What does quality care for people with melanoma look like in New Zealand?

The Quality Statements to Guide Melanoma Diagnosis and Treatment in New Zealand were launched by MelNet at the online 2022 New Zealand Melanoma Summit on 12–13 February (https://melanomasummit.com).

All health professionals in New Zealand should be familiar with its contents and aim to follow current best practice and reduce inequities. The statements are based on evidence or, when evidence is lacking, on expert consensus. Each of the 23 statements is backed up by the rationale and includes good practice points supported by references.

If you are in primary care, please download the statements document from the MelNet website (tinyurl.com/GuideMelanoma) and keep a copy readily available for reference, although note that it will be updated twice yearly to reflect the latest evidence.

1.1: Prevention and early detection of melanoma

As melanoma in New Zealand is predominantly due to ultraviolet radiation, we need to raise awareness of the damage done by solar exposure and tanning devices in all skin types and ethnicities. Exposure to UV radiation should be limited and sunburn avoided.

The danger of UV radiation is reported as the UV Index. If it is over 3 (September to April), people should be advised to limit time outdoors, choose shade, protect their eyes with wrap-around sunglasses, and protect their skin with long sleeves, a collar and a wide-brimmed hat. Broad-spectrum and water-resistant sunscreen with a sun protection factor of at least 50 should be reapplied every two hours while outdoors during the day.

Although dark skin is less prone to melanoma, Māori and other ethnic minorities are likely to be diagnosed with thicker melanoma with poorer survival than non-Māori. Early detection reduces the chance of a poor outcome; long-term survival depends on the thickness of the melanoma at the time of excision. Many forms of melanoma can be identified when in situ (non-invasive).

Encourage your adult patients – especially those over age 50 – to examine their own skin (with the help of a partner) and to seek advice from a health professional about any suspicious lesion. Explain they should expect a full-body skin check using dermatoscopy.

1.2: Training of primary healthcare professionals

Most melanomas are spotted or confirmed in primary care; thus, it is essential that primary care professionals have the competence to diagnose them and know what to do. In 2022, patients with melanoma can expect their examination to include dermatoscopy. The fundamental skills should be included as part of the General Practice Education Programme.

If you care for patients with melanoma or you undertake skin checks, the good practice points for quality statement 1.2 expect you to:

• know how to assess the patient’s risk of melanoma
• be alert for lesions with malignant features (and become familiar with the appearance of benign keratoses and melanocytic naevi – refer back to “Dermatology”, New Zealand Doctor, 12 May and 1 September 2021)
• be trained in the basic use of a dermatoscope and to refresh your knowledge
• arrange a full-body skin check for a patient at risk or presenting with a lesion of concern.

1.3: People at increased risk of melanoma

Anyone can get melanoma – most adults are at average risk and children and very dark-skinned individuals are at lower risk. It’s useful to identify people at higher risk to encourage them to present early with concerns about a skin lesion and schedule skin checks at appropriate intervals.

The usual reasons for high risk are increased age, fair skin and sun damage. Individuals may also have had a previous melanoma, familial melanoma (rare), many melanocytic naevi, giant congenital naevus, previous keratinocyte cancer or immunosuppression (especially organ transplant recipients).

A validated model for individuals to assess their risk of melanoma is provided by the Melanoma Institute Australia (melanomarisk.org.au). New Zealanders should enter Tasmania as the “Region of Australia most lived in”

People who have had melanoma, two or more first-degree relatives who had melanoma before they were 40, or many moles (especially if these are atypical) should be under the long-term care of a healthcare professional who is competent in skin surveillance using dermatoscopy and digital dermatoscopy. Consider baseline total-body photography and high-quality sequential digital dermatoscopy imaging annually for these patients.

2.1: Timely access to services

Skin lesions that are highly suspicious of melanoma are irregular in structure and colour and are not seborrhoeic keratoses; change may have been observed. Advocate for your patient when referring to secondary care with confirmed invasive melanoma or a lesion suspicious of invasive melanoma. They will likely be anxious.

Wherever the patient resides, whatever their ethnicity, and whether they are receiving publicly funded or private healthcare, the quality statements expect a referral to be followed by:

• completion of wide local excision for confirmed melanoma within 62 days, and within 31 days of the decision to treat (eg, receipt of biopsy report of melanoma)
• first specialist assessment of a high-suspicion invasive or metastatic melanoma within 14 days
• diagnostic excision for a lesion suspicious of melanoma within 14 days of specialist assessment or image-based triage.

In many parts of New Zealand, referrals to the local DHB and responses are electronic, sometimes in the form of teledermatology. High-quality macroscopic and dermatoscopic images of the lesion of concern are encouraged or required.

3.1: Patient access to trained healthcare professionals

All patients should have access to a melanoma nurse coordinator and a multidisciplinary team, including a healthcare professional trained in:

• early detection and diagnosis of melanoma, including the use of dermatoscopy
• triage and referral of suspicious or tricky lesions
• surgical management.

In primary care, patients should have access to a designated, trained GP who can assess the patient history, examine the whole skin surface, recognise benign and suspicious lesions, and who uses dermatoscopy.

Short-term monitoring of low-suspicion flat lesions is over three months and with the aid of dermatoscopic images. Suspicious thickened lesions should be referred or excised.

3.2: Excision of melanocytic lesions

The preferred biopsy technique for excision of melanocytic lesions suspected of being melanoma is a narrow complete excision biopsy, with 2mm margins, that encompasses the entire lesion and is of sufficient depth to avoid transection at the base. All tissue specimens are sent for formalin-fixed paraffin-embedded histopathology.

Diagnostic excision can be undertaken in primary care providing the health professional has the training and skills to do so.

5.1: Re-excision of histologically confirmed melanomas

Histologically confirmed melanomas are re-excised, with additional clinical margins determined by Breslow thickness (see table). Lesions with American Joint Committee on Cancer (AJCC) histological staging of T1b (Breslow thickness 0.8mm with ulceration) or higher are referred to an appropriately trained and experienced surgical specialist. The designation of such a specialist varies by region.

Re-excision of melanoma in situ to 5–10mm clinical margins, and re-excision of AJCC T1a (Breslow thickness 0.8mm without ulceration) cases of melanoma to 10mm clinical margins, can be performed as a local-anaesthetic procedure by either an appropriately trained and experienced primary healthcare doctor or a melanoma specialist.

5.2: Desmoplastic/neurotropic melanoma

5.6: Patients with loco-regionally recurrent, locally advanced and stage IV melanoma

These forms of melanoma should be discussed at a multidisciplinary meeting, whatever tumour stage is reported, on referral to secondary care.

6.1: Clinical follow-up and surveillance

6.2: Patient self-examination

7.1: Supportive care

GPs may be asked, or expected, to follow up patients with melanoma to detect recurrence early (ask about symptoms and examine the excision scar site, surrounding skin and local lymph nodes), to detect new primary melanoma (perform a full-body skin check with dermatoscopy), to teach them how to self-examine their skin, and to provide psychosocial support and information about their disease and its treatment (refer them on if needed).

Patients with additional risks, such as multiple melanomas, familial melanoma, numerous naevi, older age, very fair skin or history of keratinocyte cancers, should be offered lifelong annual or biennial skin checks.

Follow-up protocols for assessing disease recurrence or metastatic spread are as follows:

• stage 0 melanoma in situ – biennial dermatoscopic skin check for at least 10 years
• stage IA melanoma – assessed annually for 10 years
• stage IB and IIA melanoma – assessed six-monthly for two years, then annually until the 10th anniversary
• stage IB and above melanoma with no sentinel node biopsy – six-monthly ultrasound of draining node fields for two years
• stage IIB–C and IIIA–D melanoma – assessed four-monthly for two years, six-monthly in the third year and annually thereafter until the 10th anniversary
• stage IV melanoma – as for stage III, with additional visits as per clinical requirements.

Amanda Oakley, CNZM, is a specialist dermatologist at Waikato Hospital, an adjunct associate professor at Waikato Clinical Campus, and founder of DermNetNZ.org