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Melanoma: A family affair

DII small banner By Warren R. Heymann, MD
Nov. 4, 2016

It has now been 5 years since I was diagnosed with melanoma. Six years ago, my wife Ronnie found a tick on my back; when she noted a lesion in the same region a year later, I remember asking her “What did you find, another tick?” No, it was melanoma with a Breslow thickness of 0.35 mm, a low-risk lesion. As most people do, I looked for a reason. Whether true or not, I blame my melanoma on a blistering sunburn that I experienced at the Sahara Hotel in Miami Beach in 1958 — the smell of Noxzema is forever ingrained in my olfactory bulb from my mother dousing me with it to soothe the bullae. I know I’m mortal; I just hope I don’t die of melanoma — I would consider that the ultimate ironic insult.

Despite the advances of targeted therapy with BRAF, MEK, and check point inhibitors, nothing compares with early detection and surgical excision of melanoma.

Who detects melanoma? In a study of 783 patients, most melanomas were self-detected (53%). Among these patients, 32% consulted because of bleeding, itching/pain, or nodule enlargement. There were more melanomas self-detected among women than among men, and these had a better prognosis. Men had significantly more melanomas on non–easily visible locations than women did. Among melanomas noticed by dermatologists, 80% were incidental findings. Self-detected melanomas were thicker and more frequently ulcerated, developed metastases more often, and were associated with more melanoma-related deaths (1).
I am certainly grateful to my wife (for so many reasons!) for having spotted my asymptomatic lesion. There is ample literature documenting that self-skin examination (SSE) performed with a partner who can examine areas that are difficult to see, such as the scalp and back, vastly increases the effectiveness of the exam. Interestingly, training of patients with melanoma and their partners in early-detection SSE benefited some more than others. Pairs who have low relationship quality, as determined by activities performed with the partner and happiness, may have received the greatest benefits from the training intervention because they were given an activity to perform together (2). Not only can partner-associated SSE save a life, perhaps learning how to execute it may save a marriage!
When performing a full-body skin examination, I remind patients that my examination of their scalp may be suboptimal (unless there is significant pattern alopecia). This is especially important because of the potential for a worse prognosis of scalp melanomas. In a study of 1084 cutaneous head and neck melanomas (CHNM) compared with cutaneous trunk and extremity melanomas, CHNM were more frequently found in men, more often nodular and lentigo maligna cutaneous melanomas, and diagnosed at higher T stage (P ≤ .01). CHNM located on posterior sites were diagnosed at significantly higher T stage, and were significantly more often diagnosed with ulceration and at more advanced stage compared with CHNM located on anterior sites (P < .001) (3). This underscores the importance of having a partner examine the posterior scalp and neck for melanoma.

My daughter Deborah is a cosmetologist in Philadelphia specializing in hair coloring. I am delighted that during her training, she was taught the ABCDE of melanoma. She advises patients to get a professional opinion when a lesion looks suspicious. Indeed, in a study of 128  scalp and neck melanoma (SNM) patients, hairdressers detected 10 % of all SNMs, with hairdresser-detected SNMs presenting 13 years younger (53 vs. 66 years, P = 0.015), and with a trend towards lower Breslow depth (1.15 vs. 1.63) and more frequent discovery in AJCC Stage Ia or Ib (66.7% vs. 44. %) than otherwise-detected SNMs. Women with SNMs were 1.8-fold more likely than men to have their SNMs detected by a hairdresser (P = 0.001), and presented at higher AJCC clinical stage than men and required wider surgical resection margins (P = 0.011). Women with hairdresser-detected SNMs were younger, with lower Breslow thickness and lower AJCC Clinical Stage than women with otherwise-detected SNM.

I hope that melanoma never directly impacts your family. To keep it that way, involve your spouse and children by examining each other, while maintaining a sun avoidance regimen.

1. Avilés JA, et al. Who detects melanoma? Impact of detection on characteristics and prognosis of patients with melanoma. J Am Acad Dermatol 2016; 75: 967-74.
2. Hultgren BA, et al. Influence of quality of relationship between patient with melanoma and partner on partner-assisted skin examination education: A randomized clinical trial. JAMA Dermatology 2016; 152: 184-90.
3. Helsing P, et al. Cutaneous head and neck melanoma (CHNM): A population-based study of the prognostic impact of tumor location. J Am Acad Dermatol 2016; 75: 795-82.
4. Lovasik BP, et al. Invasive scalp melanoma: Role for enhanced detection through professional training. Ann Surg Oncol 2016; 23: 4049-57.

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