throughout high school.”

Study finds timing of diagnosis, treatment critical to survival
A new Cleveland Clinic study underscores the importance of early detection and treatment of melanoma, the deadliest form of skin cancer. The research, recently published in the Journal of the American Academy of Dermatology, indicates that the sooner patients were treated, the better their survival, particularly for stage I melanoma.

Using the National Cancer Database, researchers from Cleveland Clinic’s Dermatology & Plastic Surgery Institute studied 153,218 adult patients diagnosed with stage I-III melanoma from 2004 to 2012 and found that overall survival decreased in patients who waited longer than 90 days for surgical treatment, regardless of stage. In addition, the delay of surgery beyond the first 29 days negatively impacted overall survival for stage I melanoma, though not for stage II or III.

Compared to patients who were treated within 30 days, patients with stage I melanoma were 5 percent more likely to die when treated between 30 and 59 days; 16 percent more likely to die when treated between 60 and 89 days; 29 percent more likely to die when treated between 91 and 120 days; and 41 percent more likely to die when treated after 120 days. Patients with a longer time to treatment initiation tended to be older and male, and have more co-morbidities.

According to the authors, it is likely that more advanced cases represent delays in diagnosis, and these delays overwhelm the impact of a speedier treatment. However, in early-stage cases, early diagnosis allows for the opportunity to improve the chances of survival with a prompt surgery. Although many physicians follow a rule-of-thumb to treat melanoma surgically three to four weeks after diagnosis, there is no official recommendation on time to treatment.

The study is a stark reminder of the importance of detecting skin cancer early, when it’s most treatable. Anyone who notices any new, changing or suspicious spots on their skin, or any spots that are changing, itching or bleeding, should see a board-certified dermatologist for diagnosis.

The public can take steps to reduce their melanoma risk by protecting themselves from exposure to harmful ultraviolet radiation from the sun and indoor tanning beds, a risk factor for all types of skin cancer. The AAD recommends that everyone protect their skin from the sun by seeking shade, wearing protective clothing and using a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher.


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