Author: Amanda Lyons
Cancer Council Australia’s new wiki-based melanoma management guidelines can provide GPs with up-to-date information and help in diagnosis and treatment.
When people think of Australia, words like ‘sun’, ‘sea’ and ‘sand’ are often not far behind. The nation has a reputation for glorious beaches, near-constant sunshine and plenty of opportunities to enjoy the outdoors.
Unfortunately, those same aspects that make the Australian lifestyle seem so enviable can also provide the ingredients for one of its greatest scourges – melanoma.
Australia has the second highest rate of melanoma in the world,1 and a closer look at the statistics is just as alarming.
‘It was estimated that there would be 13,283 new cases of melanoma and 1774 people would die of melanoma in 2016,2 Prof Jon Emery, GP and Professor of Primary Care Cancer Research at the University of Melbourne, told Good Practice. ‘[Melanoma] accounts for 10% of all new cancers diagnosed in Australia.’2
Although the Australian Institute of Health and Welfare (AIHW) recently found the incidence of melanoma has fallen among people younger than 40, it also found that the age-standardised mortality rate has increased, as have the number of hospitalisations.1
But the news on melanoma is not all doom and gloom.
‘About 85% of patients with melanoma are cured by a surgical procedure, and only about 15% go on to develop metastatic disease and require drug therapy,’3 Prof John Thompson, Professor of Melanoma and Surgical Oncology at the University of Sydney, told Good Practice.
Keeping current with agile guidelines
Given melanoma research is a field in which new developments can happen quickly, particularly in terms of treatments, primary healthcare professionals can benefit from staying abreast of the current information.
‘GPs may not be directly involved in giving advice about what type of surgery, chemotherapy or immunotherapy the patient should have, but it’s important that they are able to explain to the patient, in broad terms, what’s likely to happen and what the options might be,’ Prof Thompson said.
A number of recent developments in the field have significant implications for certain diagnoses.
‘There are some important things happening both surgically and medically,’ Prof Thompson said.
‘The treatment of people with melanoma who get metastatic disease has changed very dramatically in recent times. Five years ago, there were very few options for people who developed it and it was almost invariably fatal within a year or two.
‘These days there are a number of very effective drugs and immunotherapies that are certainly prolonging life. We’re not yet sure whether they actually cure melanoma in the long-term, but they’re having a dramatic effect on short-term to medium-term survival.
‘And that’s changing almost month by month, as new agents become available when the results of trials come through.’
Prof Emery highlighted biopsy as another area in which recommendations in melanoma treatment have changed.
‘In the past, doctors sometimes took a partial biopsy. The risk with that is that you may end up with a false negative and actually miss the melanoma cells,’ he said.
‘The new recommendations state that if there is a lesion that is suspicious, you should do a complete excision with just a 2 mm margin. Then if it comes back as positive for melanoma you need to do a wider excision, by yourself if you can, or you refer the patient on to a dermatologist or surgeon.’
Unfortunately, medical guidelines don’t tend to move as quickly as the research field.
‘The process of developing guidelines takes quite a long time if they’re to be evidence-based,’ Prof Thompson said.
‘You have to get together all the literature, then you have to analyse and assess it. Then you have to put it all down and make recommendations.
‘There is then a fairly complex process of public consultation and, in the past, it had to be approved by the NH&MRC [National Health and Medical Research Council].
‘All of that takes a couple of years, at least. And, of course, with a field that’s moving fairly rapidly.
‘By the time the guidelines are actually printed and distributed, they are possibly out of date.’
In order to combat this problem of timeliness of information, Cancer Council Australia launched its wiki-based ‘Clinical practice guidelines for the diagnosis and management of melanoma’ at the Australasian Melanoma Conference in October last year.
These guidelines are to be the first in a series of wiki-based clinical recommendations, and they mark the first time an Australian melanoma management guide has been published in this format.
A wiki is a server program that enables collaboration between authorised users who can view and modify a website’s content. This is a more agile process than that of traditional publishing, thus allowing guidelines to be more easily updated in response to new evidence from the field.
It does not mean, however, that the process of publishing evidence-based information is any less rigorous.
‘The production of these guidelines remains fairly intensive, but the advantage of a wiki-based approach, particularly if you have an ongoing process of monitoring new evidence, is that it allows you to focus your efforts on updating just small sections of the guideline,’ Prof Thompson, who is Chair of the project’s expert working group, said.
‘So it can be a more efficient way to achieve that ongoing updating.’
The wiki format also offers its users the benefit of easier accessibility.
‘Anywhere you can get the internet, you can get the Cancer Council Australia website and [the wiki] is there,’ he said. ‘So you can use it at the bedside if you need, in your office, or anywhere.’
While some sections of the guidelines are currently available on the Cancer Council Australia website, the wiki remains a continual work in progress.
‘There are already some sections up on the Cancer Council Australia wiki,’ Prof Thompson said. ‘There are other sections coming through very shortly; it will probably be about two years before the entire process is completed.
‘And then, like painting the Sydney Harbour Bridge, we’ll start again.’
Prof Thompson believes the wiki format is definitely the way of the future for Cancer Council Australia guidelines.
‘There are a number of wiki guidelines already put out by Cancer Council Australia, such as lung cancer and sarcoma management, and there are others in the pipeline,’ he said.
‘A great advantage of [a wiki format] is that it’s so much quicker to get the guidelines approved and established.’
Prevention and diagnosis
In addition to online options like the wiki-based clinical practice guidelines, the RACGP and Cancer Council Australia each provide a number of helpful guides for GPs when considering which patients to target for melanoma prevention in the course of day-to-day practice.
‘There’s a lot covered in the Cancer Council Australia guidelines, and the RACGP’s Red Book [Guidelines for preventive activities in general practice] talks about identifying individuals who are at higher risk, particularly those with a family history of melanoma or a previous melanoma themselves,’ Prof Emery explained.
‘The Red Book also discusses additional features related to hair type, skin type and so on, which put people at moderately increased risk of melanoma. It therefore [helps identify] people who may benefit from being made aware of the possible features of a melanoma to look out for, and those who are at particularly high risk who may require regular physical examination.’
Prof Emery was also keen to emphasise the always-vital importance of protecting children from sunburn.
‘If you look at melanoma incidence rates, it is childhood and adolescence exposure to sunlight that is a much stronger predictor than ongoing exposure in middle years,’ he said.
Prof Thompson agrees with the importance of early-life prevention.
‘There is evidence that even just one or two episodes of bad sunburn in childhood can greatly increase your risk in later life,’ he said.
‘There were studies done on children who migrated to Australia in the 1950s, and it was found that if you came before the age of 15 your risk of getting melanoma and other types of skin cancer in later life was about the same as someone born in Australia.
‘If you came after 15, then the risk was greatly diminished.’4
It has been found that 95% of melanomas are caused by overexposure to ultraviolet (UV) light, which means preventive measures involving protecting your skin from the sun are particularly effective.5
While the past several decades in Australia have seen long-running campaigns focused on the importance of sun safety, including ‘slip, slop, slap’, Prof Thompson is concerned that the message has not been sufficient for large numbers of the population.
‘It’s pretty frightening to see the average Australian weekend beach scene; large numbers of people with very fair skin out there, getting more sun than they ought to,’ he said.
‘Sunscreens provide some protection, but they don’t stop you getting sunburnt. That message [‘slip, slop, slap’] is not just about putting on sunscreen, but being careful in the sun. Physical protection is by far the best, and that’s using clothes and hats and staying in the shade wherever possible.’
Prof Thompson believes GPs can be key in enforcing messages about the most effective ways to prevent melanoma.
‘[It’s important to] make sure people are educated and understand the importance of sun protection, particularly in the case of children,’ he said.
The other key role that GPs play in terms of melanoma is that of diagnosis, as catching the disease early is one of the main factors in providing a good patient outcome.
‘GPs are really crucial in applying [diagnostic] rules when somebody presents with concern about a lesion, or if the GP just happens to be examining a patient and they notice a lesion, and it is worth taking a history, particularly of recent change,’ Prof Emery said.
There are two different kinds of melanoma that may present in general practice, each with its own mnemonic to assist GPs in its diagnosis.
‘The first of the mnemonics is the “A, B, C, D rule”, where you’re looking for Asymmetry, irregular Border, variation in the Colour, and then a Diameter, usually of greater than 6 mm,’ Prof Emery explained. ‘That rule is very good for helping the detection of superficial spreading melanoma, which is the most common type.
‘Then there’s another group called nodular melanomas, and they contribute to a greater proportion of melanoma deaths. They have a slightly different biology, so they’ve added “E, F, G” into the diagnostic rules to try and identify them. Elevated, so they are raised lesions. They’re Firm, and they often Grow quite rapidly.
‘Nodular melanomas look quite different to the more common superficial spreading melanomas.’
While the statistics on melanoma can look frightening, Prof Emery observed that many patients achieve good outcomes if the disease is caught early.
‘Melanoma has a five-year survival of 90%,1 so the majority of people diagnosed with it have a good chance of long-term survival,’ Prof Emery said. ‘But early detection is really key to that.’
- The Australian Institute of Health and Welfare. Skin cancer in Australia. Cat. No. CAN 96. Canberra, ACT: AIHW, 2016.
- The Australian Institute of Health and Welfare. Melanoma skin cancer in Australia. Canberra, ACT, AIHW; 2016. Available at www.aihw.gov.au/cancer/melanoma [Accessed 24 January 2017].
- Long G. From dismal prognosis to rising star: Melanoma leads the way with new generation cancer therapies. Med J Aust 2015;202(3):115–16.
- Khlat M, Vail A, Parkin M, Green A. Mortality from melanoma in migrants to Australia: Variation by age at arrival and duration of stay. Am J Epidemiol 1992;135(10):1103–13.
- Cancer Council Australia. Risk factors/Epidemiology. Sydney, NSW: Cancer Council Australia, 2016. Available at http://wiki.cancer.org.au/skincancerstats/Risk_factors/epidemiology [Accessed 24 January 2017].