Who should have skin checks for melanoma?

This question is easily answered if you are a dermatologist who earns a fee for every skin check you do. EVERYONE! But in a cash-limited, public funded health care system, we need a certain level of evidence before we roll out a universal screening campaign of any kind. And to date the evidence of benefit for POPULATION skin screening is lacking. However, most experts agree that there is a balance in favour of TARGETTED screening. Good data, the bigger the better, is always welcome as we try to make well informed, safe and just decisions about allocating resources in the face of insatiable demand and limited resources.

A large new meta-analysis (*) in this month’s British Journal of Dermatology ‘Risk factors for subsequent primary melanoma in patients with previous melanoma: a systematic review and meta-analysis‘ by Juliet Smith and colleagues from Sydney, Australia provides such welcome data. The full article is open access so can be freely read and distributed subject to proper citation. It’s findings are hardly Earth-shattering, but such a well-founded study adds a lot of power to those who, like myself, advocate for regular life-long screening for people previously diagnosed with a melanoma and also those without a melanoma diagnosis but who have high risk factors.

What! I hear some readers say. You don’t already have life long screening for those who are known to be at the highest risk of a melanoma? Well, no, not in the British NHS we don’t. Because everything in our government-controlled, cash-limited health system is done according to top-down guidelines from the government agency NICE. They currently say that people with thin melanomas (under 1mm Breslow thickness) should get follow up for one year, thicker melanomas for 5 years (if clinically disease free). Then they are mostly discharged.

Anyway, the BJD paper offers good evidence that if you have had one melanoma, you are at increased risk of a second or subsequent melanoma if you have over 100 moles, even just one atypical mole, red or blond hair, family history of melanoma, a CDK2NA mutation (you would only know this if you had been tested, which isn’t routinely done) older age, evidence of sun damage, inadequate sun protection, first melanoma on head or neck, lentigo maligna subtype, and if you are male. All of these risk factors act independently so the risk adds up. The authors say that studies have shown the increased risk can range from 10 fold to 25 fold. That’s a lot. I have seen an Italian study where people with a melanoma had an 8% risk of getting another new one in the next 5 years.

It was my opinion for some years before I retired from clinical practice last year (since retiring I am free to speak my mind fearlessly) that anyone who had been diagnosed with a melanoma and also had over 50 moles should certainly get education, total body photography and life long surveillance, but the underfunded and badly organised British National Health Service did not provide for this. The publication of this very good piece of research supports my opinion, but it will most likely be ignored unless a sufficient amount of public opinion builds up. In the meantime, I continue to encourage GPs and other interested health care professionals to see a business opportunity to upskill in skin lesion diagnostics and offer affordable private skin checks.

Here is a case in point. A very thin melanoma picked up on a routine skin check.

It’s small, but it’s a funny shape, different to the other moles (ugly duckling) and IT WASNT THERE AT THE LAST SKIN CHECK.

The dermoscopy is essentially featureless, there is no overall pattern. You could argue for some irregular clods or faint angular lines, but I can’t see any really positive melanoma clues. HOWEVER we don’t just rely on dermoscopy, but on integrated lesion diagnostics, which takes into account that the patient is older, white, sun damaged, previously had a melanoma and this is a new lesion on sun exposed skin, and to the naked eye it looks a funny shape. Add to that, dermoscopy does not positively confirm one of the 5 common benign skin lesion types (naevus, keratosis, haemangioma. dermatofibroma, sebaceous gland hyperplasia) so by default we have to rule out melanoma.

This was an in situ melanoma, the earliest grade and 100% curable. We cannot say for certain that if this super-thin melanoma had not been picked up by a skin check that it would have gone on to metastasise, but we know that this is possible. Managing one patient with stage 4 metastatic melanoma can consume £500,000 or more of immunotherapy and other costly modern oncology drugs, and the patient may still die. When we have solid evidence that patients with a primary melanoma diagnosis have a significant increased risk of getting another new melanoma, and they get life long follow up in most countries, but not in Britain, something doesn’t seem right. It seems as if the establishment is more willing to pay £billions for oncology at stage 4 than £millions for earlier detection at stage 0 or 1.

Of further comment, it is recognised by experts in skin screening like Scott Menzies and Harald Kittler, that very early melanomas are often featureless, and as such will ONLY be picked up by digital screening, whereby there are photos of the skin that can be used for comparison. They develop features as they get thicker-and deadlier.

It is an interesting thing that most Britons don’t trust their politicians, but want them to be in charge of health policy and delivery.

(*) A meta-analysis, for those not in the know, is a ‘study of studies‘ produced by a team of workers, who may be statisticians rather than medically qualified, who search all known databases, pull out all the relevant research of sufficient quality, and use statistical methods to ‘average out;’ the findings. This has the effect of producing a piece of research which is much bigger, and therefore more valid, than the individual trials that went into it. A good meta-analysis that is good enough to get into a prestigious peer-reviewed journal will have been rigorously tested and is the nearest think to absolutely positive proof we are going to get.