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Royal College of Physicians London 19th October 2011
This meeting arranged by the melanoma study group was attended by some 250 dermatologists, plastic surgeons, oncologists, specialist nurses and others. I am on the Melanoma Study Group (MSG) (1) committee for which I volunteered on behalf of the PCDS because of my belief that hospital and community doctors need to communicate more. This edited highlight omits much of the purely secondary care material.
Julia Verne kicked off with a definitive overview of the statistics. These can be accessed in detail on the excellent South West Skin Cancer Observatory site (2). Skin cancer numbers and fatalities continue to rise, future projections are alarming. A particular challenge is the growing number of elderly skin cancer patients with co-morbidities. She offered us several ‘sound bites’ which would be useful in the struggle to wrestle reasonable resources from the commissioners in a cash strapped future. Skin cancer, Dr Verne told us, did not feature on the commissioners’ radar as deaths were relatively few compared to breast and bowel cancer. But they are rising and as her figures show already over double cervical cancer. Melanoma is now the 6th commonest cancer diagnosis in females and up by over 700% in older men over the last 40 years and is rising across all age groups, with 2 young people in the 15-34 age group diagnosed every day and 28% of all cases in the under 50s.
She also showed good evidence relating high sun bed use in Northern English cities to higher melanoma rates. The cost of skin cancer is estimated at £105 million per annum. It can only rise.
Dr Jonathan Bowling delivered a tour de force on earlier diagnosis. He argued that the ABCD rule for melanomas while useful for picking up advanced melanomas was hopeless at ruling out benign lesions. He compared reliance on Asymmetry, Border, Colour and Diameter alone with judging the portraits of past presidents hanging in the Royal College by their frames. It was the brush strokes we needed to study, and dermoscopy gave us the tool to do this. Citing the now vast published international evidence for the efficacy of dermoscopy, he advised that trained GPs could use the technique to reduce ‘the burden of benign referrals’ and hospital specialists to reduce avoidable excisions. There is 100 times more published evidence for dermoscopy than the alternative technique of SIAscopy, as shown by a PubMed search.
Dr Bowling stressed that dermoscopy was not easy; he was still learning. If we must adopt teledermoscopy services they should be locally integrated and part of an accountable, audited, learning network, not outsourced to third parties, possibly based overseas. He stressed that skin tumours do not just appear, but grow. We should be actively hunting for smaller and earlier skin cancers to achieve better outcomes and reduce costs and morbidity. He concluded by saying that there was ‘..a rising incidence of skin cancer, too many referrals and too few experts.’, a situation crying out for better use of existing resources. Research had shown that just one day of good dermoscopy training could increase GPs’ diagnostic skills significantly.
Dr Fiona Walter told us about the MoleMate (TM) (SIAscopy) trial. This diagnostic technology produces and analyses images based on blood, keratin and melanin. MoleMate was less specific than dermoscopy (59% versus 81%) but easier to use. It performed no better than ‘best practice’ and increased referrals. Dr Walter told us that 1-2% of all GP consultations concerned pigmented lesions but that GPs were only 66% accurate in assessing skin cancers, so there was a ‘..need to translate the 7 point check list (i.e. ‘best practice’-SH) into regular general practice’. No trial of dermoscopy versus SIAscopy was cited.
Professor John Thompson from Australia spoke about the new staging rules for melanoma. Basically, Breslow thickness is still key, Clarke levels add nothing. Ulceration is a bad prognostic factor but high numbers of mitoses per square millimetre is worse. He said that sentinel node biopsy was essential for staging which would become mandatory with the advent of new more effective adjuvant therapies.
We heard some complex trial statistics from Professor Keith Wheatley about narrower versus wider excision margins. The jury, it seems, is still out but there is no good evidence that 1cm margins are safer than 2cm or more. It has proved difficult to recruit the large numbers of patients required for a really good randomised trial, in view of the morbidity and cosmesis of 2cm wide excisions for which there is not great evidence. Quote ‘if there is an effect, it’s very small.’ As usual on these occasions, we were told that a much bigger and better trial is needed.
Clair McGarr, MacMillan Clinical Nurse Specialist (CNS) from Birmingham explored the role of the clinical nurse specialist, on which she had done a Master’s Dissertation. The benefits were hard to pin down but involved reduced patient anxiety, enhanced quality of life and education on skin self examination. There was evidence that patients need information and support, but the role of the CNS remains unclear. As a member of the multiprofessional team, the CNS could offer co-ordination, expertise, communication and a holistic approach. CNSs develop their own roles depending on case mix and pathways, plus their own skills and service priorities. She illustrated this with several case histories in which the presence of a CNS seemed to have helped the patient on their ‘journey’, during which they might see half a dozen specialists but have the CNS along as a helper and interpreter all along. The CNS was perceived as having more time to listen to patient and relative’s concerns than the busy doctors.
Joanne Bird, specialist research nurse from Sheffield, talked about research and patient recruitment to trials. Patients go into trials as it may help them or others, some were very keen. Barriers to participation were seen as the randomisation process, lack of previous trial experience, age over 70 and men were more likely than women to volunteer. Participants were put off by additional hospital visits, side effects, travel and parking. Trials, we were told, should be seen as a core part of every aspect of cancer care not an optional extra. And there should be collaboration between units.
Dr Danuta Orlowska, clinical psychologist at St John’s discussed the role of the clinical psychologist attached to the skin cancer MDT. She quoted James Paget who said the true physician should enquire what person has the disease, not just what disease a person has.
Up to 70% of patients have ‘distress’ with a cancer diagnosis. That distress can affect family members, who may then be less help to the cancer patient, if they have any family anyway. Distress can be present at all stages of the patient journey; we need to take it into account. Employing psychologists can be cost effective, although as one speaker said, it was unlikely to be easy to fund one in these times.
Dr Orlowska was available flexibly (including evenings) by telephone and email. Offering simple, immediate and non stigmatising referral in a 5-10 min initial contact in the clinic to sow the seeds of what is available. She reminded us that ‘no 2 patients are alike in disease...’ and that objective severity may not match degree of patient distress but depend on past experience, concurrent life events, knowledge and expectations. She helped people discover what networks, coping strategies and resources were available. She has a special interest in cognitive therapy.
Co-facilitating discussion group for patients and carers helps people to reflect and re-evaluate their lives in the light of their new status, giving examples of helping a man adapting to a terminal diagnosis, helping support his wife in a change of career for her greater financial security in the event of his death. Over 95% of users liked the service. She runs a group in which several people are passionate about spreading the word about melanoma; others want to be involved in GP training.
I had to leave for a prior commitment before the final afternoon session on new developments in the oncological management of metastatic melanoma, see my earlier MSG reports.
This was the first Focus on Melanoma event and although most attendees were from secondary care, there was strong support for better GP education and training in particular dermoscopy. I hope more GPs will come to future MSG meetings.
Stephen Hayes
(1) http://www.melanomastudygroup.co.uk/
(2) http://www.swpho.nhs.uk/skincancerhub/ |
