LOCAL FRONTIERS

The North Bay Melanoma Program

By Peter Brett, MD

Close to 200 people who live in Sonoma County will be diagnosed with melanoma this year. That’s a lot of us—not a good thing—but perhaps you’d be a little better off diagnosed this year than last.

Here’s the typical way things played out in previous years (outside the Kaiser system). Say your spouse notices an ugly mole on your ear. You decide to visit your primary care physician or dermatologist, who performs a biopsy and sends it to a pathologist for review. Diagnosis: melanoma.

But then what? Should you see a medical oncologist to see if you need extensive staging tests to determine if the melanoma has spread anywhere? Or should you instead see a general surgeon to excise the tumor? Would the surgeon know what type of surgical margins to aim for, or whether nearby lymph nodes should be removed? You’ve heard about sentinel lymph node biopsies; but do you need one, and who around here has the expertise to perform one or determine if it’s even warranted? Should you see a plastic surgeon, or if this is your ear, maybe you’re better off with a head-and-neck surgeon? Should you receive chemotherapy or interferon after surgery to prevent the melanoma spreading? Are there promising clinical trials you should be enrolling in? And who’s going to keep on eye on you for the long term?

In past years, the answers to these questions would depend on whom you asked. Some physicians seemed to know some of this stuff, but did anyone really know all of it? Many of us in private practice who see patients with cancer had the perception that local melanoma care was poorly coordinated from start to finish. And I think patients had this perception as well. As a result, many patients traveled to UCSF’s Melanoma Clinic, where they could receive a treatment recommendation and surgery—including a lymph node biopsy—if necessary.

The care at the UCSF clinic brought its own set of problems, however. Treatment recommendations seemed reasonable, but driving to San Francisco is a long (and increasingly expensive) trip for many patients. In addition, there was often a long wait to get into the clinic (usually many weeks), and an even longer wait for surgery (usually very many weeks). The clinic didn’t offer clinical trials to patients, nor did they have medical oncologists on staff who could provide interferon or other chemotherapy treatment if needed.

Recognizing these problems, a group of Sonoma County physicians from various medical practices interested in melanoma care began meeting in June 2007 to see if we could improve the situation for our patients. We developed the following goals for a local melanoma program, which we hoped would:

Provide seamless coordination of care from the time a patient’s melanoma was diagnosed, through work-up, treatment and long-term follow-up.
Develop and adhere to evidence-based treatment protocols so that all patients would be treated with state-of-the-art care founded on conclusions from well-performed clinical trials.
Develop and maintain the expertise to treat essentially all stages and presentations of melanoma, from the most superficial to the most advanced.
Provide outreach to the community of patients, caregivers and physicians in the area so that all would feel connected to the program and could receive support, communication and education.
Develop our own clinical trials and bring nationally sponsored clinical trials to our patients for situations when state-of-the-art isn’t good enough.
Provide rapid evaluation and treatment of all patients to improve the chance of cure and allay patient anxiety.
Hold a multidisciplinary melanoma tumor board where patients’ cases could be discussed with active input from experts in oncology, surgery, dermatology, pathology and radiology.

We ended up creating the North Bay Melanoma Program, which is now almost a year old. We evaluate 5-10 newly diagnosed melanoma patients each month, so we believe we’re seeing most of the non-Kaiser patients in the region. And while the program is still quite young, we feel we’ve worked through the growing pains inherent in developing any complex program and are now accomplishing many of the tasks we set ourselves at the beginning.

Sentinel Node Biopsy

The first treatment principle for melanoma is to excise the melanoma. If we get widely around the melanoma, it rarely comes back near where it began. If the melanoma hasn’t sent “seedling” cells to other parts of the body, wide excision should cure it. Generally, the deeper the melanoma penetrates into the skin (the Breslow depth), the wider the surgical margin needed to prevent a local recurrence.

If thin melanomas with favorable pathologic characteristics are excised with margins of 1 cm down to the fascia, the melanoma will return near where it started less than 5% of the time.[1] In contrast, deep melanomas or those with aggressive features require a negative surgical margin of at least 2 cm on all sides to keep the local recurrence rate under 5%.[2] In our Melanoma Tumor Board, we often discuss the appropriate type of surgery for patients with melanomas that vary in aggressiveness.

Even with appropriate excision, melanoma can still return, since it may have sent microscopic “seedling” metastases to nearby lymph nodes, or even to distant organs. Fortunately, melanoma often spreads to lymph nodes first, so if we can detect that spread early and remove the nodes, we can sometimes prevent spread to other parts of the body.

The surgeons in the North Bay Melanoma Program perform sentinel lymph node biopsies on patients who we think have at least a 10% chance of microscopic spread to the nodes. The concept here is that if melanoma spreads, it will first travel to the sentinel node before spreading to other nodes. If we remove the sentinel node, and it’s free of melanoma, we can be pretty certain that the melanoma hasn’t spread to other nodes or organs. On the other hand, if the melanoma has spread to the sentinel node, we usually perform a complete dissection of the nodal group, removing another 10-20 nodes.

There is some controversy over the value of performing sentinel node biopsies for melanoma. A recent large randomized study found that survival free of disease was improved with sentinel node biopsies, but overall survival was not.[3] I believe the procedure is still worthwhile for selected patients, however. For one thing, knowing whether the sentinel node contains melanoma gives us valuable prognostic information. In addition, patients whose melanoma has spread to the sentinel node fare much better if they get a lymph node dissection immediately, instead of waiting until they develop large lymph nodes that may be filled with melanoma cells. In that case, the chance for cure would be low.

—Allen Cortez, MD

References

Veronesi U, et al, “Thin stage I primary cutaneous malignant melanoma,” N Engl J Med, 318:1159-62 (1988).
Balch CM, et al, “Efficacy of 2-cm surgical margins for intermediate-thickness melanomas,” Ann Surg, 218:262-267 (1993).
Morton DL, et al, “Sentinel node biopsy or nodal observation in melanoma,”
N Engl J Med, 356:418-421 (2007).

Here’s a revised version of the opening scenario, where your spouse notices an ugly mole on your ear. You again see your primary care physician or dermatologist, who performs a biopsy. If the pathology report returns “melanoma,” your physician usually faxes or phones a referral request to the North Bay Melanoma Program. As the director, I like to evaluate all new patients, and I make a special effort to see them within 1-2 days of referral. I take a comprehensive history, perform a physical exam, review the pathology data, and discuss with you the preliminary clinical stage of the melanoma, the prognosis at this point, and the work-up and treatment options. I point you to our website (www.melanomaprogram.org), which includes many educational materials. I may also order appropriate blood and imaging tests, and send you to a surgeon for a wide excision.

Our program includes surgeons who are skilled in performing different aspects of melanoma surgery, from surgery to the head and neck area, to plastic surgery in areas requiring delicate reconstruction, to performing sentinel and complete lymph node dissections (see sidebar). All of our surgeons are committed to treating patients expeditiously, and we can usually arrange a surgical consultation within a few days, with surgery to follow within a week or two. In your case, I’d probably arrange for you to see a head-and-neck surgeon.

Meanwhile, we present your case to our multidisciplinary Melanoma Tumor Board, which meets regularly in Santa Rosa and includes pathologists, dermatologists, radiologists, surgeons, oncologists and sometimes your primary care physician. We look at slides from your biopsy and your imaging studies, and we discuss your melanoma’s stage and prognosis. We also make recommendations for further work-up and treatment. Your case will be presented again several months later if you have a relapse or if your outcome was better or worse than expected.

After your surgery, I meet with you again to discuss the outcome and to make a more accurate determination of your prognosis. We jointly decide if you need further treatment. It’s possible, for example, that you might benefit from adjuvant chemotherapy (commonly interferon), which can lower the risk of relapse in high-risk situations. If you had a sentinel lymph node containing melanoma, you might need a more complete lymph node dissection. If in the worst of situations you have distant metastatic disease, you might benefit from being put on one of our treatment clinical trials, or you might receive standard chemotherapy or immunotherapy.

All patients need total skin and systemic (total body) follow-up. We think it’s important for patients to receive follow-up of their skin forever, since they’ll be at continued risk for developing new primary melanomas. We therefore encourage you to see your primary care physician or dermatologist regularly for these important skin exams.

You will be at variable risk for developing lymph node or distant recurrence as well, so a medical oncologist with a nurse practitioner will see you regularly for surveillance systemic exams for at least five years. We’ve started a clinical trial using high-resolution MRI scans of the regional lymph nodes of patients who have a moderate risk of developing nodal recurrence.1 We hope to detect nodal recurrence earlier than can be detected clinically, before systemic spread develops.

What’s so different about this approach to patient care, compared to the past? A lot. How often do you as a physician get a chance to review a patient’s CT scan carefully with a radiologist? How often can you review a patient’s biopsy with a pathologist, so that you really understand whether this seems to be a serious cancer or not? When have you seen dermatologists sit down side by side with oncologists to express their concern over the risk of a patient developing a new primary skin cancer? Have you seen plastic surgeons in private practice debate the relative merits of different approaches to tissue repair? Can radiation oncologists discuss with general surgeons the risk of lymphedema if a patient might need to undergo both lymph node dissection and radiation to the same lymph node area? When was the last time you had a lively debate about the data from a recent Phase 3 clinical study, and used the results to inform your decision-making for a patient?

All these conversations take place regularly when our physicians gather for their regular tumor board. The patient being discussed has a careful and thorough “going-over” from a multidisciplinary team. Instead of the fractionation of care that often results when specialists approach treatment of a disease, in this case specialists work together to come up with a coordinated plan, similar to the approach taken at academic medical centers. There’s no reason why coordinated multidisciplinary care shouldn’t be used in private practice as well.

Clinical Case

A middle-aged construction worker came to his family physician in Santa Rosa complaining of a “mushroom-like” growth on his upper right arm. On exam he otherwise appeared healthy, but he had a red, ulcerated, exophytic mass on the upper right arm measuring 2 x 3 cm (see photo). Narrow excisional biopsy showed that the mass was an ulcerated amelanotic melanoma, more than 10 mm deep.
ulcerated amelanotic melanomaulcerated amelanotic melanoma
The family physician referred the patient to the North Bay Melanoma Program, where I evaluated him, ordered staging tests, and presented his case to our Melanoma Tumor Board within a few days. Clinical exam, blood tests, PET/CT scan, and high-resolution MRI of regional lymph nodes showed no evidence that the melanoma had spread.

The tumor board’s consensus was that the patient’s prognosis was poor even with treatment, with a greater than 50% chance that he would eventually develop systemic spread of his cancer, even with normal staging tests. We recommended a wide local excision of the tumor site on the arm with 2 cm margins to reduce the risk of local recurrence. Because the risk of systemic recurrence was so high, we concluded that sampling sentinel lymph nodes by biopsy was unlikely to affect his outcome. A surgeon in the Melanoma Program performed wide excision of the tumor soon after the patient’s case was presented. The patient will next receive high-dose interferon to reduce the risk of systemic recurrence.

—Peter Brett, MD

Unfortunately, the barrier to setting up a specialty disease program in our community turns out to be fairly high. Cost, however, is not a main concern. The only hard costs are some conference room space, a “free lunch” for tumor board meetings, and some mailers and ads to keep the program visible. My medical group, Redwood Regional Medical Group, provides some administrative support and helps underwrite these costs.

We initially thought that specialists might have a hard time coming together across competing practices and medical groups to cooperate in taking care of patients; but this potential lack of cooperation never developed. The melanoma program now has physicians participating from more than 10 unrelated (and sometimes competing) medical practices, yet the idea of turf wars just hasn’t come up.

Sunscreen Primer

Because ultraviolet light has been implicated as a major factor in causing skin cancer, especially non-melanoma types, dermatologists have long recommended the use of sunscreens. Unfortunately, there is little direct evidence that regular application of sunscreens reduces the incidence of any skin cancer type, even though there are plenty of epidemiological and clinical data linking sun exposure to the increased incidence of basal cell carcinoma and squamous cell carcinoma. This paradox might best be explained by two factors: deficiencies in sunscreen ingredients, and improper use of the products.

Sunscreens contain chemicals that absorb portions of the ultraviolet (UV) spectrum that have been associated with tumor initiation and promotion. However, there has been far too much emphasis on protecting from UVB light (290-320 nm) and not enough against UVA (320-400 nm). UVA (tanning parlor light) has been shown to be carcinogenic, but few sunscreens offer protection from those rays. As a result, the Food and Drug Administration wants to change the sunscreen labeling system. The current SPF (sun protection factor) ratings only indicate the amount of protection from UVB light, so consumers have no way of knowing how effective products are against UVA light. The new rating system would include a four-point scale for UVA protection.

Until recently, sunscreens did a poor job of shielding from UVA light, even though they prevented sunburns—a crude but easily observed measure of photodamage. People who applied sunscreen believed they were protected from skin cancer, when in fact they may have increased their exposure to UVA light, which does not cause a sunburn but can damage the skin. Fortunately, a new generation of UVA-protective chemicals has arrived, including products such as Mexoryl and Helioplex. These seem to offer significantly more UVA protection, especially when combined with proven anti-UVB ingredients.

Another important factor in sunscreens’ lack of efficacy is improper application by the consumer. Laboratory studies evaluating SPF ratings use three times the quantity of sunscreen that the average person applies. Furthermore, in actual use, the creams often rub off or dissolve in water.

Sunscreens should be thought of as a third line of defense, in addition to avoiding the sun and wearing protective clothing. Frequent, liberal application of sunscreens with higher SPF ratings and UVA absorbers could potentially reduce the alarming number of skin cancers.

—Dale Westrom, MD

The major barrier, frankly, is the hurdle we all face in our day-to-day practices: how to create any more time to dedicate to any more patient care. All physicians in the melanoma program donate some of their professional time to participate in tumor board meetings, and to keep up with the relevant scientific literature. All have made a commitment to evaluate and treat patients rapidly. Keeping a complex program running takes significant ongoing dedication of time and effort.

This barrier of committing time might ordinarily prove insurmountable, but I’ve been impressed that we’ve been able to overcome it, and I believe there are at least two reasons why. First, we seem to be building a true camaraderie among the physicians who participate. Other meetings I’ve attended in the past few years usually only concern financial or political problems in our medical community. By contrast, melanoma meetings are devoid of politics or finances. We meet solely to discuss how best to treat or improve the care of patients with this serious disease—almost certainly what physicians enjoy doing most. This cooperation is incredibly refreshing, and it brings everyone together in a spirit of common purpose.

Second, our program is building a reputation for excellent subspecialty care, something that in the past was the exclusive province of the academic medical center. We are becoming known throughout the region, even in neighboring counties, where many of our referrals now originate. As our reputation grows, we’ve been able to attract promising clinical trials previously unavailable in our area. And the more we discuss, evaluate and treat melanoma, the smarter we all get. We’re all starting to feel like “experts,” which helps raise the profile of medical care in Sonoma County. In the end, the commitment to the melanoma program is a burden worth bearing.

E-mail: pbrett@pacbell.net

References

http://clinicaltrials.gov/ct2/show/NCT00463892

Dr. Brett, a medical oncologist with Redwood Regional Medical Group, directs the North Bay Melanoma Program.

Back to Sonoma Medicine Summer 2008 Table of Contents

Sonoma Medicine, Volume 59, Number 3 (Summer 2008).

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