Current Status of Malignant Melanoma

Malignant melanomas continue to be a frequent problem presenting at our clinic. Just as for national trends, the number of melanomas seen has dramatically increased in the 23 years I have been practicing dermatology. The lifetime risk is now 1 in 58 Americans, compared to 1 in 1500 about 60 years ago. I thought it would be useful for our patients to know current important facts about melanomas.

Ultraviolet light is a proven cause of melanomas. The World Health Organization has listed ultraviolet light as a carcinogen just like nicotine and arsenic. The risk is particularly severe for young women. On the other hand, 18% of women and 6% of men still use tanning beds, and for women 18 to 24 years old, 33% still tan.

Sunscreen prevents melanomas. In the past there was some quibbling over how well sunscreen protected against melanomas, but it was thought that was due to my generation using sunscreens as “sun tan lotion”, allowing them to spend more time in the sun. These sunscreens prevented sunburns but did not block UVA. This same wavelength is in tanning beds.

Now there is a definitive study that proves sunscreen prevents melanomas; the study looked at the incidence of melanomas in Queensland, Australia (with the highest melanoma rate in the world) between people who used sunscreen daily and those who used it occasionally over a 5 year period. Ten years later, the daily sunscreen users had 50% fewer melanomas.

Once you have a melanoma your treatment depends on the stage.  Early melanomas have a high cure rate with surgical excision. Late stage melanomas, which spread to lymph nodes or other body sites, have a very low cure rate. For patients who do not have enlarged lymph nodes on exam there has been an ongoing discussion of whether they should undergo a selective lymph node biopsy of a “sentinel node”, the node that is most likely to have microscopic tumor spread. Patients who had melanoma in this node would then have all their lymph nodes in that area removed. A recent review, however, showed no survival benefit after the procedure for any stage of melanoma. They did show that the procedure was useful for determining prognosis in patients with intermediate depth melanomas. I think that there will be more discussion over time, but for now I will continue to recommend the procedure for some patients. Other tests like chest X-rays, blood work and CT scans have not been shown to be of value in patients without signs or symptoms of the tumor having spread. We are modifying our protocol accordingly.

What about treatments for late stage melanomas? These patients have a poor prognosis with a lifespan measured in months. Bristol -Meyers is releasing ipilimumab for this group. For 15-20% of patients treated, their survival extended beyond 2 years, and for others it offered at least an additional 4 months. This is significant, because no other drug can match this success.

Bottom line– use sun screen, protect your skin, avoid tanning booths and seek medical help when you suspect any skin changes!