How Do Melanoma Guidelines from Different Organizations Compare?

Craig A. Elmets, MD 

Better evidence was linked to greater consensus, but when data were scarce, guidance varied.

Melanoma is a serious malignancy that is responsible for the majority of skin cancer deaths. Several highly respected organizations throughout the world have published evidence-based guidelines for the appropriate care of melanoma patients. The authors of this review compared guidelines created by organizations in four geographic regions — the U.S., Canada, Europe, and Australia/New Zealand.

The recommendations were consistent on a number of points:

Good evidence is lacking to support a benefit from routine total body melanoma screening on morbidity, survival, or quality of life. (Some groups recommend such screening in high-risk situations — immunosuppression; large numbers of nevi or >5 atypical nevi; childhood radiation; strong family history of melanoma.)

Excisional biopsies are recommended for lesions <2 cm in nonsensitive skin types.

Melanomas 1 cm to 2 cm in thickness should be excised with a 1-cm to 2-cm margin.

Lymphatic mapping and sentinel lymph node biopsy are important for prognosis in patients with melanoma thickness 0.75 mm to 4.0 mm or in those with high-risk lesions.

In disseminated metastatic disease, either ipilimumab or vemurafenib should be employed, depending on BRAF mutation biomarker testing.

Recommendations for follow-up and surveillance also varied greatly, although it is well established that most melanoma recurrences will develop within 5 years, risk for a second melanoma ranges from 2% to 8%, and most recurrences are identified by the patients themselves. There is little information on the effects of close surveillance on survival, disease control, and quality of life. For example, for stage IIb, IIc, III, and IV melanoma, the Australian Cancer Network endorses a comprehensive examination every 3 to 4 months for 5 years and annually thereafter. The U.S. National Comprehensive Cancer Network suggests every 3 to 4 months for 3 years and then annually. Canadian Cancer Care Ontario and Canadian Medical Association recommend this schedule only for stage III and IV cancers, and the European Society for Medical Oncology does not provide strong recommendations on follow-up.

CITATION(S):

Fong ZV and Tanabe KK.Comparison of melanoma guidelines in the United States, Canada, Europe, Australia and New Zealand: A critical appraisal and comprehensive review. Br J Dermatol 2013 Oct 14; [e-pub ahead of print].