Optimizing Outcomes in Melanoma
Melanoma is a malignant tumor derived from melanocytes (the cells that give skin its color) and is the deadliest form of skin cancer risk factors for melanoma include family history, sex, age, skin pigmentation, sunburn susceptibility, tanning ability, nevus (moles) count and freckling and psychological health. In addition, socioeconomic features, occupation, access to health, and preventive measures, latitude have been demonstrated to impact the morbidity of melanoma (Helgadottir et al, 2018). Shared success and progress of the pigment cell research community in the understanding of cellular and immunological homeostasis of pigment cells but also clinical challenges and hurdles in the treatment of melanoma and dermatological disorders continue to drive further research activities. Investigators in the pigment cell research community have diverse but complementary backgrounds. The cross-disciplinary nature of the field is unique, unified around the passion of understanding normal pigmentation and benign or malignant pigmentary diseases (Filipp et al, 2018).
Treatment landscape for advanced-stage unrespectable or metastatic melanoma has shifted dramatically over a short period of time. Before 2011, metastatic melanoma was considered a devastating disease and was almost uniformly fatal within 18 months of diagnosis. Standard of care treatment during this time in fit patients’ immunotherapy the median overall survival of patients. The development of multimodality strategies including radiation, surgery and systemic therapy is a feature of most current research.
The goals of therapy in the palliative delay in disease progression for a small minority, are for a better quality of life and durable clinical responses for a large majority with effective disease control and palliative care for this majority. There is a natural history of metastatic melanoma including differences in the pace of disease progression and sites of metastatic melanoma are first detected.
Such patients, who commonly have the brain and visceral organ involvement, are largely incapable of achieving long-lasting remission from either molecularly targeted treatment or novel immunotherapies. The immunotherapies of choice used to be interferon and interleukin cytokines. This was especially true of advanced-stage melanomas. The problem with these treatments has been substantial toxicity with only modest clinical benefit. Despite progress in the clinical management of advanced-stage melanoma, many patients eventually develop resistance to treatment. there is, unfortunately, an absence of clinical trials linking two or more new treatments to judge their effectiveness.
Two goals of therapy that have emerged in the management of the patient with metastatic melanoma: sort term palliation and induction of remission. Over a short period of time, the number of effective treatment options for the patient with advanced-stage melanoma has increased considerably now multiple treatment options available. Importantly, in this rapidly evolving therapeutic landscape, patients should continue to be encouraged to consider participation in clinical trials where possible during therapy (Luke, 2017).
Advanced care providers and nurses are fundamental players in the assessment and management of immunotherapy-related dermatologic adverse events. Dermatologic conditions in an oncology setting have been reported to cause a negative impact on quality of life. Importantly the trajectory of these untoward events may ultimately lead to inconsistent dosing and discontinuing of therapy which may affect clinical outcomes. The study of immunotherapy related dermatologic adverse events underscores the field of supportive oncology in addressing untoward events, quality of life, and psychosocial impact.
Advance care providers and nurses must be skilled in both the dermatologic assessment and grading in patients in novel therapies. Both clinical visits and telephone triage are essential platforms to comprehensively assess a patient’s skin, mucosa, and associated symptoms. It is important to utilize standardized grading tools when communicating with the interdisciplinary team. Both advance care nurses and providers require sound critical judgment for expert assessment which supports a framework for patient education and advocacy.
In the management of adverse reactions, advance care providers and nurses must draw on their expert knowledge of disease process, pharmacologic mechanism of action, and the nursing process. Oncologists, dermatologists, pharmacists, along with other services are paramount in the structure of a multidisciplinary team. Immunotherapies continue to provide a platform for improvements in clinical outcomes through timely referrals for treatment aid in continuing diligent preventing, managing and monitoring adverse effects (Ciccolini et al, 2017).
Early detection and appropriate clinical management of melanoma ensure that most people with the disease have a good prognosis, with about 90% of patients still alive five years after diagnosis. People with melanoma often experience fear that the disease could spread. This study showed that patients who were part of the study valued their inclusion and individual access to psychological support.
Participants expressed the need for ongoing support when the study was completed. The timing of the intervention in relation to high-risk clinic appointments was found to be feasible and was very high study retention. Based on the experiences of this study minor modifications were made to the protocol for the larger trial. The study suggested that tailored psycho-educational support for people at risk of developing another melanoma was of great benefit. The study found that the implementation of a phone based psycho-educational program scheduled around high-risk clinic appointments was highly feasible and acceptable to patients.
These findings have encouraged this group of researchers to carry out a larger controlled trial to evaluate the efficacy and cost-effectiveness of this intervention, comprising the booklet they devised. The findings will further inform the implementation of support in the clinical care of patients with melanoma (Dieng et al, 2017).
The number of cancer survivors is rising as a result of the increasing incidence of cancer and advances in the treatment and early detection. On completion of curative cancer treatment, the patient usually receives follow-up in secondary care services setting by medical specialists. Due to the rising number of cancer survivors, the limited capacity of secondary care facilities to provide follow-up care and the increasing costs, general practitioners are increasingly involved in the follow-up care.
Recurrences regularly occur between scheduled follow-up visits and are often initially presented as symptoms to the general practitioners. In addition, recurrences that occur many years after the initial treatment are probably also first present to the general practitioners. It is important that general practitioners are able to detect recurrence and refer patients in time to secondary care for treatment.
Topics of recurrence risk management available are potentially of relevance to general practitioners for melanoma: The main focus of guidelines. Guidelines agree on both routine and non-routine test but except and evidence-based recommendations showed discrepancies in preferred time intervals. Awareness of cancer recurrence is also often mentioned in guidelines.
However, signs and symptoms that may indicate recurrence are reported by few guidelines. Signs of recurrence also received little attention in scientific literature this study found, especially in the primary care settings. Recurrences are also detected by the patient themselves. This study showed there is limited applicability of cancer guidelines for the general practitioner, which was also highlighted by an earlier study focusing on breast cancer, colorectal cancer, and prostate cancer guidelines. These have little to do with melanoma guidelines (Spronk et al, 2017).
The incidence of second melanoma is increasing in melanoma survivors with the cumulative risk ranging from 2% to 5% at periods from five to 20 years after initial diagnosis. Although an optional surveillance strategy after treatment of primary cutaneous melanoma has not been determined through available guidelines differ slightly between specialty organizing bodies and between countries.
Because patient adherence is central to the effectiveness of any clinical intervention clinicians providing care to melanoma patients should be familiar with the complexities of patient adherence as it relates to melanoma surveillance. While much of this falls in the hands of doctors mainly dermatologists (doctors who treat skin problems), it may be of greater effectiveness if a multidisciplinary fashion was utilized. The number of patients in need of melanoma surveillance has grown as a result of its increasing incidence partly due to earlier detection and improved prognosis.
This study found surveillance adherence rates up to 76% at five years after diagnosis apart from variations in follow-up schedule used, potential causes of such differences in reported adherence rates might be in part due to exclusion of melanomas thicker than 1.5mm. previous studies on melanoma surveillance adherence have reported conflicting results with one study showing positive correlation between thickness and surveillance adherence while others showed either no correlation or inverse association. And because of the Affordable Care Act policy incentives to relegate financial barriers to melanoma surveillance make adherence even harder for the patient (Reserva et al, 2017).
Despite enormous international efforts, skin melanoma is still a major clinical challenge. Melanoma takes a top place among the most common cancer types and it has one of the most rapid increase incidences in many countries around the world. Until recent years, there have been limited options for effective systemic treatment of disseminated melanoma. However, lately, medicine has experienced a rapid advancement in the understanding of the biology and molecular background of the disease. This has led to new treatment targeted therapies adapted to distinct melanoma subtypes. Not only are these treatments more effective but they can be rationally prescribed to the patient standing to benefit.
Over the last decade, new therapies for melanoma have been developed with impressive effects on survival. Personalized medicine allows earlier intervention as well as the possibility to choose more efficient therapies tailored to the specific patient. For primary melanoma, surgery is still the gold standard with low risk of dissemination and good results for the long-term survival, mainly for melanomas (Helgadottir et al, 2018).
Ciccolini, K. et al. (2017). advanced care provider and nursing approach to assessment and management of immunotherapy-related dermatologic adverse agents. Journal of the Advanced Practioner in Oncology,8(2).
Dieng, M. et al. (2017). Psychoeducational intervention for people at high risk of developing another melanoma: A pilot randomized controlled study. BMJ Open Journals,7(10).
Filipp, F.V. et al. (2018). Frontiers in pigment cells and melanoma research. Pigment Cell & Melanoma Research.
Helgadottir, H. et al. (2018). Personalized medicine malignant melanoma: Towards patient-tailored treatment. Frontiers in Oncology,8(202).
Luke, J.J. et al. (2017). Targeted agents and immunotherapies: Optimizing outcomes in melanoma. Nature Reviews Clinical Oncology,14(8).
Reserva, J. et al. (2017). A retrospective analysis of surveillance adherence of patients after treatment of primary cutaneous melanoma. The Journal of Clinical and Aesthetic Dermatology,10(12)
Spronk, I. et al. (2017). Review of guidance on recurrence risk management for general practitioners in breast cancer, colorectal cancer, and melanoma guidelines. Family Practice, 34(2).