Melanoma risk in current melanoma patients demands careful, ongoing follow-up

Boston - About 76,000 new cases of invasive melanoma occur in the United States each year, according to the American Cancer Society, and patients who have had one melanoma have a 5 to 10 percent risk of developing another primary tumor during their lifetime. As a result of this increased risk, careful follow-up of these patients is critical, says Arthur Sober, M.D., professor of dermatology at Harvard Medical School.

Such follow-up is also important to look for evidence of recurrence at the site of the initial tumor or in the regional lymph nodes, Dr. Sober says. Additionally, most melanoma patients have sun damage, which contributes to their production of melanoma.

Critical criteria
According to Dr. Sober, evaluations should meet several criteria, starting with a thorough exam in a location with adequate lighting.

“It includes a full-body visual examination, examination of the scar, palpation of the skin around the scar, because sometimes you can feel subcutaneous recurrence more easily than see it, and palpation of the lymph node areas,” he says.

He also recommends a tool that has yet to become completely standard in the United States.

“The majority of American dermatologists are not using dermoscopy as they appear to be in Europe and in Australia. As more residents are taught dermoscopy, however, I think the trend will be for a greater proportion of dermatologists to start using the technology,” he explains.

“Dermatologists who do use it, and are conversant with it, find it improves their diagnostic accuracy for difficult lesions in the range of 10 percent. You're able to see pigment disorganization and vascular structures better with dermoscopy than with the naked eye,” Dr. Sober says.

Studies show that other tests aren’t effective for following-up melanoma patients, Dr. Sober says.

“There is no evidence that blood tests, radiological scans or ultrasounds are any benefit if the patient does not have symptoms that suggest the spread of disease. In asymptomatic patients with localized disease, we don’t recommend any blood work or radiological investigations,” he says, adding that there may actually be more drawbacks than benefits in doing those tests.

“If you do these tests you're going to find false positives about 15 percent of the time. They’re not meaningful in the management of these patients and can lead to additional scans, additional anxiety, additional radiation and sometimes additional diagnostic tests such as biopsies, which may be invasive and may have complications, along with increased costs,” he explains.

Frequency facts
According to Dr. Sober, the frequency with which follow-up should be scheduled is a more subjective decision.

“No evidence-based studies indicate how frequently follow-up exams should take place,” he says. “It’s more a consensus of experts or local practice, and in general, they are done at a minimum of once a year.

“Most patients are actually seen more frequently, especially early in the course of their disease follow-up - within the first five years, for example. After five years, many patients are seen once a year,” he adds.

Additional factors may come into play in determining exam frequency. The presence of dysplastic nevi or clinically atypical moles also plays a role, Dr. Sober says.

“Many patients with either a large number, or a number that are particularly peculiar, are seen at least twice a year. Follow-up is determined by precursor lesions or risk factors other than those associated with melanoma itself. Even after five years, follow-up may continue twice a year,” he says.

A new approach
Last year, Dr. Sober was involved with a study (Lipworth AD, Park JM, Trefrey BL, et al. J Am Acad Dermatol. 2011;64(6):1060-1067) that took a unique approach to follow-up skin exams. Regular exams were scheduled at standard frequencies, but then patients were given a different directive.

“They were told if they had any concerns during that interval about a new or changing mole or had any other symptoms that they could come in sooner. There was an open access clinic where the patient could come in within a week of calling,” Dr. Sober says.

“We wondered if people who were well but worried would simply come in more frequently, or would patients find something relevant between follow-ups,” he explains. “We found that patients coming during those intervals were four times more likely to find either a new melanoma or a recurrent melanoma than the group we routinely followed at regular intervals.”

In other words, the patients were attuned to their own bodies, he says. An additional benefit of the need-based follow-up is that it reduces patient anxiety, Dr. Sober says. Patients know they can get in if they are worried, whether they actually have a problem or not.