Major Finding: Of 1,108 patients who underwent serial screening, there were no deaths due to melanoma or any other skin cancer, no metastases, and no sentinel node biopsies, since all melanomas were detected while in their radial growth phase, when their Breslow depth was well under 0.75 mm.
Data Source: A single-center longitudinal, observational study.
Disclosures: None reported.
MADRID — A novel program of recalls for twice-yearly full skin examinations in patients at increased risk for melanoma has uniformly resulted in very early detection and cure of melanomas over a 17-year period in a private-practice dermatologist's office.
From mid-1992 through mid-2009, during which 1,108 patients underwent serial screening, there were no deaths due to melanoma or any other skin cancer, no metastases, and no sentinel node biopsies, since all melanomas were detected while in their radial growth phase, when their Breslow depth was well under 0.75 mm, Dr. Ronald N. Shore reported at the 13th World Congress on Cancers of the Skin sponsored by the Skin Cancer Foundation.
This extensive experience challenges the recent controversial U.S. Preventive Health Services Task Force statement that screening for melanoma hasn't been shown to be of value.
“It is my belief that it is now possible to protect patients at increased risk or at high risk of melanoma with extraordinary efficacy. What is needed is to identify such individuals and to offer them the opportunity to participate in a serial screening program,” explained Dr. Shore, a Rockville, Md., dermatologist who is also on the clinical faculty at Johns Hopkins University, Baltimore.
When patients present with recognized risk factors for melanoma, physicians should seriously consider recommending and performing such serial screening procedures, he added. “The skill that is required when examining patients is not to know what lesions are melanomas, but what lesions could be melanomas, so that such lesions are biopsied or at least monitored.”
The genesis for Dr. Shore's screening program lay in the teachings of well-known dermatopathologist Wallace Clark, who asserted that melanomas in their early developmental radial growth phase almost never metastasize, and that this phase lasts for at least 6 months.
Dr. Shore fashioned a screening program founded on what he considered to be five key elements: performing thorough skin exams, biopsying all suspicious lesions, recalling patients every 6 months, educating patients regarding the importance of returning when called, and encouraging self-screening through teaching the classical features of melanoma. Patients were selected for serial screening based on standard risk factors, including fair skin, prior nonmelanoma skin cancer, history of significant sunburns, and positive family history.
In retrospect, however, he has concluded that the self-examination component wasn't particularly useful. For example, during a recent 5-year period in which 10 new cases of melanoma were detected through the screening program, all were in the radial growth phase, the greatest Breslow depth was only 0.15 mm, and seven melanomas were in men over age 50—but only one cancer was detected by a patient.
“This was particularly surprising to us, as all patients had been familiarized with the features of melanoma. It appears that in very early cases of melanoma, where lesions are asymptomatic and flat, most patients are not particularly adept at recognizing them,” he continued.
Median time between skin examinations in the series was 9 months rather than the sought-after 6 months.
“Most patients feel wonderful coming in for exams because they know what our experience has been and they feel reassured that they will not die of melanoma,” he observed in response to an audience question.
Dr. Shore noted that two prior studies have also reported 100% survival of screened patients at increased risk for melanoma (Cancer 1989;63:386-9 and J. Am. Acad. Dermatol. 2004;50:15-20).
Session cochair Dr. Fernando Stengel, chief of dermatology at the Clinicas Hospital in Buenos Aires, commented that Dr. Shore's experience seems unusual in that he didn't encounter any of the feared nodular melanomas that are so fast growing they have defied efforts to improve outcome through early detection.
Dr. Shore replied that some of the early melanomas detected in his series showed nodular-like histology. This leads him to suspect that “we basically catch them before they evolve into rapidly expanding lesions.”
“Most patients feel wonderful coming in for exams because … they feel reassured that they will not die of melanoma,” said Dr. Ronald N. Shore.
Source Catherine Harrell/Elsevier Global Medical News