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All of us must sympathise with Peter Foremans story of the tragic delay in diagnosis and subsequent loss of his son from melanoma.1 It is not possible to know whether earlier treatment would have been lifesaving. The history of growth over a short period of months is characteristic of nodular melanoma, an uncommon subtype of the disease, which is particularly aggressive when arising in the scalp and frequently leads to death of the patient. Unfortunately they are misdiagnosed in 50% of cases, as they often have no distinctive clinical features.However, we disagree with his assertion that an adversarial medical-legal system will be beneficial. The resultant defensive practices would inevitably lead to huge increases in costs and innumerable unnecessary surgeries with accompanying complications.The management of melanoma in New Zealand (NZ) is generally very good. Overall, for all melanomas, NZ outcome results are similar to those in Australia or Canada, with NZ 5-year survival rates for recent patients being 94% for women, and 88% for men. US results are marginally better, but their data does not include the whole population, as ours does. But in all these countries, there are types of melanoma that are much more difficult to detect and treat, including melanomas on the scalp, and nodular melanoma. Melanoma death rates in NZ in those diagnosed up to age 45 have been decreasing slowly, although rates at older ages continue to increase.2Early detection is most effective for common melanomas such as superficial spreading melanoma, which often develop slowly, giving good opportunities for detection. But nodular and some other melanomas may grow more rapidly and may not be benefitted by earlier detection efforts. For every melanoma that occurs, there are many other non-cancer lesions that appear similar, so more intensive detection efforts come at a cost in unnecessary biopsies and anxiety for patients. While we hope earlier detection efforts are worthwhile, and we work on that basis, the extent of its benefits is uncertain.It is highly likely that mortality from melanoma will be unchanged; rates of death from melanoma have continued to rise, despite annual increases in reported incidence of melanoma.2 The majority of excised melanomas are in situ or thin (defined as less than 1 mm in thickness). We do not know if early detection means increased survival rates we can only hope that this is true and do our best to identify and remove the aggressive tumours before they have metastasised.We are engaged in reviewing melanomas diagnosed in the Waikato Region during 2010-2012. Breslow thickness is the most important prognostic feature for melanoma. In our database of 577 invasive melanomas, median depth is 0.8 mm. There are 80 nodular melanomas, which have a median depth of 2.8 mm, and 334 superficial spreading melanoma, with a median depth of 0.65 mm.The prognosis for thick melanoma is abysmal (10-year survival 60-67%3,4; and unfortunately a high proportion of scalp tumours are thick at presentation.5 Scalp location has been reported to be an independent predictor of recurrence6 and fatality.7 As a recent retrospective review concludes, Further research is needed to characterise the environmental, microenvironmental, and genetic causes of the increased aggressiveness of scalp melanoma and to identify more effective treatment and surveillance methods. 6The Ministry of Health has recently published Provisional Standards of Service Provision for Melanoma Patients in New Zealand.8 These recognise the need to (a) improve education of health professionals in the recognition of melanoma, and, (b) to provide rapid and expert specialist support in diagnosis and management.We urge District Health Boards to implement the recommendations.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Amanda OakleyHonorary Associate Professor of Medicine-Department of Dermatology, Waikato Hospital-Hamilton, New Zealand Marius RademakerHonorary Associate Professor of Medicine-Department of Dermatology, Waikato Hospital-Hamilton, New Zealand Mark ElwoodProfessor of Cancer Epidemiology-School of Population Health, University of Auckland-Auckland, New Zealand

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

'- 1. Foreman PA. Missed melanomas [letter]. N Z Med J 6 June 2014;127(1395):86-7. http://journal.nzma.org.nz/journal/127-1395/6158/content.pdf 2. Sneyd MJ, Cox B. A comparison of trends in melanoma mortality in New Zealand and Australia: the two countries with the highest melanoma incidence and mortality in the world. BMC Cancer. 2013;13:372. 3. Larson DL, Larson JD. Head and neck melanoma. Clin Plast Surg. 2010;37:73-7. 4. de Giorgi V, Rossari S, Gori A, et al. The prognostic impact of the anatomical sites in the 'head and neck melanoma': scalp versus face and neck. Melanoma Res. 2012;22:402-5. 5. Sarnoff DS. Heads Up for Scalp Melanoma. J Drugs Dermatol. 2014;13:525-6. 6. Terakedis BE, Anker CJ, Leachman SA, et al. Patterns of failure and predictors of outcome in cutaneous malignant melanoma of the scalp. J Am Acad Dermatol. 2014;70:435-42. 7. Kricker A, Armstrong BK, Goumas C, et al; GEM Study Group. Survival for patients with single and multiple primary melanomas: the genes, environment, and melanoma study. JAMA Dermatol. 2013;149:921-7. 8. Standards of Service Provision for Melanoma Patients in New Zealand - Provisional. Ministry of Health, December 2013. Accessed 8 June 2014 at http://www.health.govt.nz/system/files/documents/pages/standards-of-service-provision-melanoma-patients-jan14.doc -

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All of us must sympathise with Peter Foremans story of the tragic delay in diagnosis and subsequent loss of his son from melanoma.1 It is not possible to know whether earlier treatment would have been lifesaving. The history of growth over a short period of months is characteristic of nodular melanoma, an uncommon subtype of the disease, which is particularly aggressive when arising in the scalp and frequently leads to death of the patient. Unfortunately they are misdiagnosed in 50% of cases, as they often have no distinctive clinical features.However, we disagree with his assertion that an adversarial medical-legal system will be beneficial. The resultant defensive practices would inevitably lead to huge increases in costs and innumerable unnecessary surgeries with accompanying complications.The management of melanoma in New Zealand (NZ) is generally very good. Overall, for all melanomas, NZ outcome results are similar to those in Australia or Canada, with NZ 5-year survival rates for recent patients being 94% for women, and 88% for men. US results are marginally better, but their data does not include the whole population, as ours does. But in all these countries, there are types of melanoma that are much more difficult to detect and treat, including melanomas on the scalp, and nodular melanoma. Melanoma death rates in NZ in those diagnosed up to age 45 have been decreasing slowly, although rates at older ages continue to increase.2Early detection is most effective for common melanomas such as superficial spreading melanoma, which often develop slowly, giving good opportunities for detection. But nodular and some other melanomas may grow more rapidly and may not be benefitted by earlier detection efforts. For every melanoma that occurs, there are many other non-cancer lesions that appear similar, so more intensive detection efforts come at a cost in unnecessary biopsies and anxiety for patients. While we hope earlier detection efforts are worthwhile, and we work on that basis, the extent of its benefits is uncertain.It is highly likely that mortality from melanoma will be unchanged; rates of death from melanoma have continued to rise, despite annual increases in reported incidence of melanoma.2 The majority of excised melanomas are in situ or thin (defined as less than 1 mm in thickness). We do not know if early detection means increased survival rates we can only hope that this is true and do our best to identify and remove the aggressive tumours before they have metastasised.We are engaged in reviewing melanomas diagnosed in the Waikato Region during 2010-2012. Breslow thickness is the most important prognostic feature for melanoma. In our database of 577 invasive melanomas, median depth is 0.8 mm. There are 80 nodular melanomas, which have a median depth of 2.8 mm, and 334 superficial spreading melanoma, with a median depth of 0.65 mm.The prognosis for thick melanoma is abysmal (10-year survival 60-67%3,4; and unfortunately a high proportion of scalp tumours are thick at presentation.5 Scalp location has been reported to be an independent predictor of recurrence6 and fatality.7 As a recent retrospective review concludes, Further research is needed to characterise the environmental, microenvironmental, and genetic causes of the increased aggressiveness of scalp melanoma and to identify more effective treatment and surveillance methods. 6The Ministry of Health has recently published Provisional Standards of Service Provision for Melanoma Patients in New Zealand.8 These recognise the need to (a) improve education of health professionals in the recognition of melanoma, and, (b) to provide rapid and expert specialist support in diagnosis and management.We urge District Health Boards to implement the recommendations.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Amanda OakleyHonorary Associate Professor of Medicine-Department of Dermatology, Waikato Hospital-Hamilton, New Zealand Marius RademakerHonorary Associate Professor of Medicine-Department of Dermatology, Waikato Hospital-Hamilton, New Zealand Mark ElwoodProfessor of Cancer Epidemiology-School of Population Health, University of Auckland-Auckland, New Zealand

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

'- 1. Foreman PA. Missed melanomas [letter]. N Z Med J 6 June 2014;127(1395):86-7. http://journal.nzma.org.nz/journal/127-1395/6158/content.pdf 2. Sneyd MJ, Cox B. A comparison of trends in melanoma mortality in New Zealand and Australia: the two countries with the highest melanoma incidence and mortality in the world. BMC Cancer. 2013;13:372. 3. Larson DL, Larson JD. Head and neck melanoma. Clin Plast Surg. 2010;37:73-7. 4. de Giorgi V, Rossari S, Gori A, et al. The prognostic impact of the anatomical sites in the 'head and neck melanoma': scalp versus face and neck. Melanoma Res. 2012;22:402-5. 5. Sarnoff DS. Heads Up for Scalp Melanoma. J Drugs Dermatol. 2014;13:525-6. 6. Terakedis BE, Anker CJ, Leachman SA, et al. Patterns of failure and predictors of outcome in cutaneous malignant melanoma of the scalp. J Am Acad Dermatol. 2014;70:435-42. 7. Kricker A, Armstrong BK, Goumas C, et al; GEM Study Group. Survival for patients with single and multiple primary melanomas: the genes, environment, and melanoma study. JAMA Dermatol. 2013;149:921-7. 8. Standards of Service Provision for Melanoma Patients in New Zealand - Provisional. Ministry of Health, December 2013. Accessed 8 June 2014 at http://www.health.govt.nz/system/files/documents/pages/standards-of-service-provision-melanoma-patients-jan14.doc -

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

All of us must sympathise with Peter Foremans story of the tragic delay in diagnosis and subsequent loss of his son from melanoma.1 It is not possible to know whether earlier treatment would have been lifesaving. The history of growth over a short period of months is characteristic of nodular melanoma, an uncommon subtype of the disease, which is particularly aggressive when arising in the scalp and frequently leads to death of the patient. Unfortunately they are misdiagnosed in 50% of cases, as they often have no distinctive clinical features.However, we disagree with his assertion that an adversarial medical-legal system will be beneficial. The resultant defensive practices would inevitably lead to huge increases in costs and innumerable unnecessary surgeries with accompanying complications.The management of melanoma in New Zealand (NZ) is generally very good. Overall, for all melanomas, NZ outcome results are similar to those in Australia or Canada, with NZ 5-year survival rates for recent patients being 94% for women, and 88% for men. US results are marginally better, but their data does not include the whole population, as ours does. But in all these countries, there are types of melanoma that are much more difficult to detect and treat, including melanomas on the scalp, and nodular melanoma. Melanoma death rates in NZ in those diagnosed up to age 45 have been decreasing slowly, although rates at older ages continue to increase.2Early detection is most effective for common melanomas such as superficial spreading melanoma, which often develop slowly, giving good opportunities for detection. But nodular and some other melanomas may grow more rapidly and may not be benefitted by earlier detection efforts. For every melanoma that occurs, there are many other non-cancer lesions that appear similar, so more intensive detection efforts come at a cost in unnecessary biopsies and anxiety for patients. While we hope earlier detection efforts are worthwhile, and we work on that basis, the extent of its benefits is uncertain.It is highly likely that mortality from melanoma will be unchanged; rates of death from melanoma have continued to rise, despite annual increases in reported incidence of melanoma.2 The majority of excised melanomas are in situ or thin (defined as less than 1 mm in thickness). We do not know if early detection means increased survival rates we can only hope that this is true and do our best to identify and remove the aggressive tumours before they have metastasised.We are engaged in reviewing melanomas diagnosed in the Waikato Region during 2010-2012. Breslow thickness is the most important prognostic feature for melanoma. In our database of 577 invasive melanomas, median depth is 0.8 mm. There are 80 nodular melanomas, which have a median depth of 2.8 mm, and 334 superficial spreading melanoma, with a median depth of 0.65 mm.The prognosis for thick melanoma is abysmal (10-year survival 60-67%3,4; and unfortunately a high proportion of scalp tumours are thick at presentation.5 Scalp location has been reported to be an independent predictor of recurrence6 and fatality.7 As a recent retrospective review concludes, Further research is needed to characterise the environmental, microenvironmental, and genetic causes of the increased aggressiveness of scalp melanoma and to identify more effective treatment and surveillance methods. 6The Ministry of Health has recently published Provisional Standards of Service Provision for Melanoma Patients in New Zealand.8 These recognise the need to (a) improve education of health professionals in the recognition of melanoma, and, (b) to provide rapid and expert specialist support in diagnosis and management.We urge District Health Boards to implement the recommendations.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Amanda OakleyHonorary Associate Professor of Medicine-Department of Dermatology, Waikato Hospital-Hamilton, New Zealand Marius RademakerHonorary Associate Professor of Medicine-Department of Dermatology, Waikato Hospital-Hamilton, New Zealand Mark ElwoodProfessor of Cancer Epidemiology-School of Population Health, University of Auckland-Auckland, New Zealand

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

'- 1. Foreman PA. Missed melanomas [letter]. N Z Med J 6 June 2014;127(1395):86-7. http://journal.nzma.org.nz/journal/127-1395/6158/content.pdf 2. Sneyd MJ, Cox B. A comparison of trends in melanoma mortality in New Zealand and Australia: the two countries with the highest melanoma incidence and mortality in the world. BMC Cancer. 2013;13:372. 3. Larson DL, Larson JD. Head and neck melanoma. Clin Plast Surg. 2010;37:73-7. 4. de Giorgi V, Rossari S, Gori A, et al. The prognostic impact of the anatomical sites in the 'head and neck melanoma': scalp versus face and neck. Melanoma Res. 2012;22:402-5. 5. Sarnoff DS. Heads Up for Scalp Melanoma. J Drugs Dermatol. 2014;13:525-6. 6. Terakedis BE, Anker CJ, Leachman SA, et al. Patterns of failure and predictors of outcome in cutaneous malignant melanoma of the scalp. J Am Acad Dermatol. 2014;70:435-42. 7. Kricker A, Armstrong BK, Goumas C, et al; GEM Study Group. Survival for patients with single and multiple primary melanomas: the genes, environment, and melanoma study. JAMA Dermatol. 2013;149:921-7. 8. Standards of Service Provision for Melanoma Patients in New Zealand - Provisional. Ministry of Health, December 2013. Accessed 8 June 2014 at http://www.health.govt.nz/system/files/documents/pages/standards-of-service-provision-melanoma-patients-jan14.doc -

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