Training dermatologists to detect melanoma at its earliest stages
Clayton R. Boldt, Ph.D.
Each May, Skin Cancer Awareness Month serves as a reminder of how individuals can work to lower their risk of skin cancer – the most common form of the disease in the United States – which will affect roughly one in five Americans at some point in their lives.
Melanoma, an aggressive form of skin cancer, represents just 1% of diagnoses but accounts for the majority of skin cancer-related deaths. MD Anderson’s Melanoma Moon Shot™ specifically seeks to reduce melanoma incidence and mortality through integrated research efforts. MD Anderson’s Moon Shots Program™ is a collaborative effort to accelerate the development of scientific discoveries into clinical advances that save patients’ lives.
Working with the Melanoma Moon Shot and the cancer prevention and control platform, Kelly Nelson, M.D., associate professor of Dermatology and co-lead of the moon shot’s prevention flagship, is leading an effort to improve training for dermatology residents in the use of dermoscopy for melanoma screening. She spoke with Cancer Frontline about those efforts.
Q: What’s the current impact of melanoma, and why is there a focus from the Melanoma Moon Shot on prevention?
A: Melanoma is the most lethal skin cancer and, unfortunately, its incidence is continuing to rise. The American Cancer Society estimates there’ll be about 91,000 new cases diagnosed in 2018, and about 9,000 people will die from melanoma.
We know that the incidence of melanoma increases with age, but it's also one of the most common cancers in young adults, especially young women. What we see in our practice is that no demographic is immune from melanoma. Melanoma happens to people of all ethnicities and ages, including children, and it happens on areas of the body that never see the sun.
The Melanoma Moon Shot seeks to address primary prevention and early diagnosis of melanoma. Primary prevention includes efforts to stop melanoma in the first place. For example, our team, led by Dr. Jeffrey Gershenwald, works with MD Anderson’s Government Relations experts and the cancer prevention and control platform to focus efforts on serving as educational resources to stakeholders interested in public policies to reduce minors’ access to tanning beds, which can significantly increase melanoma risk. Early diagnosis is considered secondary prevention. This is the concept that melanoma is going to happen, but we want to catch it at its very earliest stage.
Q: What are the benefits of early detection on patient outcomes? What screening is recommended for skin cancer?
A: Early detection has enormous survival implications for melanoma. When we look specifically at melanoma that has not spread to the lymph nodes, which includes Stage 1a tumors, where there's only very early invasion into the top layers of the skin, there is a 10-year survival probability of 98%. That's in contrast to the most advanced stage of melanoma that has not spread to the lymph nodes, which has a survival probability of 75%.
The U.S. Preventive Services Task Force (USPSTF) recommends sun protective counseling for young people, but it does not currently recommend across-the-board screening for melanoma among asymptomatic adults with no personal history of skin cancer. Our research is addressing how to successfully tease out high-risk people who are not already coming to the dermatologist for structured melanoma screening.
Q: Can you describe dermoscopy and how it is beneficial for screening?
A: Dermoscopy is a relatively low-tech device that can significantly improve providers’ diagnostic accuracy for melanoma. It’s a handheld 10X magnifier attached to a bright light, and it magnifies specific structures in an existing mole or skin lesion. Being an expert in dermoscopy lets the physician remove fewer normal moles while also detecting melanoma at its earliest stages.
The hard thing, though, is unless you have a photographic memory or you obsessively photograph every tumor that you biopsy like I do, you lose the opportunity to go back and learn from the unexpected pathology diagnoses. Thankfully the cost of dermoscopic photography has plummeted.
It’s important for screening because, for institutions like the USPSTF, they look at the balance of the cost of screening to the benefits of detecting a cancer at its earliest stage. Screening for melanoma has been somewhat criticized because of the high number of normal tumors that are biopsied in the course of diagnosing melanoma. Enhancing providers’ skill level with dermoscopy can help reduce the cost of screening.
Q: Can you describe how your moon shot project utilizes a telementoring platform to train dermatologists?
A: Formal dermoscopic education is best received during dermatology residency training, but most programs aren’t large enough to support a faculty member whose main focus is on dermoscopy and early detection of melanoma. After moving to MD Anderson, I visited most of the dermatology residency programs across Texas and there was a lot of interest to improve the quality of dermoscopy education within the residency programs.
Working with the Moon Shot Program’s cancer prevention and control platform, we’re able to use Project ECHO®, a telementoring platform, to train residents in the use of dermoscopy and teach and support providers as they gain a new skill set.
With my leadership team members, Stephanie Savory, M.D., of UT Southwestern and Janice Wilson, M.D., of UT Medical Branch, we provide dermoscopy education on a monthly basis with a lot of education-based metrics, which allow us to continually improve the education we’re providing.
Q: How has this project been received by participants?
A: Very enthusiastically. We ask the dermatology residents and their faculty members to show up bright and early at 7 a.m., and the amount of voluntary participation has been really outstanding. We have interest outside of Texas for us to expand our training curriculum, and our entire program is being built so that it is scalable and deployable in other interested institutions.
We've tried to use this past year as a bit of a beta-test year because we’ve learned so much as we’ve gotten up and going. Our main goal over the summer is to take a look back at all the lectures that we’ve produced and all the metrics we've generated to continue to improve the education we’re providing.
Q: What are your goals for the current and future projects?
A: Certainly we have the goal of continued, iterative improvement of the dermoscopy lectures that we’re providing. We also hope to work with other institutions interested in taking the content we’ve developed and providing it to their dermatology residencies.
Our broader goal though is to determine the most efficient way to work with primary care physicians to encourage their directed screening for people who are at an increased risk of melanoma, so that we can reach the people who aren’t already in our dermatology offices receiving care.
Kelly Nelson, M.D., associate professor of Dermatology
"After moving to MD Anderson, I visited most of the dermatology residency programs across Texas and there was a lot of interest to improve the quality of dermoscopy education within the residency programs."