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Melanoma: What’s New in Prevention, Diagnosis and Treatment

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Many adults grew up during the sun-loving era of the 1950s, ’60s and ’70s. Now: It’s believed to be partially responsible for the quadrupling of melanoma cases over the past several decades. More than 9,000 Americans die from the disease each year.

Patients and doctors also are paying more attention to skin changes that might be cancer—and spotting melanoma earlier.

Major good news: Early-stage melanoma is usually cured by lesion-removing surgery. The five-year survival rate for early-stage melanoma is 99%. But even stage III melanoma, cancer that has spread to nearby skin or lymph nodes, has a five-year survival rate of 63%. Stage IV melanoma, in which cancer has metastasized or spread to other sites in the body, has a five-year survival rate of 20%—but even for these advanced cases, new therapies designed to contain or reverse the disease are extending lives. Here’s what’s new…

DIAGNOSIS

Examination of all the skin on your body by a savvy dermatologist at least once a year—and a biopsy of any suspicious moles—is still the best first-line of defense against melanoma. Be alert to the “ABCDE” warning signs for melanoma (see below). Bring any skin changes to your doctor’s attention immediately (even if it isn’t time for your yearly skin check).

Diagnostic danger: Melanoma is tough to diagnose, particularly in its early, or “thin,” stage, when the mole is less than one-millimeter thick.

My advice: If your doctor tells you that you have melanoma, ask to have your biopsy slide sent to another pathologist for a second opinion. Check first with your insurance provider to see if that’s covered and if you need preauthorization.

Also important: Most people think of melanoma as a brown or black spot that is changing. But amelanotic melanoma is pale and reddish and has a poor prognosis because it’s usually detected after it has spread. What to do: Alert your doctor to both dark and light unusual skin changes.

New option: If you have a suspicious lesion, you may be able to avoid surgical biopsy. Ask your doctor about having genetic testing instead, such as the Dermtech Pigmented Lesion Assay (PLA). It is highly accurate in distinguishing malignant melanoma from benign nevi, and may be covered by your insurer.

NEW THERAPIES

New therapies are brightening the previous grim outlook for advanced melanoma.

For example, several recently ­approved oral drugs inhibit a genetic mutation called BRAF that drives approximately 40% to 60% of melanomas. These drugs, which slow the growth of tumors and extend life, include vemurafenib (Zelboraf) and dabrafenib (Tafinlar).

A new class of drugs called MEK inhibitorstrametinib (Mekinist), ­cobimetinib (Cotellic) and others—inhibit the MEK protein, which helps speed the growth and spread of melanoma tumors.

New development: Combining dabrafenib and trametinib more than doubles average survival for ­advanced melanoma from five months to 11 months. Unfortunately, these drugs do have side effects, ranging from headaches and fatigue to kidney and heart problems—and even, ironically, basal cell carcinoma, another type of skin cancer. Also, although they can slow and shrink tumors and extend life for months, even years, the cancer eventually returns. What to do: Make sure your oncologist tests your ­tumor for ­genetic mutations.

Immunotherapy—drugs such as pembrolizumab (Keytruda), nivolumab (Opdivo) and ipilimumab (Yervoy) that stimulate the immune system to fight cancer—is another new way to treat advanced melanoma. But the drugs work only in a small percentage of patients, control cancer for a limited time, are very expensive and have a range of debilitating and even deadly side effects.

New development: Combination immunotherapy—such as the ­immunotherapeutic drug Keytruda with cellular therapy, which uses immune cells such as interleukin or interferon—is showing better ­results in clinical trials. FDA-approved interferon and interleukin-based treatments for melanoma include aldesleukin (Proleukin), interferon alfa-2b (Intron A) and peginterferon alfa-2b (Sylatron).

FEWER SURGICAL COMPLICATIONS

Once melanoma is diagnosed, a sentinel-lymph-node biopsy can determine whether it has spread to nearby lymph nodes. Often, all lymph nodes in an area are removed if cancer is found in the sentinel lymph node. However, removing all the lymph nodes in an arm or a leg can cause lymphedema—permanent, painful swelling of the limb that limits activity and can lead to frequent infections.

New scientific finding: Less extreme surgery is just as effective, according to a study conducted at 63 medical centers and reported in The New England Journal of Medicine. Details: 1,900 patients with melanoma that had spread to at least one lymph node either had all their lymph nodes in the area of the affected node immediately removed…or had only the affected lymph node or nodes removed, while the other nodes in the area were tracked with ultrasound. If melanoma occurred in a new node, the other lymph nodes were removed. After three years, the two groups had the same survival times. But patients who had all their lymph nodes removed had four times the risk for severe swelling in the affected arm or leg.

ABCDE Warning Signs of Melanoma

Asymmetry…irregular Borders…more than one or uneven distribution of Color…Diameter larger than one-quarter inch…Evolution, such as changes in color and/or size.

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Source: Marianne Berwick, PhD, distinguished professor, department of internal medicine, University of New Mexico School of Medicine, and former chief, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Comprehensive Cancer Center, both in Albuquerque. She is author or coauthor of more than 200 scientific papers on melanoma published in leading medical journals, including JAMA Dermatology, Journal of the National Cancer Institute and Melanoma Research. Date: July 1, 2018 Publication: Bottom Line Health
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