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DR. TODD BURDETTE 

NH has 3rd highest incidence of melanoma


The incidence of melanoma has increased at an alarming rate, doubling in Caucasian women and growing by more than three-fold in Caucasian men during the past 30 years. In the United States, the projected number of newly diagnosed cases of melanoma for 2015 is 73,870, with 9,940 people expected to die from the disease.

According to the National Cancer Institute, the number of newly diagnosed cases of melanoma in New Hampshire in 2011 was 395 with 40 people having died from the disease. For a fair-skinned person the lifetime risk of developing melanoma in 2015 is 1 in 40 or 2.4 percent. Melanoma is more common in older individuals with the average age at the time of diagnosis being 62 years. It is, however, the third most common form of cancer in young people 15 to 39 years of age.

Surprisingly, New Hampshire has the third highest incidence of melanoma in the country at 31.4 cases per 100,000 people. Only Vermont at 32.3 and Delaware at 32.6 have higher rates of melanoma.

Who’s at risk

Melanoma remains a disease primarily associated with light skin coloration and a fair complexion in people of Northern European and Scandinavian ancestry (which accounts for 93.9 percent of New Hampshire’s population). Hispanics develop melanoma at a rate of approximately 18 percent compared to whites, while African Americans and Asians have an incidence of 5 percent.

Some of the factors that may predispose an individual to developing melanoma include light skin color, blond hair and light colored eyes, having multiple blistering sunburns before the age of 20, chronic sun exposure including indoor tanning, having a large number of skin moles, freckling in response to sun exposure, poor ability to tan, age over 50, a family history of melanoma, past history of sun-induced skin cancers such as basal cell carcinoma and squamous cell carcinoma, and having a suppressed immune system.

Although the incidence of melanoma has increased, mortality from the disease has not. This is in part due to the great strides in promoting greater public awareness of the disease (May is National Melanoma Awareness Month). Skin screening exams performed by dermatologists and primary care physicians have led to the earlier diagnosis of melanoma when the disease is relatively easy to treat with an operation.

ABCDEs guide

Almost every Caucasian has cutaneous pigmented nevi (moles), and when examining the skin for suspicious changes, the “ABCDEs” of melanoma diagnosis is a very useful guide. “A” stands for lesion Asymmetry, “B” stands for Border irregularity, “C” stands for Color change such blue, red and whitish pigments, “D” stands for a Diameter of more than 6 millimeters (or the size of a pencil eraser), while “E” stands for Evolution over time. The “E” designation is particularly useful for diagnosing melanomas that lack the classic features such as amelanotic melanoma (melanomas that have lost the ability to express pigment). If a mole shows any of these ABCDE features, it should be brought to the attention of a health care provider for evaluation and possible biopsy.

Once biopsied, there are several features of melanoma that are import in determining how aggressive the tumor is and how likely the cancer is to spread. These features are tumor thickness in millimeters (thicker cancers are more advanced and more dangerous), the presence of tumor surface erosion and the number of cell divisions seen (known as mitotic rate). Overall, the thickness of the melanoma is the most important piece of the diagnostic information that can be disclosed with a biopsy. The location on the body where the melanoma was found (head and neck are the worst while the arms and legs are less worrisome) and the patient’s gender (men tend to do worse than women).

Treatment

The main treatment for melanoma is surgical removal of the cancer with a margin of normal-appearing skin and fat tissue around it. The margin goes up as the thickness of the melanoma increases. Generally, chemotherapy is not recommended if the melanoma is thinner than 4 mm and/or the cancer has not spread or metastasized.

If melanoma has been found in nearby lymph nodes (metastatic disease) but has not yet spread to other parts of the body, removal of the remaining nearby lymph nodes is strongly encouraged. Scans to look for spread to other organs are also done. Chemotherapy used in treating metastatic melanoma is evolving. Many patients will take Interferon therapy, which is sometimes combined with experimental treatments. Patients with lymph node involvement should consider joining a clinical trial to get access to the most current treatment options.

If the disease is widespread, surgery is not always done. Sometimes, metastases are removed to try to slow disease progression or relieve symptoms. New chemotherapy regimens for widespread disease use specific proteins in the melanoma and require DNA testing of the tumor for the BRAF gene mutation. Then a drug that is specific to the particular strain of melanoma is chosen. These new therapies have been shown to extend survival by several months and sometimes years, but cures are still uncommon.

For anyone with a history of melanoma, close follow up is necessary to look for new spots of melanoma and allowing for early treatment. Generally, if a person has one melanoma, the chance of having a second unrelated melanoma during his or her lifetime is about 8 percent.

In summary, the treatment of melanoma has changed significantly over the past 30 years. With the introduction of better public awareness campaigns, earlier diagnosis is more common. The establishment of narrower recommended margins of excision has made the surgical treatment of the primary cancer much less morbid and disfiguring.

In addition, the introduction of sentinel node technology has rendered removing a large number of lymph nodes unnecessary in the vast majority of patients, thereby limiting morbidity.

Lastly, the emergence of potentially more effective chemotherapy for high-risk patients and those with metastatic disease has given hope to those who have this potentially lethal cancer. Ongoing research trials and emerging new treatment options continue to shed light on the disease process and provide better and more focused patient specific therapeutic alternatives.


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