Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

See implementation: getting started for information about putting the recommendations on dermoscopy, managing suboptimal vitamin D levels, sentinel lymph node biopsy and completion lymphadenectomy into practice.

Communication and support

  • To help people make decisions about their care, follow the recommendations on communication, information provision and support in NICE's guideline on improving outcomes for people with skin tumours including melanoma, in particular the following 5 recommendations:

    • 'Improved, preferably nationally standardised, written information should be made available to all patients. Information should be appropriate to the patients' needs at that point in their diagnosis and treatment, and should be repeated over time. The information given must be specific to the histopathological type of lesion, type of treatment, local services and any choice within them, and should cover both physical and psychosocial issues.'

    • 'Those who are directly involved in treating patients should receive specific training in communication and breaking bad news.'

    • 'Patients should be invited to bring a companion with them to consultations.'

    • 'Each LSMDT [local hospital skin cancer multidisciplinary team] and SSMDT [specialist skin cancer multidisciplinary team] should have at least one skin cancer clinical nurse specialist (CNS) who will play a leading role in supporting patients and carers. There should be equity of access to information and support regardless of where the care is delivered.'

    • 'All LSMDTs and SSMDTs should have access to psychological support services for skin cancer patients.'

Assessing melanoma

Dermoscopy and other visualisation techniques

  • Assess all pigmented skin lesions that are either referred for assessment or identified during follow‑up in secondary or tertiary care, using dermoscopy carried out by healthcare professionals trained in this technique.

Photography

  • For a clinically atypical melanocytic lesion that does not need excision at first presentation in secondary or tertiary care:

    • use baseline photography (preferably dermoscopic) and

    • review the clinical appearance of the lesion, and compare it with the baseline photographic images, 3 months after first presentation to identify early signs of melanoma.

Taking tumour samples for genetic testing

  • If targeted systemic therapy is a treatment option, offer genetic testing using:

    • a secondary melanoma tissue sample if there is adequate cellularity or

    • a primary melanoma tissue sample if a secondary sample is not available or is of inadequate cellularity.

Managing suboptimal vitamin D levels

  • Measure vitamin D levels at diagnosis in secondary care in all people with melanoma.

Staging investigations

Sentinel lymph node biopsy

  • Consider sentinel lymph node biopsy as a staging rather than a therapeutic procedure for people with stage IB–IIC melanoma with a Breslow thickness of more than 1 mm, and give them detailed verbal and written information about the possible advantages and disadvantages, using the table below.

Possible advantages of sentinel lymph node biopsy

Possible disadvantages of sentinel lymph node biopsy

The operation helps to find out whether the cancer has spread to the lymph nodes. It is better than ultrasound scans at finding very small cancers in the lymph nodes.

The purpose of the operation is not to cure the cancer. There is no good evidence that people who have the operation live longer than people who do not have it.

The operation can help predict what might happen in the future. For example, in people with a primary melanoma that is between 1 and 4 mm thick:

  • around 1 out of 10 die within 10 years if the sentinel lymph node biopsy is negative

  • around 3 out of 10 die within 10 years if the sentinel lymph node biopsy is positive.

The result needs to be interpreted with caution. Of every 100 people who have a negative sentinel lymph node biopsy, around 3 will subsequently develop a recurrence in the same group of lymph nodes.

People who have had the operation may be able to take part in clinical trials of new treatments for melanoma. These trials often cannot accept people who haven't had this operation.

A general anaesthetic is needed for the operation.

The operation results in complications in between 4 and 10 out of every 100 people who have it.

Managing stage III melanoma

Completion lymphadenectomy

  • Consider completion lymphadenectomy for people whose sentinel lymph node biopsy shows micro‑metastases and give them detailed verbal and written information about the possible advantages and disadvantages, using the table below.

Possible advantages of completion lymphadenectomy

Possible disadvantages of completion lymphadenectomy

Removing the rest of the lymph nodes before cancer develops in them reduces the chance of the cancer returning in the same part of the body.

Lymphoedema (long‑term swelling) may develop, and is most likely if the operation is in the groin and least likely in the head and neck.

The operation is less complicated and safer than waiting until cancer develops in the remaining lymph nodes and then removing them.

In 4 out of 5 people, cancer will not develop in the remaining lymph nodes, so there is a chance that the operation will have been done unnecessarily.

People who have had the operation may be able to take part in clinical trials of new treatments to prevent future melanoma. These trials often cannot accept people who have not had this operation.

There is no evidence that people who have this operation live longer than people who do not have it.

Having any operation can cause complications.

Adjuvant radiotherapy

  • Do not offer adjuvant radiotherapy to people with stage IIIB or IIIC melanoma unless a reduction in the risk of local recurrence is estimated to outweigh the risk of significant adverse effects.

Follow-up after treatment for melanoma

Follow-up for all people who have had melanoma

  • Consider personalised follow‑up for people who are at increased risk of further primary melanomas (for example people with atypical mole syndrome, previous melanoma, or a history of melanoma in first‑degree relatives or other relevant familial cancer syndromes).

Follow-up after stage IIC melanoma with no sentinel lymph node biopsy or stage III melanoma

  • Consider surveillance imaging as part of follow‑up for people who have had stage IIC melanoma with no sentinel lymph node biopsy or stage III melanoma and who would become eligible for systemic therapy as a result of early detection of metastatic disease if:

    • there is a clinical trial of the value of regular imaging or

    • the specialist skin cancer multidisciplinary team agrees to a local policy and specific funding for imaging 6‑monthly for 3 years is identified.

Take into account the possible advantages and disadvantages of surveillance imaging and discuss these with the person, using the table below.

Possible advantages of surveillance imaging (having regular scans)

Possible disadvantages of surveillance imaging (having regular scans)

If the melanoma comes back (recurrent melanoma), it is more likely to be detected sooner. It is possible that this could lead to a better outcome by allowing treatment with drugs (such as immunotherapy drugs) to start earlier.

Although early drug treatment of recurrent melanoma might improve survival, there is currently no evidence showing this.

Some people find it reassuring to have regular scans.

Some people find that having regular scans increases their anxiety.

Scans expose the body to radiation, which can increase the risk of cancer in the future.

Scans of the brain and neck increase the risk of developing cataracts.

Scans of the chest cause a very small increase in the risk of thyroid cancer.

Scans may show abnormalities that are later found to be harmless, causing unnecessary investigations and anxiety.

  • National Institute for Health and Care Excellence (NICE)