Structured melanoma surveillance may reduce biopsies, appears safe

4 minute read

Australian researchers hope total body photography and digital dermoscopy could soon be listed on the MBS.

Patients with a high risk of melanoma had fewer biopsies and no increased risk of malignant melanomas when managed with structured surveillance, according to a new Australian study.

The findings have prompted calls for more widespread adoption of the technique in primary care.

Australia has the world’s highest incidence rate for melanoma, affecting approximately one in 13 men and one in 21 women aged over 85. But research suggests that in high-risk populations the threshold for biopsy can be particularly low.

“Unnecessary surgery will mean comorbidity with scarring, infection, bleeding – a lot of post-surgical problems – and then, of course, it’s time and money for the patient,” said Professor Pascale Guitera, Director of Dermatology at the Melanoma Institute Australia and Director of the Sydney Melanoma Diagnostic Centre at Royal Prince Alfred Hospital.

Professor Guitera and colleagues recently published a paper in JAMA Dermatology that bolstered evidence for structured surveillance – which involves the use of total body photography (TBP), sequential digital dermoscopy (SSDI) and six-monthly skin examinations – over immediate excision.

The research followed about 600 patients considered to be high risk for developing melanoma, with the vast majority having a history of multiple primary melanomas.

Patients were recruited from four clinics in NSW – Royal Prince Alfred Hospital, Newcastle Skin Check, Melanoma Institute Australia and Westmead Hospital – between 2012 and 2018.

Participants were reviewed at one of the four clinics every six months by a clinician using a handheld dermoscopy device to compare the skin to baseline total body photography, with sequential digital dermoscopy of some lesions as required.

Results from the study showed a marked decrease in the rate of benign lesions biopsied, with just 2.4 benign melanocytic lesions biopsied for every melanoma.

This was better than the commonly accepted benign-to-malignant excision ratio of 5:1 for dermatology specialists and 20:1 for generalists, said the authors.

“The overall benign to malignant excision ratio was 0.8:1.0, and the benign melanocytic to melanoma excision ratio was 2.4:1.0, both of which were similar across centres,” Professor Guitera and colleagues wrote.

Study co-author Professor Anne Cust, a researcher at the Melanoma Institute of Australia and the University of Sydney, said surveillance helped determine whether to remove a lesion.

“This study used photography as a way to monitor whether the lesion was changing over time, because changes indicate that it might be a melanoma,” she told The Medical Republic.

“This was used as an additional threshold to decide whether to remove something from the skin, and in that way it was able to decrease the number of lesions which were cut out.”

The researchers also found favourable long-term early detection and excision results, which they said were “reassuring” in that it meant thick melanomas were unlikely to be missed.

According to the authors, this early detection helped build the case for efficiency, and recommended the method be implemented in more primary care clinics.

“These results, together with substantially increasing health system costs for melanoma treatment, suggest that cost-effectiveness may be higher than previously estimated,” the authors wrote.

Professor Guitera said that one of the questions she hoped to answer with the study was whether screening would help change the final outcome measures for patients.

“When we detect melanoma early, we reduce the number of biopsies – which is basically what we demonstrate – you can hope to have a better outcome for your patients,” she told TMR.

Professor Cust believes total body photography and sequential digital dermoscopy are useful in primary care.

“Total body photography is particularly useful for people that have a lot of moles on the body, because it can be really hard to keep a note of your own moles and to work out which ones might be changing,” she said.

Although she hoped the techniques will be included in the MBS over the coming years, Professor Cust encouraged GPs with an interest in skin cancers to start learning sooner rather than later.

“GPs should already be able to access total body photography and sequential digital dermoscopy, but they would need to seek some training on how they should optimally use the technology,” she said.

For this, Professor Cust recommended GPs approach their college or an independent training body.

JAMA 2021, March 17

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