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American Academy of Dermatology updates guidelines for primary cutaneous melanoma
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The American Academy of Dermatology released new guidelines on melanoma treatment.
The guidelines address areas such as melanoma in pregnancy and genetic testing for hereditary risk.
“Melanoma is the deadliest form of skin cancer, and we hope these guidelines will help dermatologists and other physicians enhance their delivery of life-saving treatment to patients,” Susan M. Swetter, MD, FAAD, professor of dermatology, director of the pigmented lesion and melanoma program, and physician leader of the cancer care program in cutaneous oncology at Stanford University Medical Center and Stanford Cancer Institute, said in a press release. “In order to provide the best possible resource for practitioners, we reviewed the latest scientific data and addressed certain topics that were not covered in the [academy’s] previous melanoma guidelines.”
Swetter — chair of the work group that developed the guidelines — spoke with HemOnc Today about why they are needed and the key points that have been added.
Question: How did you and your colleagues develop these guidelines?
A: Both the American Academy of Dermatology (AAD) and National Comprehensive Cancer Network review worldwide data to establish guidelines. Both organizations use a similar system to grade the evidence, the strongest of which comes from prospective randomized trials, meta-analyses of phase 2 or phase 3 trials, and systematic reviews of the published data. More limited-quality evidence includes consensus statements, opinion, case studies and disease-oriented evidence that may not contain patient outcomes data.
The scope of the updated AAD melanoma guidelines was developed by an interdisciplinary work group formed 2 years ago. The group included multiple melanoma specialists in cutaneous, surgical and medical oncology, as well as dermatopathology and Mohs surgery. We worked with AAD staff to review the existing worldwide data, rate the evidence and incorporate it into the guideline.
Q: Why are the guidelines needed?
A: Clinical practice guidelines evolve as new data are published worldwide, and evidence-based recommendations are critical to optimize patient care and outcomes. For instance, it is only in the past year that effective systemic adjuvant therapies for surgically resected stage III melanoma have been approved. Adjuvant anti-PD-1 monotherapy and combination BRAF/MEK inhibitors are now associated with improved DFS and OS. This makes accurate staging of patients with cutaneous melanoma even more important, and this involves pathological staging with sentinel lymph node biopsy for appropriate patients. As molecular techniques are further investigated, we anticipate ongoing advances in the ability to determine which patients benefit most from surgery or systemic therapy.
Q: What key points have been added or changed from pr ior guidelines?
A: Three new topics emerged from our work group. These included melanoma in pregnancy, genetic testing for hereditary melanoma and multigene testing for mixed tumor syndromes that may include melanoma as a cancer. We also addressed dermatologic toxicities associated with newer melanoma drugs and discussed data related to various molecular techniques, including gene expression profiling for both melanoma diagnosis and prognostication.
Q: What major points do you and your colleagues want to emphasize to clinicians?
A: The AAD guidelines are directed toward clinical dermatologists, dermatology surgeons and dermatopathologists who diagnose and treat primary cutaneous melanoma, whereas the NCCN melanoma guidelines are also directed to surgical, medical and radiation oncologists. Dermatologists in the United States should refer to both sets of guidelines for optimal, evidence-based melanoma management.
Q: Are there any updates on melanoma screening?
A: Screening for melanoma was beyond the purview of the clinical practice guideline. This area and challenging issues are being further investigated, including management of atypical Spitz tumors — generally in the pediatric and adolescent population — and optimal management for clinically atypical/histologically dysplastic nevi. Hopefully, we will have enough evidence-based data in the future to establish guidelines for these topics.
Q: Is there anything else that you would like to mention?
A: There has been an explosion of data for melanoma pathogenesis and treatment over the past decade. Although much of this has focused on novel therapies for advanced disease, we soon will see trials of immunotherapy and targeted agents for patients with cutaneous melanoma. The hope is that less-invasive procedures for melanoma will be performed in the future, replaced by better drugs and novel techniques that reduce morbidity and save lives. – by Jennifer Southall
Reference:
Work Group, et al. J Am Acad Dermatol. 2018;doi:10.1016/j.jaad.2018.08.055.
For more information:
Susan M. Swetter, MD, FAAD, can be reached at Stanford University Medical Center, Dermatology/Cutaneous Oncology, 900 Blake Wilbur Drive, W3045, Stanford, CA 94305; email: sswetter@stanford.edu.
Disclosure: Swetter reports no relevant financial disclosures.