Melanoma diagnosis article

1. One thing we neverwantto missisthe conditionwhere earlydiagnosisisassociatedwithbetterpatient
outcomes. The classic in dermatology is malignant melanoma, especially rapidly growing lesions.
A recentVictorianstudyinthe AustralasianJournal of Dermatology(Volume 57, Issue 2 May 2016 Pages
97–101) lookedatthe clinical pathwaysandmissedopportunitiesforthe diagnosisof nodularmelanoma
versus superficial spreading melanoma.
Nodular melanomasare a dangerous form of melanoma as they are oftenrapid growing, and present a
diagnosticconundrumwhere theyare more likelytobe thickerat the time of diagnosisthanothertypes
of melanoma. To illustrate, nodular melanoma (NM) accounts for 14% of all melanomas diagnosedin
Victoria and contributes 43% of melanoma-related deaths.
NM grows more rapidly than superficial spreading melanoma (SSM) (0.49 mm/month of thickness vs
0.13 mm/month). NM accounts for nearly 50% of all melanomas thicker than 2 mm.
With NM diagnostic delay (which essentially means delay in removing) is more likelyto endanger the
patient due to their rapid vertical growth phase resulting in thicker lesions.
This study looked at where delay in diagnosis occurred in both NM and SSM.
The study looked at 60 patients with NMand 60 with invasive SSM. There was no significant difference
between the two groups with regard to age, sex, skin phototype, tumour site or maximum lesion
diameter.There were differences,however,intermsof histopathological features,withNMbeingthicker
thanSSM(P < 0.01),more likelytobe amelanotic(P < 0.01),havingahighmitoticrate (P < 0.01),andbeing
ulcerated (P < 0.01).
A single interviewer conducted phone interviews for all patients using a standardised questionnaire to
gatherinformationonthe pathwaytomelanomadiagnosis,includingthenumberof doctorsconsultations
prior to biopsy.Diagnosticdelaydatawere dividedasper previousstudiesinto‘overall delay’,‘patient's
delay’and‘doctor'sdelay’.‘Overall delay’todiagnosiswasdefinedasthe time betweenwhenthepatient
firstnoticedthe lesionandwhenthe lesionwasbiopsied.‘Patient'sdelay’wasdefinedasthe time from
when the patient first noticed the lesion to when they sought medical attention by a doctor. ‘Doctor's
delay’ was defined as the time from when the doctor first saw the lesion to the time of biopsy.

2. They found the following;
 Doctors were more likely to reassure patients with NMthat the lesions were benign compared
with patients with SSM(47 vs 27%).
 Patient's with NMwere more likelyto have multiple doctor consultations prior to a biopsy. Of
them,26 (43%) NM were biopsiedattheirfirstvisit(or bookedinfor a plannedbiopsyata later
date or referredtoanotherdoctor for the purpose of biopsy).Incontrast,42 (70%) of SSMwere
biopsied at first visit (or booked in for a planned biopsy at a later date or referred to another
doctorfor the purpose of biopsy).Althoughone-quarterof all lesionsincludingbothSSMandNM
wouldgoontobe biopsiedonthe secondreview,allremainingSSMweresubsequentlydiagnosed
on a thirdreview. In comparison, 33% of NM required at least three and up to six reviews until
they were ultimately diagnosed.
 The medianoverall delaytodiagnosis was 5.5 months (0.9–30 months) for SSMand 6.5 months
(2.3–2.7 months) for NM. The median patient'sdelay to diagnosiswas 2 months (0–12 months)
for SSM and 3 months(1–12.5 months) forNM. The mediandoctor's delaywas 0 months (0–7.7
months) for SSMand 0.6 months (0–5.3 months) for NM.
Campaigns advocating the early detection of melanomas are based on the assumption that greater
tumourthicknessesare associatedwithlongerdelaysindiagnosis.Moststudies,however,havefoundno
overall correlation between delay to diagnosis and Breslow thickness (some have however).
Ultimately,the delayindiagnosisthatwe cando somethingaboutiswhatwe do once a patientpresents
to usconcernedre alesion.Here the overalldelaytodiagnosiswascomparable forbothNMandSSMand
was consistentwithfindingsinmostotherstudies.They showedthatduringthisdelay,patientswithNM
presented more frequently to doctors, providing more opportunities for an earlier diagnosis over the
same time frame.Intermsof the impactof thison prognosis,the consequencesassociatedwithamissed
opportunitytodiagnose anNM are greaterthan those for an SSMdue to the more rapidvertical growth
of the former.Indeed, thereisreasontobelieve thatrapidgrowthmaybe the keydriverof thicktumours
rather than time delay to diagnosis as most studieshave foundno overall correlation between delay to
diagnosis and Breslow thickness.
Doctors' behaviour differed greatly between the two subtypes, with NM patients more likely to be
reassuredbytheirphysicianthatthe lesionwas benign.Furthermore,NMwere lesslikelytobe biopsied
and less likely to be referred for an immediate biopsy on the first presentation.
The authors suspectthat the 22% of NM that requiredmore than three presentationsuntil biopsywere
deemed benign early on and largelydisregarded at further follow ups until the patient's insistence or a
markedchange in the morphologyof the lesionpromptedadelayedbiopsy.One NMwas diagnosedasa
blood blister and another underwent serial cryotherapythree timesover 3 months before a biopsy was
finally undertaken.

3. PatientswithNMwere oftenrepeatedlyreassuredtheirlesionswerebenign,toldthat‘observation’was
appropriate or askedto ‘watch’or ‘monitor’the lesionthemselvesbefore patient'sinsistence ora gross
morphological change promptedabiopsy.A message thatobservationisnota satisfactorymanagement
optionfor a raisedlesionforwhichthe differential diagnosisincludesskincancerneedsto be promoted
more effectively.
This isa pointof much interestto me. You oftensee shortterm monitoringadvocated,and I thinkit has
a place butitcarriesa riskas exemplifiedhere.Beforeentering someoneintomonitoringaskyourself will
this problem be any less at review? Will I be able to make a diagnosis then more readily than now and
could delay in diagnosis be dangerous?
The authorsfeel thattheABCD(asymmetry,border,colour,diameter) rule fordiagnosingmelanomaleads
doctorsto underdiagnose nodularmelanoma asbenignoranon-melanomaskincancer,withreassurance
given to the patient, further increasing missed opportunities for early diagnosis. They advocate adding
EFG for elevated, firm and growing. Lin and colleagues showed that only 41% of NM are listed on the
pathology request slip as being possible melanomas and appear to be poorly recognised by physicians
compared with SSM. By addressing the earlier diagnosis of NM with renewed focus we may make the
biggestimpactonthe overall mortalityof melanoma.Greaterawarenessandindex of suspicionforNMis
needed, particularly in the setting of a lesion for which a patient is repeatedly re-presenting and
communicating concern.