Frequency of ‘regular’ skin checks by dermatologists for melanoma survivors

Abstract

Dermatological examinations, which occur with varying intervals (every 3–6 months) in the first 2–3 years after diagnosis and then annually, are the cornerstone of melanoma followup recommendations based on stage of disease. They are carried out with the intention of detecting local and distant metastatic melanoma; they are not for the express purpose of early detection of a second melanoma. The benefit of physician-provided surveillance has been demonstrated in the decreased Breslow thickness between the first and second melanoma in many studies. Other benefits of regular skin examinations with a dermatologist are patient reassurance, reduction of melanoma survivors’ anxiety, and education in skin self-examination and sun protection. Strong evidence to support specific follow-up intervals and duration of follow-up does not exist, which is partly due to lack of clarity about the risk of developing another melanoma. Now, Cust et al. provide a risk prediction model to tailor recommendations to the needs of the survivor with primary melanoma. Risk stratification based on this model may become the basis for specific follow-up recommendations that involve more frequent visits and different services for high-risk vs. low-risk melanoma survivors. For example, low-risk melanoma survivors may have dermatology visits every 6 months for the first 2 years, then annually for 5 years and cease having visits. Dermatological care would provide surveillance, teach skin self-examination, support survivors’ confidence in performing skin selfexamination with the assistance of a partner, and teach sun protection. This approach may empower the survivor to manage their own care after 5 years, reducing their anxiety and leading to more efficient use of healthcare resources. Melanoma survivors with stages 0–II may prefer patient-led surveillance to more frequent traditional physician-led surveillance. At the other extreme of the risk spectrum, the highrisk patient with multiple atypical naevi may have sequential dermoscopy at 3-month intervals for suspicious lesions, totalbody digital imaging of naevi, and, if proven cost-effective, artificial intelligence-based deep-learning algorithms to target lesions most concerning for malignancy. Physician surveillance may continue for 10 or more years, as the survivors’ 10-year risk of subsequent melanoma is 20% or higher. Watts et al. reported that specialized clinic care with intensive surveillance for high-risk melanoma survivors was more costeffective than standard care. Cost savings were attributed to earlier detection of melanoma resulting in less extensive treatment and a lower rate of excisional biopsies for suspicious lesions. When considering the cost-effectiveness of specialized care, the likelihood of making a difference in the quality of life, as well as the survival, of the patient is important. The unknown element in making recommendations for the frequency and duration of follow-up care is the difference in the quality of life of the melanoma survivor that can be attributed to reassurance, empowerment and education of at-risk family members. The global burden of melanoma was 282 000 cases in 2016 and 62 000 deaths. The interval and duration of follow-up, as well as the intensity of the follow-up based on the risk of the melanoma survivor, are important to 220 000 melanoma survivors a year.