28 July 2015

Guideline on deadliest form of skin cancer to reduce variation in care

NICE’s latest guideline aims to improve survival rates and reduce variation in the care of patients with melanoma, currently the fastest growing form of cancer.

The guideline covers the full pathway of care, and includes recommendations on managing low vitamin D levels, and the use of sentinel lymph node biopsy for staging.

Melanoma is a form of skin cancer that occurs when cells in the skin develop abnormally. It accounts for more deaths from cancer than all other skin cancers combined.

The disease is linked to exposure to ultraviolet (UV) light which is emitted by the sun and by sunbeds. Estimates suggest that up to 86 per cent of malignant melanomas could be caused by exposure to UV light.

Over the past 30 years rates of malignant melanoma have risen faster than any of the current ten most common cancers. Studies have linked the rising incidence with the increased sun exposure people are experiencing through repeated holidays abroad.

NICE’s guideline on melanoma focusses on staging, identifying treatments for each stage of the disease including when the cancer has spread, and outlines the best follow-up care after treatment.

Measure vitamin D levels at diagnosis

Since melanoma is linked to sun exposure, and around 10 per cent of patients with melanoma have a subsequent melanoma, clinicians often ask patients to reduce their contact with the sun at diagnosis.

However, in the UK where people get limited sun exposure, avoiding the sun can hamper the uptake of vitamin D. Vitamin D is important for keeping bones and teeth healthy, and a lack can lead to deformities such as rickets in children, and osteomalacia in adults which causes pain and tenderness.

Consequently, the guideline recommends that all people with melanoma should have their vitamin D levels measured at diagnosis in secondary care.

Measuring vitamin D levels at diagnosis allows doctors to identify people with melanoma whose vitamin D levels are low and who might benefit from supplements in line with national policies. It will also help identify people with high vitamin D levels who do not need supplementation and in whom supplementation might be harmful.

Knowing a person’s vitamin D level will also improve the accuracy of the advice given to them about the risks and benefits of sunlight exposure.

Listen to a podcast on the evidence behind these recommendations, and how healthcare professionals might be able to put them into practice.

Use sentinel lymph node biopsy for staging rather than treatment

The guideline also recommends that doctors should use sentinel lymph node biopsy to stage rather than treat people under certain conditions.

Sentinel lymph node biopsy is a test that can be used to see if the melanoma has spread to the lymph nodes – the first area that a cancerous cell would arrive if it has spread.

NICE says doctors should consider using this test as a staging rather than a therapeutic procedure for people with stage IB–IIC melanoma with a Breslow thickness of more than 1 mm. Patients should also be given detailed verbal and written information about the possible advantages of using the procedure using a table provided.

Clinicians should explain that there are no clear survival benefits to using the procedure. However, it can be used to predict what might happen in the future and people who have had the operation may be able to take part in clinical trials of new treatments for melanoma.

Listen to a podcast on the evidence behind the recommendations on sentinel lymph node biopsy. 

Professor Mark Baker, Centre for Clinical Practice director at NICE, said: “At this time of year, we all want to get out there and enjoy the sun, and there are plenty of ways to do that safely: using a sunscreen with a high SPF, spending time in the shade between 11am – 3pm, ensuring you don’t burn, and covering up with a hat, t-shirt and sunglasses. But, overexposure to ultraviolent light from the sun can have very serious repercussions.

“Melanoma causes more deaths than all other skin cancers combined. Its incidence is rising at a worrying rate – faster than any other cancer. If it is caught early, the melanoma can be removed by surgery. If it is not diagnosed until the advanced stages, it may have spread, so it is harder to treat. However, there are a number of options available to help slow the progress of the disease and improve quality of life.

“This new guideline addresses areas where there is uncertainty or variation in practice, and will help clinicians to provide the very best care for people with suspected or diagnosed melanoma, wherever they live.”

This new guideline addresses areas where there is uncertainty or variation in practice, and will help clinicians to provide the very best care for people with suspected or diagnosed melanoma

Professor Mark Baker, Centre for Clinical Practice director at NICE