Melanoma

  1. What is Melanoma? 

  2. What does melanoma look like? 

  3. How important is early detection? 

  4. How common is melanoma in Australia?

  5. What causes melanoma?

  6. What type of person has a higher risk of developing melanoma?

  7. Do sunbeds (solariums) cause an increased risk for developing melanoma?

  8. Can dark skinned people develop melanoma?

  9. How is melanoma diagnosed?

  10. How do I know how “bad” my melanoma was?

  11. What are the subtypes of melanoma?

  12. How are melanomas on the skin treated? 

  13. Are there any alternative (non-surgical) treatments for melanomas on the skin?

  14. What can be done when a melanoma has spread to other organs (metastatic disease)?

  15. How can melanoma be prevented?

  16. Can sunscreens prevent melanoma?

  17. Sun avoidance and sunscreens will make me vitamin D deficient?

1. What is Melanoma? 

Melanoma is a skin cancer that arises from melanocytes, the cells that produce the pigment of the skin (melanin). If left untreated or diagnosed late, melanoma has a high risk of spreading to the body (metastasis), which makes it the most dangerous and potentially deadly form of skin cancer.

2. What does melanoma look like? 

Less than half of melanomas arise from moles while the majority arises on normal looking skin. Melanomas usually appear as enlarging coloured skin spots. They can have various shades of brown, black and blue and are usually asymmetric with irregular borders. They can be flat or raised and typically have a smooth surface, not warty or scabby. A small proportion of melanomas are not pigmented, but appear as changing "skin coloured" or pink spots. Because of this, any changing skin spot should be reported to your doctor. Melanoma can arise in any area of the skin, but has a predilection for the back in males and the legs in females.

Remember that the majority of melanomas have no symptoms when they are found. Some may be itchy or sore, while bleeding is a late sign. Most cases are detected solely by their appearance.

3. How important is early detection? 

It is very important to remove a melanoma early in its life. This is because "thin" melanoma have a very good prognosis (96% cure rates). Therefore early detection is vital in controlling the disease (see section on "checking your own moles"). The most common site for melanoma in men is the back and in women the legs. However, you should check all of your skin.

4. How common is melanoma in Australia?

Melanoma is one of the commonest cancers in Caucasians and the 4th overall in Australia. Among young adults, it is the commonest type of cancer, causing a huge impact in families and productive members of society. Australia and New Zealand have the highest rates of melanoma in the world, considered to be 11 times higher than the estimated global average. In 2017, 1,839 Australians are expected to die from melanoma. Fortunately, most cases are diagnosed early and can be effectively treated. Overall, the chances of surviving for at least 5 years after a diagnosis of melanoma is as high as 90% in Australia.

5. What causes melanoma?

Melanoma is caused by a combination of genetic predisposition and excessive exposure to ultraviolet (UV) radiation. Intermittent (recreational) sun exposure, which more easily causes sunburns compared to chronic and occupational exposure, is strongly linked to the development of melanoma. A history of sunburn with blisters, especially in childhood, considerably increases the risk of having a melanoma during life.

 

6. What type of person has a higher risk of developing melanoma?

A person’s risk of developing melanoma is based on factors that cannot be modified (such as age, gender and inherited predisposition) and those that can be changed, related to our behaviour, lifestyle and environment (such as UV exposure). The following factors increase someone’s chances of developing a melanoma:

  • Fair freckled skin, that burns easily and does not tan (skin phototype I);

  • Blue or green eyes, blonde or red hair;

  • Multiple moles, usually more than 100;

  • Multiple atypical, funny-looking moles, named “dysplastic naevus”;

  • High levels of sun exposure, especially intermittent type (e.g. during outdoor recreational activities or holidays), or use of solariums;

  • History of sunburn with blisters, especially during childhood;

  • Personal history of any skin cancer, including melanoma and non-melanoma skin cancers (NMSC);

  • Family history of melanoma, especially in first-degree relatives (parents, siblings or children);

  • Increased age – risk is higher after 50, but melanoma can develop in young people;

  • Male gender – melanoma is 1.5 times more common in men than women in Australia;

  • Conditions that weaken the immune system (immunosuppression);

  • Inherited mutations (e.g. in CDKN2A or CDK4 genes) or rare genetic conditions (e.g. Xeroderma pigmentosum);

  • Geographic location with high UV index - the incidence of melanoma in Victoria is almost half of that in Queensland.

 

7. Do sunbeds (solariums) cause an increased risk for developing melanoma?

Solariums or sunbeds are devices that artificially emit UV radiation for skin tanning. They can emit up to five times the UV radiation of the midday summer sun and are considered even more dangerous than natural sun exposure. Sunbeds produce UVA and UVB radiation, both considered carcinogenic to humans. A study published in 2012 showed that people who use a solarium before the age of 35 have a 59% higher risk of melanoma than those who do not use solariums. The risk of squamous cell carcinoma (SCC) is twice that of non-users. Therefore, commercial solariums have been banned in NSW since December 2014 and in all states and territories across Australia from January 2016. Nowadays, offering any kind of UV tanning services for a fee is considered illegal in Australia. 

 

8. Can dark skinned people develop melanoma?

The incidence of melanoma in non-Caucasians is low. It is uncommon among Aboriginal, Asiatic and African populations. However, non-Caucasians are more likely to experience delayed diagnosis and have poorer chances of survival compared to Caucasians. Dark skinned people tend to develop melanoma subtypes that are rare in Caucasian populations more frequently, such as on the palms and soles (acral lentiginous melanoma) and on the nails (subungual melanoma).

 

9. How is melanoma diagnosed?

Many melanomas are self-detected or detected by relatives. Everybody should routinely check their own skin, looking for new or changing spots. The ABCDE rule is very helpful for this screening. If you find something suspicious, you should see your doctor as soon as possible.

During routine skin checks performed by your doctor, all of your skin should be examined, head-to-toe, preferentially with the aid of a dermoscope. Some lesions may be difficult to diagnose and sometimes the difference between benign moles and melanomas is not so obvious (see: “How can moles be differentiated from melanoma”). For these cases, more advanced diagnostic tools may be required, all of which are available at the SMDC.

The diagnostic confirmation of melanoma will always require a biopsy. The standard approach is to remove the entire lesion (excisional biopsy) including 2 mm of normal-looking skin surrounding it. Partial biopsies (i.e. punch biopsies or shave biopsies) are usually not recommended when a melanoma is suspected, unless the lesion is too large and a complete excision biopsy is difficult to perform. They can be less accurate than excisional biopsy and should be performed by trained practitioners only

 

10. How do I know how “bad” my melanoma was?

For any type of cancer, the chances of cure and survival (prognosis) will depend on the staging. The stage reflects the severity of the disease and ranges from I to IV. The higher the stage, the worse the melanoma is. Information provided by the skin biopsy report combined with diagnostic tests, such as scans and lymph node biopsies, when indicated, are taken into account to define the melanoma stage.

The single most important factor to define prognosis in melanoma is the Breslow thickness, and your doctor will frequently mention it. It is a measure in millimetres (mm) of the depth or thickness of the tumour in the biopsy tissue. The lower the Breslow, the thinner the melanoma is, and the better the chance of a cure. According to this measure, the melanoma is classified as:

  • In situ (non-invasive): malignant cells are restricted to the epidermis, the top layer of the skin;

  • Thin: Breslow up to 1.0 mm

  • Intermediate: Breslow from 1.0 to 4.0 mm

  • Thick: Breslow greater than 4.0 mm

An in situ melanoma has a risk of spreading within the body close to zero and 97% of people survive 5 years after the diagnosis. While for a thick melanoma, there is a 40% chance of finding melanoma cells in the lymph nodes by the diagnosis, and the survival rate in 5 years drops to 70% or lower, depending on other characteristics of the tumour.

That is why it is so important to diagnose and treat a melanoma early in its life. “Thin” melanomas have a very good prognosis. Early detection is vital in controlling the disease and is the main goal at the SMDC.

 

11.What are the subtypes of melanoma?

A melanoma usually has a “name” and a “surname”. The subtype of melanoma helps your doctor understand and predict its behaviour better. The main subtypes of melanoma are the following:

  • Superficial spreading melanoma (SSM): the most common subtype, represents about 50% of melanomas.

    • Can develop in pre-existing moles in the skin or, more commonly they are new lesions arising on healthy skin

    • SSM can appear as a new spot, or an existing spot, freckle or mole that changes size, colour or shape

    • A patient diagnosed with SSM is at increased risk of new primary melanomas 

  • Nodular melanoma (NM): represents 10-15% of melanomas.

    • This is a highly dangerous form of melanoma that grows and can spread quickly, and differs from SSM in appearance

    • NM has little radial growth within the epidermis but penetrates vertically into the dermis early

    • NM can develop de novo in normal- appearing skin, or within another type of melanoma

    • NM develops most commonly on the head and neck, in sun-damaged skin and in older people, particularly men

  • Lentigo maligna (LM): is a slow-growing form of melanoma in situ that can be difficult to recognise. It can resemble a freckle and usually develops on skin heavily damaged by the sun in older people, especially on the head and neck. Lentigo maligna tends to be ill-defined and more frequently comes back after excision (local recurrence) compared to other types of melanoma. It often represents a diagnostic and therapeutic challenge due to:

    • Frequent large size, ill defined and heterogeneous;

    • Non-pigmented margins, difficult to see with conventional examination;

    • Predilection for cosmetically sensitive areas, usually on the face;

    • Predilection for older people, usually in the 7th or 8th decades, that commonly are dealing with other health conditions;

    • High tendency to come back after surgery (local recurrence).

 

When a lentigo maligna becomes invasive, it is named , which represents 4-15% of all invasive melanomas.

The Dermatology team at SMDC is world-renowned for its work and research about lentigo maligna, especially diagnosis and mapping of margins with the aid of In Vivo Confocal Microscopy.

  • Acral melanoma: represents 1-3% of melanoma in Caucasians, but up to 58% in dark skinned people. Arises on palms and soles and diagnosis is often delayed, leading to poorer chances of cure;

  • Subungual melanoma: accounts for approximately 1% of melanomas in Caucasians, but represents a higher percentage in dark skinned populations. They are most commonly located on the big toe or thumb nails and frequently diagnosed late, with poorer prognosis than other subtypes;

  • Desmoplastic melanoma: represents around 2.7% of all invasive melanomas. Is typically found on sun-damaged skin of older people and can often be hard to detect as it may be non-pigmented and confused with other skin lesions. Researchers from SMDC and Melanoma Institute Australia showed recently that In Vivo Confocal Microscopy is useful for diagnosing this type of melanoma, detecting if it is invasive on the skin and guiding appropriate sites for biopsy in large lesions found in cosmetically sensitive areas, like the face.

 

12. How are melanomas on the skin treated? 

The standard treatment for melanoma on the skin is surgery. Usually the suspicious lesion is removed and diagnosed by means of an excisional biopsy. If a diagnosis of melanoma is confirmed, a second “cut” is necessary to warrant a larger safety margin. This procedure is known as “wide excision”. The extent of the scar required for the wide excision depends mainly on the Breslow thickness, but is usually around 1 cm of skin surrounding the scar of the excisional biopsy. Most excisions leave non-disfiguring linear (straight line) scars. However, this also depends on the site of the melanoma. Areas with poor skin elasticity may require a repair with a skin graft or flap.

Depending on the Breslow thickness and other factors, it may be necessary to check your lymph nodes and discuss performing a sentinel lymph node biopsy. See more information about stage III melanoma.

 

13. Are there any alternative (non-surgical) treatments for melanomas on the skin?

By far, the treatment of choice for melanoma on the skin is surgical excision. Non-surgical treatments, such as radiation therapy, are reserved for exceptional situations, e.g. when surgery cannot be tolerated due to other health issues or after surgery when there are residual melanoma cells (positive margins) in areas not suitable for further excisions.

Lentigo maligna is an exception in terms of management. This slow-growing and non-invasive subtype of melanoma has been increasingly treated with non-surgical options in recent years, especially radiotherapy or imiquimod cream (Aldara®). The response rate is about 70%, however we don’t know for sure the rate of success of these treatments in the long term and which one is better. To answer these questions, researchers from SMDC and other institutions worldwide are conducting, since 2015, the RADICAL trial, that is currently recruiting new patients.

14. What can be done when a melanoma has spread to other organs (metastatic disease)?

Up to recent years, the only treatment options for these cases were surgical resection of metastasis, when possible, aiming more for improvement of symptoms and quality of life rather than cure; and chemotherapy that provided very little benefit and major side effects.

Fortunately, in the past 10 years, there has been amazing advances in this field, considered to be a breakthrough in the battle against melanoma. A better understanding of the biology and immunity of melanoma provided basis for the development of drugs that target cancer’s specific genes (“targeted therapy” with drugs named vemurafenib, dabrafenib, trametinib, cobimetinib or a combination of them), or that triggers the body’s immune system to attack melanoma cells (“immunotherapy” with drugs named ipilimumab, nivolumab, pembrolizumab or a combination of them).

These drugs can provide shrinkage of tumours, improvement in symptoms and increase in survival. In 2017, favourable results were announced also for patients with involved lymph nodes, whose tumours had been removed surgically, aiming to prevent melanoma from spreading. 

We are proud to say that we have been in the frontline of these discoveries. We are still working with an international network and pharmaceutical companies to develop new drugs and mostly "new cocktails" to find the right treatment for the right patients. These drugs are currently standard treatments for metastatic disease and are being listed on the PBS.    

 

15. How can melanoma be prevented?

Many risk factors for melanoma, such as fair skin, gene mutations and family history of melanoma, are inherited and cannot be changed. However, reducing sun exposure and avoiding sunburn from early childhood can definitely prevent melanoma and are easily feasible by means of simple changes in our routine and behaviour. Here are some tips to protect your skin from the sun:

  • Seek shade and avoid outdoor activities in peak sun-hours (10am to 4pm), but specially around midday;
  • Wear sun-protective clothes, covering as much skin as possible;
  • Wear a wide brim hat, that protects head, face and ears;
  • Wear sunglasses with adequate UV protection (lens categories 2, 3 and 4 – according to Australian/NZ standards);
  • Apply broad spectrum sunscreen (protection against both UVA and UVB rays, SPF30+ or higher, preferably 50+ in Australia) – 20 minutes before going out, thick layer, reapplying regularly (every 2 hours and after swimming);
  • Never, ever, use tanning beds or solariums!
  • And always remember: there is no “safe tan”!

 

Apart from that, it is important to check your own skin regularly and have yearly full skin examination by your doctor, especially if you have increased risk for melanoma. 

 

 

 

 

 

 

16. Can sunscreens prevent melanoma?

An important study conducted in Australia from 1992 to 1996 (Nambour Skin Cancer Prevention Trial) provided strong evidence that daily use of sunscreens can cut in half the incidence of melanoma. Furthermore, the incidence of melanoma among young adults in Australia fell from 1983 to 1996, coinciding with strong public health messages to use sun protection. Sunscreens have also been shown to reduce sunspots (actinic keratosis) and SCCs, while having an additional favourable cosmetic anti-aging effect. However, sunscreens are often used to prolong intentional sun exposure and real-life use is far from ideal. Most people apply insufficient amounts and frequently forget to reapply it regularly. For these reasons, it is recommended to use sunscreens to complement rather than replace physical protection (shade, hats, clothing).

 

17. Sun avoidance and sunscreens will make me vitamin D deficient?

Getting adequate levels of vitamin D is vital, especially for bone health. By far, the main source of this vitamin is the skin, that produces it when exposed to UVB radiation. Foods, in general, do not provide enough of it. The amount of sun exposure required to get adequate vitamin D levels depends on skin type (the fairer your skin, the less you need), age (longer sun exposure required in the elderly), latitude, season, time of the day and cloud cover. Daily exposure to as little as one-third of a sun-burning dose on 15% of your body surface (hands, arms and face; or legs) can produce sufficient amounts of vitamin D. In Australia, for fair skin people (those that tend to burn rather than tan) this can be achieved around 6-8 minutes just before 10am or just after 2pm (standard time, during summer, in most of the country). During winter, it may take up to 30-50 minutes in southern parts of Australia but still less than 10 minutes in the north.

Therefore, it is not necessary to tan or burn your skin to produce vitamin D! Moreover, correctly applied sunscreens can reduce vitamin D production but with real-life use, this was proven not to be a problem. Considering risks and benefits, it is better to keep protecting from the sun and take vitamin D supplements if necessary, than intentionally sunbathe to produce more vitamin D.  In addition, it is worth warning that solariums should never be considered to boost vitamin D levels.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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