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Caring for patients with melanoma in the primary care setting Mary Rea, PA-C; Laura Perrino, PA-C; Victoria Sheets, PA-C; M. Jane McDaniel, BSMT, MLS(ASCP)SC

ABSTRACT The incidence of melanoma is steadily rising and mortality continues to increase. This article describes types of melanoma and the role of primary care providers in the long-term management and follow-up of patients diagnosed with melanoma. Keywords: melanoma, skin cancer, ABCDE criteria, “ugly duckling sign,” nevi, dermoscopy

Learning objectives

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Identify the clinical manifestations of melanoma. Apply diagnosis and staging criteria to skin lesions. Develop treatment and follow-up plans for patients diagnosed with melanoma.

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h iincidence he id off melanoma l h has b been rising i i ffor the h past 30 years. According to the American Cancer Society, an estimated 76,100 people in the United States will be diagnosed with melanoma in 2014, and 9,710 people will die of the disease.1,2 Although specialists typically treat patients with melanoma, care often begins and ends with the primary care provider, and early detection is crucial to improved survival.3 This article focuses on primary care providers’ role in the long-term management and follow-up of patients with melanoma, including screening and diagnosis, patient education, and referring patients to specialists for appropriate treatment. EPIDEMIOLOGY AND INCIDENCE From 1970 to 2009, the incidence of melanoma increased 800% in young women and 400% in young men.4 Melanoma accounts for only 5% of all skin cancer diagnoses but the vast majority of skin cancer deaths. The lifetime risk of white Mary Rea practices at Salem Chest Specialists in Winston-Salem, N.C. Laura Perrino is a hospitalist at Denver (Colo.) Health Medical Center. Victoria Sheets practices at Salem Chest Specialists. M. Jane McDaniel is an instructor in the PA program at Wake Forest School of Medicine in Winston-Salem, N.C. The authors have disclosed no potential conflicts of interest, financial or otherwise. Acknowledgment: The authors would like to thank Carol Hildebrandt for her assistance with this manuscript. DOI: 10.1097/01.JAA.0000450802.96673.fb Copyright © 2014 American Academy of Physician Assistants

men developing melanoma is 1 in 36; for white women the risk is 1 in 55, with an annual increase of incidence estimated between 3% and 7%.5 White non-Hispanics have the highest incidence of melanoma, followed by Hispanics and Asians/ Pacific Islanders; blacks have the lowest incidence rate.6 Diagnoses made in individuals under the age of 40 tend to occur in women; incidence in those over 40 is higher in males.6 Although melanoma is the most common type of cancer in young adults ages 25 to 29 years, the fastest rate of growth in the last generation has occurred in older adults, with the mean age of diagnosis being 52 years.6 PATHOPHYSIOLOGY The pathophysiology of melanoma is varied. Research focuses on the multiple stepwise biologic and tumorforming pathways that result in the malignant skin lesions.7 Each pathway causes specific mutations that directly lead to impairment of the normal cell cycle checkpoints, ultimately causing unregulated growth of tumor cells.7 Malignant melanoma cells arise from melanocytes, resulting in an abnormal expression of melanin and an irregular pigmented lesion on the skin’s surface.8

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Key points Melanoma, although a preventable cancer, is increasing in incidence. Screening for melanoma begins with a thorough understanding of the patient’s risk factors. A suspicious lesion should be evaluated using ABCDE criteria and the “ugly duckling sign,” with the possible help of dermoscopy. Excisional biopsy is the gold standard for diagnosing melanoma. Primary care providers should be comfortable with the referral process for patients suspected of or diagnosed with melanoma.

Superficial spreading lesions, the most common subtype of melanoma, tend to begin with a horizontal growth phase in which the melanoma is confined to the epidermis. As cells continue to multiply, the lesion enters a vertical growth phase and infiltrates the dermis. Once malignant melanoma cells penetrate the dermis, they can metastasize due to the dermal vascular supply.9 SCREENING GUIDELINES Expert organizations disagree on recommendations concerning whole-body skin examinations for the detection of melanoma. The American Cancer Society’s guidelines for the early detection of cancer recommend skin examination for patients age 20 years and older as part of a general cancer screening.10 This includes screening every 3 years for patients ages 20 to 40 years, and annually for those over 40 years.8 However, adherence to screening guidelines for physicians performing skin cancer screenings is estimated to be around 26%.11 In 2009, the US Preventive Services Task Force (USPSTF) found insufficient evidence for or against regular skin examinations for the general population.12 The statistical benefits of screening remain ambiguous, and primary care providers must use their best clinical judgment, taking into account patient demographics and risk factors, when deciding whether to include screening in the physical examination. RISK FACTORS Four major risk factors for melanoma have been identified: • Genetics Up to 12% of patients with melanoma have a family history of melanoma (one or more first-degree relatives).6 Skin phenotypes also affect the risk. Patients with lighter skin pigmentation, blond or red hair, blue or green eyes, more freckles, and tendency to sunburn have increased risk of melanoma. A lower incidence in darkerskinned individuals suggests that skin pigmentation is protective. • Personal history Between 5% and 10% of patients with a personal history of melanoma will develop it again during their lifetime.13 26

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• Sun exposure About 50% of melanoma cases worldwide are due to sun exposure.6 Intermittent exposure, defined as periodic and intense sunlight exposure, has the highest association for developing melanoma. Sunburn history with blistering and peeling burns is used as a measure of intermittent exposure. A single blistering sunburn in childhood doubles a person’s chance of developing melanoma. In patients ages 15 to 29 years, melanoma is most common on the trunk. This may be due to the bikini effect, or the cultural changes that have increased deliberate sun tanning of this part of the body.6 Tanning bed use increases a patient’s risk of melanoma by at least 20%, with even higher incidences reported in patients who began using tanning beds before age 30 years.14 In light of the abundance of literature linking indoor tanning with an increased risk of melanoma, healthcare providers must counsel patients about the danger of tanning bed use.15 • Nevi Adults with more than 100 typical nevi, children with more than 50 typical nevi, and anyone with atypical nevi have increased melanoma risk.16 Nevi appear to serve as a genetic marker for increased risk rather than premalignant lesions themselves. PATIENT WORKUP Qualification of suspicion The management of patients with suspicious skin lesions begins with clinical identification of such a lesion. A good clinical eye is still the first step in caring for a patient with cutaneous malignancy, and ABCDE criteria (Asymmetry, Border, Color, Diameter, and Evolution) are still used in the clinical setting.8 The Glasgow seven-point checklist is recommended for providers seeking to identify suspicious lesions on physical examination.17 The presence of any one of the major factors is an indication for action, whether referral or biopsy. In addition, the presence of any minor criteria reinforces the provider’s decision. Although sensitivity of the revised Glasgow seven-point checklist (Table 1) is 100% by recent research, the specificity was shown to be 37%.18 TABLE 1.

Glasgow seven-point checklist18

Patients with any of the major factors should undergo biopsy or be referred to a specialist. Presence of any minor factors reinforces the provider’s decision. Major factors • Change in size of an existing lesion or presentation of a new lesion • Change in shape of a lesion • Change in color Minor factors • Diameter of 7 mm or more • Inflammation of the area • Crusting or bleeding of the lesion • Sensory changes in the region of the lesion

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Lentigo maligna (10% to 15%)

Tan-brown macules gradually enlarging and assuming a speckled appearance. Most commonly found in older patients and on sun-exposed areas.

Acral lentiginous (less than 5%)

Macules or slightly raised lesions with variations of color presentation, including brown, black, and blue areas. Lesions have irregular borders and present on soles, palms, and palmar/plantar surfaces of digits.

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Dark blue, black, or gray elevated nodule, often polypoid. May appear pink and become eroded.

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DIAGNOSTICS The next step is a biopsy of the suspected lesion, with excisional biopsy being performed if possible. Decisions concerning the removal of a suspicious lesion must be made using the clinician’s best judgment and experience with the evaluation of pigmented lesions. Using a dermoscope to evaluate lesions may help with this decision process—a clinical review concluded that dermoscopy is useful and fairly inexpensive for detecting melanoma in the family practice setting.21 Dermoscopy may increase provider confidence when assessing lesions and may reduce the number of unnecessary biopsies. Limitations to dermoscopy include

Nodular (15% to 30%)

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If a suspicious lesion is identified, palpate the patient’s inadequate training for providers, as well as failure in clinicervical, axillary, and inguinal regions for lymphadenopa- cian compliance.21 thy; positive findings may indicate metastasis. Once the decision to biopsy has been made, the provider Another useful tool in identifying a suspicious lesion is must decide which type of biopsy is warranted. The three the “ugly duckling” sign, a tool based on the predilection major techniques for biopsy of a pigmented lesion are shave for melanoma lesions to present with a different profile biopsy, punch/incisional biopsy, and excisional biopsy; than the patient’s other nevi. This tool is based on the providers should choose the technique that will best yield theory that an individual tends to make a certain type of an accurate diagnosis.22 mole. When multiple nevi are present, they will meet a Before lesion biopsy, administer local anesthesia with certain profile for that individual. A lesion deviating from 1% lidocaine with epinephrine at 1:100,000. If the patient this profile and having a different appearance than other reports an allergy to lidocaine, another agent such as existing nevi should raise suspicion for malignancy, even procainamide can be used.22 if it does not fit other criteria for a suspicious lesion.19 A shave biopsy is the most commonly used technique, but Clinical manifestations Melanoma can present as one has significant limitations: this technique may dissect the of four major subtypes: superficial spreading, nodular, base of the lesion, skewing the evaluation of lesion depth.22 lentigo maligna, and acral lentiginous. Superficial spread- Because lesion depth is the top prognostic factor, shave biopsy ing melanoma is the most common subtype and accounts is not recommended for the diagnosis of a lesion suspicious for about 70% of all melanoma.5 for melanoma. Incisional biopsies pose similar concerns, and also fail to reveal symmetry and borders of the lesion, Most superficial spreading melanomas arise as primary lesions in normal skin, growing slowly over a period of hindering the pathologist’s ability to make an accurate 2 years.20 The lesions can present with a variation of colors includTABLE 2. Clinical manifestations of the four major subtypes of melanoma20 ing black, brown, blue, gray, and red. These macules or plaques Subtype Description Image gradually darken and change in size, taking on an irregular, Superficial spreading Mixture of brown, black, blue, (70%) and red pigmented plaque that asymmetric shape.20 Multiple gradually darkens with changes primary sites are rare, and lesions in shape. Lesions tend to tend to occur on the back (in present on the back (both both sexes) and on the legs sexes) and legs (women). (women). Descriptions for the other three subtypes can vary significantly (Table 2).20

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Caring for patients with melanoma in the primary care setting

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diagnosis.22 The limited circumstances in which punch biopsy may be more appropriate include extensive or large pigmented lesions with unclear margins, facial lentigo maligna, and pigmented lesions in mucosal areas.22 Superficial shave biopsy is not recommended in any circumstance. Excisional biopsy is considered the gold standard for melanoma diagnosis.22 Excisional biopsy should be made with a number 15 blade in an elliptical fashion to include a 2- to 3-mm margin.22 A commonly described limitation to this method includes low provider comfort level with the procedure. STAGING AND CLASSIFICATION Clark level The Clark level (Table 3) provides a method of determining how deep the tumor has penetrated into the skin; however, it is not a good predictor of survival.23,24 Breslow thickness Breslow thickness, which is superior to the Clark level as a diagnostic indicator, measures the vertical depth of tumor from the granular level layer downward (Table 4). An ocular micrometer is used to measure the thickness of the excised tumor. This measure is the most important prognostic indicator of the primary tumor.25 Pathologic staging differs from clinical staging in that pathologic staging is based on the histopathology of primary lesions as well as regional metastases including lymph node involvement. Tumor node metastasis (TNM) classification Further classification of a melanoma is achieved using the TNM classification system developed by the American Joint Committee on Cancer (AJCC) (Table 5). This system evaluates the skin involvement of the lesion as well as lymph node involvement and the presence of other metastases.26 REFERRAL Referrals should be made based on current guidelines and the provider’s comfort level. The Glasgow scale provides guidelines that can help in referral decisions. However, action should be taken urgently, whether by referral or biopsy.27 If a lesion is highly suspicious for melanoma, an urgent referral should be made to a dermatologist or specialist proficient in the treatment of melanoma.28 If the primary care provider has performed a biopsy and a histopathology report reveals a diagnosis of melanoma, urgent referral should be made as soon as the pathology report is received. Because research has revealed a trend in missed skin cancer diagnoses in the primary care setting, referral to a specialist is recommended in the evaluation process as early as possible.29 TABLE 3.

Clark level and lesion progression24

• Level I—confined to epidermis (“in situ”) • Level II—invasion of the papillary dermis (upper) • Level III—filling of the papillary dermis (lower) • Level IV—extending into the reticular dermis • Level V—invasion of subcutaneous tissue 28

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TABLE 4.

Breslow thickness and 5-year survival rates25

• less than 1 mm—95% to 100% • 1 to 2 mm—80% to 96% • 2.1 to 4 mm—60% to 75% • greater than 4 mm—37% to 50%

TREATMENT The primary treatment of melanoma is surgical excision, which should be performed within 4 to 6 weeks of initial diagnosis, with the safety margins based on the Breslow tumor thickness. If the melanoma is in situ, 0.5 cm to 1 cm free margins are adequate. For more extensive lesions, free margins up to 3 cm may be required.30 These guidelines are subject to change based on the subtype of melanoma, as different subtypes have different growth patterns. Sentinel lymph node biopsy is a valuable staging tool. Patients with metastasis shown in sentinel lymph biopsy should undergo therapeutic lymph node dissection, which is considered the standard of therapy. All metastatic skin lesions should be removed surgically when possible. If lesions are too numerous or too extensive, adequate surgical removal may not be feasible. At this point, systemic therapies may be indicated based on the decision between the patient and the specialist. Patients with metastatic disease involving other organ systems may undergo systemic or radiation therapies depending on their and their providers’ preferences.31 Most recent advancements in the treatment of metastatic melanoma involve high-dose interleukin-2, ipilimumab, vemurafenib, and T-cell immunotherapy. Extensive research is addressing other possible treatment modalities that are based on molecular defects associated with the molecular carcinogenesis of malignant melanoma.32,33 FOLLOW-UP Primary care providers can be instrumental in early detection of melanoma and need to feel more comfortable with inspecting skin areas where melanoma predominates.34 An important TABLE 5.

TNM classification for melanoma26

T classification T1 T2 T3 T4 N classification N1 N2 N3

M classification M1a M1b M1c

Lesion thickness (mm)

≤1 1.01-2 2.01-4 >4 Number of metastatic nodes 1 2-3 4 or more, or matted nodes, or intrasite metastases or satellites with metastatic nodes Site Distant skin, subcutaneous or nodal Lung All other viscera, any distant metastasis Volume 27 • Number 7 • July 2014

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Caring for patients with melanoma in the primary care setting

engaging in shared care with dermatologists and surgical oncologists. Four models of shared care have been proPsychological • Fear of death or recurrence of the malignancy posed for early-stage melanoma. Three of the • Anger toward healthcare provider regarding diagnosis four models include the primary care provider • Newfound issues with self-esteem alternating visits with the dermatologist or • Guilt for being a “burden” surgical oncologist. Patient survival rates for • Depression early-stage melanoma are very high if primary • Sexual dysfunction care providers and melanoma specialists proSocial • Well-being of other family members or loved ones vide adequate follow-up and shared care.37 • Possibility of infertility due to treatment Behavior modifications for better sun pro• Accessibility to support groups or patient associations tection include using sunscreen with a high Physical • Ability to perform activities of daily living sun protection factor, avoiding the sun during • Dealing with adverse reactions to treatment high-exposure times, eliminating tanning, • Maintaining adequate nutrition wearing protective clothing, and limiting outOccupational • Potential job loss door activities.35 All patients with melanoma • Loss of former responsibilities should follow up with a dermatologist. • Lack of financial support Patients should be taught to perform skin Financial • Possibilities for reimbursement for costs related to care self-examinations using the ABCDE criteria, • Adjusting to possible changes in income although only an estimated 20% to 25% of patients perform these examinations.11 The role for the primary care provider is appropriate short- and specific timeline of follow-up depends on the stage of long-term follow-up of patients diagnosed with melanoma. the primary lesion and presence and extent of metastasis Follow-up care for melanoma patients is crucial to wound (Table 7).32 Providers also should encourage patients to have healing, promoting healthful future behaviors, and providregular eye examinations, oral examinations, and pelvic ing emotional and physical support for patients’ most wor- examinations in women because of the possibility for eye risome concerns.35 Opportunities for patient education and mucosal involvement. include specifics of the diagnosis, prognosis, and warning Patients with melanoma may express concern for the assosigns for recurrence or metastasis. ciated increased risk of a melanoma diagnosis in their firstPatients have stated that they are most concerned with skin degree relatives. Primary care providers can educate patients self-examination, sun exposure, familial risk, and maintaining about genetic susceptibility for melanoma and encourage health insurance benefits.35 A randomized controlled trial patients to pass along education to family members.35 published in 2012 further identified some of the physical, A study found that patients considered the largest bensocial, and emotional concerns affecting patients (Table 6).36 efits of follow-up to be reassurance of being checked by a These concerns can be addressed by primary care providers skilled specialist, early detection of new melanomas, TABLE 6.

Examples of shared concerns identified by patients diagnosed with cancer

TABLE 7.

Follow-up for melanoma39

Staging description

Follow-up

Additional testing

In-situ primary lesion

Evaluation every 6 months for the first year, then yearly

None

Primary lesion confined to skin, up to 1 mm in thickness

Every 3-4 months for the first year, every 6 months for the second year, then yearly

None

Thicker primary lesion, 1-4 mm without metastasis

Every 3-4 months for the first 3 years, every 6 months for the next 2 years, then yearly

Complete blood cell (CBC) count, chemistry panel, lactate dehydrogenase (LDH) level

Metastasis to one or more sentinel lymph nodes or adjacent skin

Every 3-4 months for the first 3 years, every 6 months for the next 2 years, then yearly

CBC count, chemistry panel, LDH level, positron emission testing (PET) scan and/or CT scan

Metastasis to internal organ, distant lymph nodes, or skin far from primary site

Every 3-4 months for patients at high risk for relapse. Palliative care should monitor patient as needed. Additional care may be needed for patients undergoing systemic therapy.

CBC count, chemistry panel, LDH level. PET scan and/or CT scan every 2-4 months for the first 5 years, then yearly. Additional testing as warranted.

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treatment of other skin cancers such as basal cell carcinoma and squamous cell carcinoma, general education of melanoma including self-skin examinations, opportunity to ask questions of specialists, and information about sun protection for the patient and family.38 CONCLUSION The overall management of patients with melanoma is multidisciplinary, but in many instances begins and ends with the primary care provider. Successful management improves the patient’s quality of life, whether by physical, educational, or emotional support. The goal is to decrease the incidence of advanced disease while providing better care for those afflicted by this preventable cancer. As providers trained to be patient advocates and valuable assets to healthcare teams, physician assistants are vital in achieving this goal. JAAPA Earn Category I CME Credit by reading both CME articles in this issue, reviewing the post-test, then taking the online test at http://cme.aapa.org. Successful completion is defined as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of July 2014.

REFERENCES 1. American Cancer Society. Melanoma skin cancer. http://www. cancer.org/cancer/skincancer-melanoma/detailedguide/ melanoma-skin-cancer-key-statistics. Accessed May 2, 2014. 2. American Cancer Society. Cancers Facts & Figures 2013. http:// www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures 2013/index. Accessed May 2, 2014. 3. Rigel DS, Carucci JA. Malignant melanoma: prevention, early detection, and treatment in the 21st century. CA Cancer J Clin. 2000;50(4):215-236. 4. Reed KB, Brewer JD, Lohse CM, et al. Increasing incidence of melanoma among young adults: an epidemiological study in Olmsted County, Minnesota. Mayo Clin Proc. 2012;87(4):328-334. 5. Garbe C, Leiter U. Melanoma epidemiology and trends. Clin Dermatol. 2009;27(1):3-9. 6. Herzog C, Pappo A, Bondy M, et al. Malignant melanoma. In: Bleyer A, O’Leary M, Barr R, Ries LAG, eds. Cancer Epidemiology in Older Adolescents and Young Adults 15 to 29 Years of Age, Including SEER Incidence and Survival: 1975-2000. National Cancer Institute, NIH Pub. No. 06-5767. Bethesda, MD; 2006. 7. Alonso SR, Ortiz P, Pollán M, et al. Progression in cutaneous malignant melanoma is associated with distinct expression profiles: a tissue microarray-based study. Am J Pathol. 2004;164(1):193-203. 8. Pluta RPM, Burke AE, Golub RM. Melanoma. JAMA. 2011;305 (22):2368. 9. Piérard GE. Cell proliferation in cutaneous malignant melanoma: relationship with neoplastic progression. ISRN Dermatol. 2012;2012:828146. 10. Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2009: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 2009;59(1):27-41. 11. Tyagi A, Miller K, Cockburn M. e-Health tools for targeting and improving melanoma screening: a review. J Skin Cancer. 2012;2012:437502. 12. U.S. Preventive Services Task Force. Screening for skin cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150(3):188-193. 13. Melanoma Research Foundation. Melanoma pathology–understanding your report. http://www.melanoma.org/understandmelanoma/diagnosing-melanoma/melanoma-pathology. Accessed April 24, 2014. 14. Boniol M, Autier P, Boyle P, Gandini S. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ. 2012;345:e4757.

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15. Guy GP Jr, Berkowitz Z, Tai E, et al. Indoor tanning among high school students in the United States, 2009 and 2011. JAMA Dermatol. [Feb. 26, 2014]. http://archderm.jamanetwork.com/ article.aspx?articleid=1833428. Accessed April 24, 2014. 16. Tucker MA, Fraser MC, Goldstein AM, et al. A natural history of melanomas and dysplastic nevi: an atlas of lesions in melanoma-prone families. Cancer. 2002; 94(12):3192-3209. 17. Mackie RM. An Illustrated Guide to the Recognition of Early Malignant Melanoma. Edinburgh: Blackwood Pillans and Wilson Ltd.; 1986. 18. Healsmith MF, Bourke JF, Osborne JE, Graham-Brown RA. An evaluation of the revised seven-point checklist for the early diagnosis of cutaneous malignant melanoma. Br J Dermatol. 1994;130(1):48-50. 19. Grob JJ, Bonerandi JJ. The ‘ugly duckling’ sign: identification of the common characteristics of nevi in an individual as a basis for melanoma screening. Arch Dermatol. 1998;134(1):103-104. 20. Evans BC, Sober AJ, Tsao H, et al. Cutaneous melanoma. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell KW, eds. Fitzpatrick’s Dermatology in General Medicine, 8th ed. New York, NY: McGraw-Hill Medical; 2012. 21. Herschorn A. Dermoscopy for melanoma detection in family practice. Can Fam Physician. 2012;58(7):740-745, e372-e378. 22. Silverstein D, Mariwalla K. Biopsy of the pigmented lesions. Dermatol Clin. 2012;30(3):435-443. 23. Wisco OJ, Sober AJ. Prognostic factors for melanoma. Dermatol Clin. 2012;30(3):469-485. 24. Clark WH Jr, From L, Bernardino EA, Mihm MC. The histogenesis and biologic behavior of primary human malignant melanomas of the skin. Cancer Res. 1969;29(3):705-727. 25. Breslow A. Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg. 1970;172(5):902-908. 26. Balch CM, Gershenwald JE, Soong SJ, et al. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol. 2009;27(36):6199-6206. 27. Goulart JM, Quigley EA, Dusza S, et al. Skin cancer education for primary care physicians: a systematic review of published evaluated interventions. J Gen Intern Med. 2011;26(9):1027-1035. 28. National Institute for Health and Care Excellence. Referral guidelines for suspected cancer. http://www.nice.org.uk/CG027. Accessed April 24, 2014. 29. Gerbert B, Maurer T, Berger T, et al. Primary care physicians as gatekeepers in managed care. Primary care physicians’ and dermatologists’ skills at secondary prevention of skin cancer. Arch Dermatol. 1996;132(9):1030-1038. 30. Martinez JC, Otley CC. The management of melanoma and nonmelanoma skin cancer: a review for the primary care physician. Mayo Clin Proc. 2001;76(12):1253-1265. 31. Garbe C, Peris K, Hauschild A, et al. Diagnosis and treatment of melanoma. European consensus-based interdisciplinary guidelines–Update 2012. Eur J Cancer. 2012;48(15):2375-2390. 32. Takahashi S. Molecular-target therapy for advanced malignant melanoma. Gan To Kagaku Ryoho. 2013;40(1):19-25. 33. Simeone E, Ascierto PA. Immunomodulating antibodies in the treatment of metastatic melanoma: the experience with anti-CTLA-4, anti-CD137, and anti-PD1. J Immunotoxicol. 2012;9(3):241-247. 34. Markova A, Weinstock MA, Risica P, et al. Effect of a webbased curriculum on primary care practice: basic skin cancer triage trial. Fam Med. 2013;45(8):558-568. 35. Oliveria SA, Shuk E, Hay JL, et al. Melanoma survivors: health behaviors, surveillance, psychosocial factors, and family concerns. Psychooncology. 2013;22(1):106-116. 36. Bergholdt SH, Søndergaard J, Larsen PV, et al. A randomized controlled trial to improve general practitioners’ services in cancer rehabilitation: effects on general practitioners’ proactivity and on patients’ participation in rehabilitation activities. Acta Oncol. 2013;52(2):400-409. 37. Rychetnik L, Morton RL, McCaffery K, et al. Shared care in the follow-up of early-stage melanoma: a qualitative study of Australian melanoma clinicians’ perspectives and models of care. BMC Health Serv Res. 2012;12:468. 38. Morton, RL, Rychetnik, L, McCaffery, K, et al. Patients’ perspective of long-term follow-up for localised cutaneous melanoma. Eur J Surg Oncol. 2013;39(3):297-303. 39. Shenenberger DW. Cutaneous malignant melanoma: a primary care perspective. Am Fam Physician. 2012;85(2):161-168. Volume 27 • Number 7 • July 2014

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Caring for patients with melanoma in the primary care setting.

The incidence of melanoma is steadily rising and mortality continues to increase. This article describes types of melanoma and the role of primary car...
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