Melanoma survivorship: research opportunities

Prevalence and correlates of adherence to skin examination among adolescent and young adult survivors of melanoma from the Project Forward Study

BACKGROUND

Melanoma is a common cancer among adolescents and young adults (AYAs), yet adherence to recommended surveillance and factors related to adherence are not well understood in this population. This study assessed the prevalence and correlates of physician-conducted skin examination (PSE) and skin self-examination (SSE) among AYA-aged long-term survivors of melanoma.

PROCEDURES

Melanoma cases were identified from the Los Angeles County cancer registry and surveys were then completed by 128 respondents diagnosed between the ages 0 and 24, with stage 1 melanoma or higher, at least 5 years from diagnosis, and who were between the ages 18 and 39 at the time of survey.

RESULTS

Eighty-two percent of AYA melanoma survivors reported SSE within the past 6 months, while 65% reported annual PSE. Greater health care self-efficacy was positively associated with adherence to PSE, SSE, and both types of skin examinations (P < .01). Higher socioeconomic status and having a regular source of primary health care were positively associated with annual PSE and adherence to both surveillance practices (P < .05 and P < .01, respectively). Hispanic ethnicity was negatively associated with annual PSE compared to non-Hispanics (P < .01), and greater depressive symptoms were negatively associated with adherence to both skin examinations (P < .05).

CONCLUSIONS

High rates of SSE were observed, but PSE adherence was lower than optimal in this sample. Interventions to improve PSE are needed for at-risk AYA survivors of melanoma, and strategies that help melanoma survivors navigate the health care system and access primary care may facilitate greater adherence.

Communication about melanoma and risk reduction after melanoma diagnosis

BACKGROUND

Melanoma patients are advised to perform regular risk-reduction practices, including sun protection as well as skin self-examinations (SSEs) and physician-led examinations. Melanoma-specific communication regarding family risk and screening may promote such behaviors. To this end, associations between patients' melanoma-specific communication and risk reduction were examined.

METHODS

Melanoma patients (N = 169) drawn from a population-based cancer registry reported their current risk-reduction practices, perceived risk of future melanoma, and communication with physicians and relatives about melanoma risk and screening.

RESULTS

Patients were, on average, 56 years old and 6.7 years' post diagnosis; 51% were male, 93% reported "fair/very fair" skin color, 75% completed at least some college, and 22% reported a family history of melanoma. Patients reported varying levels of regular (always/nearly always) sun protection: sunscreen use (79%), shade seeking (60%), hat use (54%), and long-sleeve shirt use (30%). Only 28% performed thorough SSE regularly, whereas 92% reported undergoing physician-led skin examinations within the past year. Participants who were female, younger, and had a higher perceived risk of future melanoma were more likely to report past communication. In adjusted analyses, communication remained uniquely associated with increased sunscreen use and SSE.

CONCLUSIONS

Encouraging melanoma patients to have a more active role in discussions concerning melanoma risk and screening with relatives and physicians alike may be a useful strategy to promote 2 key risk-reduction practices post melanoma diagnosis and treatment. Future research is needed to identify additional strategies to improve comprehensive risk reduction in long-term melanoma patients.

The experience of melanoma follow-up care: an online survey of patients in australia

Investigating patients' reports on the quality and consistency of melanoma follow-up care in Australia would assist in evaluating if this care is effective and meeting patients' needs. The objective of this study was to obtain and explore the patients' account of the technical and interpersonal aspects of melanoma follow-up care received. An online survey was conducted to acquire details of patients' experience. Participants were patients treated in Australia for primary melanoma. Qualitative and quantitative data about patient perceptions of the nature and quality of their follow-up care were collected, including provision of melanoma specific information, psychosocial support, and imaging tests received. Inconsistencies were reported in the provision and quality of care received. Patient satisfaction was generally low and provision of reassurance from health professionals was construed as an essential element of quality of care. "Gaps" in follow-up care for melanoma patients were identified, particularly provision of adequate psychosocial support and patient education. Focus on strategies for greater consistency in the provision of support, information, and investigations received, may generate a cost dividend which could be reinvested in preventive and supportive care and benefit patient well-being.

Red meat and fruit intake is prognostic among patients with localized cutaneous melanomas more than 1mm thick

BACKGROUND

As the 10-year mortality for localized cutaneous melanoma more than 1.00 mm thick approaches 40% following complete resection, non-therapeutic interventions that can supplement recommended active surveillance are needed. Although guidelines recommending nutrition, physical activity and tobacco cessation for cancer survivors have been published, data describing their associations with melanoma survivorship are lacking.

METHODS

Analysis of modifiable lifestyle behaviors collected on the 249 cases with melanomas more than 1.00 mm thick enrolled in the Connecticut Case-Control Study of Skin Self-Examination study was conducted. Independent associations with melanoma-specific survival were evaluated through Cox proportional hazards modeling adjusting for age, gender, Breslow thickness, ulceration and the presence of microsatellites. Independently significant variables were then combined into a single model and backwards elimination was employed until all remaining variables were significant at p<0.05.

RESULTS

Following adjustment for age, Breslow thickness and anatomic site of the index melanoma, daily fruit consumption was associated with improved melanoma-specific survival (HR=0.54; 95% CI: 0.34-0.86) whereas at least weekly red meat consumption was associated with worse outcomes (HR=1.84; 95% CI: 1.02-3.30). Natural red (HR=0.44; 95% CI: 0.22-0.88) or blond (HR=0.52; 95% CI: 0.29-0.94) hair were also favorably prognostic. Higher fish consumption was of borderline significance for improved survival only when considered independently (HR=0.65; 95% CI: 0.40-1.05); no association was seen following adjustment for red meat and fruit consumption (p>0.10).

CONCLUSIONS

Dietary choices at the time of diagnosis are associated with melanoma-specific survival in patients with melanomas more than 1.00 mm thick. Further validation of our findings in larger cohorts with repeated post-diagnostic measures is warranted to further evaluate whether dietary modification during the survivorship period can improve melanoma-specific survival.

Targeting multiple key signaling pathways in melanoma using leelamine

Melanoma is a highly drug-resistant cancer with resistance developing to agents targeting single proteins. To circumvent this problem, a new class of agent inhibiting multiple key pathways important in this disease is being developed to reduce the likelihood of developing resistant disease. The phosphoinositide 3-kinase (PI3K), mitogen-activated protein kinase (MAPK), and STAT3 pathways are constitutively activated in 50% to 70% of melanomas, promoting disease development. To identify a drug simultaneously targeting the PI3K, MAPK, and STAT3 cascades, a natural product library was screened to identify leelamine as a potential inhibitor. Leelamine was 4.5-fold more effective at inhibiting cultured melanoma cell survival than normal cells, with average IC(50) values of 2 and 9.3 μmol/L, respectively. It inhibited cellular proliferation at a concentration of 2.5 μmol/L by 40% to 80% and longer exposure increased apoptosis 600%. Leelamine inhibited the growth of preexisting xenografted melanoma tumors by an average of 60% by targeting the PI3K, MAPK, and STAT3 pathways without affecting animal body weight or blood markers of major organ function. The mechanism of action of leelamine is mediated by disruption of cholesterol transport, causing decreased cellular proliferation and consequently leading to increased tumor cell apoptosis as well as decreased tumor vascularization. Thus, a unique agent and novel mechanism of action has been identified for the treatment of melanoma that acts by inhibiting the activity of three major signaling pathways regulating the development of this disease.

Extra-intestinal malignancies in inflammatory bowel disease: results of the 3rd ECCO Pathogenesis Scientific Workshop (III)

The incidence of lymphoproliferative disorders (LD) is increasing in developed countries. Patients with inflammatory bowel disease (IBD) exposed to thiopurines are at additional risk of three specific forms of LD: Epstein-Barr-Virus-related post-transplant like LD, hepato-splenic T-cell lymphoma and post-mononucleosis lymphoproliferation. The risk of the two latter forms of LD can be reduced when considering specific immunosuppressive strategies in young males. It is still unclear whether the risk of uterine cervix abnormalities is increased in IBD women, irrespective of the use of immunosuppressants. Given the excess risk demonstrated in various other contexts of immunosuppression, it is currently recommended that all women with IBD, particularly those receiving immunosuppressants, strictly adhere to a screening program of cervical surveillance and undergo vaccination against HPV, when appropriate. Patients with IBD receiving immunosuppressants are at increased risk of skin cancers. The risk of non-melanoma skin cancer is notably increased in patients receiving thiopurines. Recent data suggest that the risk of melanoma is mildly increased in patients exposed to anti-TNF therapy. All IBD patients should adhere to a program of sun protection and dermatological surveillance, whose details should take into account the other non-IBD-related risk factors.

Simultaneous targeting of COX-2 and AKT using selenocoxib-1-GSH to inhibit melanoma

Melanoma is a highly metastatic and deadly disease. An agent simultaneously targeting the COX-2, PI3K/Akt, and mitogen-activated protein kinase (MAPK) signaling pathways that are deregulated in up to 70% of sporadic melanomas might be an effective treatment, but no agent of this type exists. To develop a single drug inhibiting COX-2 and PI3K/Akt signaling (and increasing MAPK pathway activity to inhibitory levels as a result of Akt inhibition), a selenium-containing glutathione (GSH) analogue of celecoxib, called selenocoxib-1-GSH was synthesized. It killed melanoma cells with an average IC(50) of 7.66 μmol/L compared with control celecoxib at 55.6 μmol/L. The IC(50) range for normal cells was 36.3 to 41.2 μmol/L compared with 7.66 μmol/L for cancer cells. Selenocoxib-1-GSH reduced development of xenografted tumor by approximately 70% with negligible toxicity by targeting COX-2, like celecoxib, and having novel inhibitory properties by acting as a PI3K/Akt inhibitor (and MAPK pathway activator to inhibitory levels due to Akt inhibition). The consequence of this inhibitory activity was an approximately 80% decrease in cultured cell proliferation and an approximately 200% increase in apoptosis following 24-hour treatment with 15.5 μmol/L of drug. Thus, this study details the development of selenocoxib-1-GSH, which is a nontoxic agent that targets the COX-2 and PI3K/Akt signaling pathways in melanomas to inhibit tumor development.

Association between multiple cutaneous melanoma and other primary neoplasms

BACKGROUND

The risk of a subsequent cancer is an important issue for patients with melanoma. The development of a second primary cancer in patients with a solitary melanoma has been discussed in several studies. However, to our knowledge, the incidence of second primary cancer (SPC) in patients with multiple primary melanoma (MPM) has not been thoroughly investigated.

AIM

To quantify the incidence of SPC in patients with MPM, with the aim of possibly developing further preventive measures.

METHODS

In a retrospective study, 76 patients with MPM were identified from 2155 patients being followed up at our unit.

RESULTS

Of the 76 patients, 12 (16%) developed another neoplasm, with 59% of them having nonmelanoma skin cancer (NMSC), and 41% other noncutaneous cancers. By contrast, only 8% of those with single primary melanoma had other neoplasms (21% of whom had NMSC).

CONCLUSIONS

Patients with MPM, especially men with skin phototype II, have a significantly increased incidence of developing SPC, particularly NMSC. Thus, careful monitoring is essential not only to detect recurrence of the original cancer or development of another primary melanoma, but also development of new malignancies of different types, particularly NMSC.

Perceptions of genetic research and testing among members of families with an increased risk of malignant melanoma

BACKGROUND

Several melanoma susceptibility genes have been identified. As part of the international genetic research programme of the GenoMEL consortiums research on genetic mutations in melanoma families, the aim of this study was to examine family members' views about their risk of melanoma, gene testing and genetic research.

METHODS

Self-report data were gathered using online and paper-based surveys available in four languages among 312 individuals (62% from Europe, 18% from Australia, 13% from the United States of America (USA) and 7% from Israel).

RESULTS

Fifty three percent had been diagnosed with a melanoma, and 12% had a positive susceptibility gene test result. Respondents with many moles and freckles were more likely to perceive themselves at risk for developing melanoma (odds ratio [OR](Freckles)=2.24 with 95% confidence interval [CI]=1.18-4.26; OR(Many moles)=6.92, 95%CI=2.37-20.23). Respondents who had received a non-informative (negative) genetic test result were much less likely to perceive themselves at increased risk (OR=0.17, 95% CI=0.04-0.73). Safe-guards were perceived as important to protect genetic information, but there was also support for the storage and exchange of such information. Overall, respondents were in favour of genetic testing, even if current knowledge about melanoma risk genes is still limited. Contrary to previous studies, participants reported that a non-informative (negative) genetic test result, although not necessarily indicative of lower risk of melanoma, would be likely to reduce their practise of preventive behaviours.

CONCLUSIONS

Participants were influenced by their phenotype and test results in risk estimations. They expressed positive views on genetic research and towards genetic testing, but reported that a non-informative (negative) test result might be associated with an (erroneous) perception of reduced risk and fewer preventive behaviours. These results highlight the urgency of improving the quality of genetic counselling and increasing the effectiveness of communication regarding genetic test results.

Psychosocial aspects of post-treatment follow-up for stage I/II melanoma: a systematic review of the literature

BACKGROUND

Patients treated for melanoma are advised to have lifelong full body skin examinations. Extended intervals between examinations have been proposed, but although this may be clinically effective, psychosocial aspects of follow-up are not well understood. This systematic review summarised patient and clinician preferences, experiences and adherence with recommended follow-up of stage I/II melanoma.

METHODS

Medline, PsycINFO, CINAHL, Embase, Cochrane Library, ACP Journal Club and NHS Economic Evaluation Database were searched from database inception to week 3 April 2010, to identify original studies of psychosocial outcomes of follow-up after treatment of stage I/II primary cutaneous melanoma, as reported by patients or clinicians. The results were synthesised, and characteristics likely to maximise patients' well-being and adherence to follow-up schedules were proposed.

RESULTS

We found 15 studies that met the inclusion criteria. Anxiety with melanoma follow-up was common; patients valued reassurance, information and psychosocial support, but long-term adherence to schedules was variable. Some wanted more emotional support from their clinician than was provided. Clinicians sometimes ordered additional blood and imaging tests to reassure patients. GPs were hesitant to conduct melanoma follow-up, but a trial providing technical training and protocols reported positive outcomes. Both patients and GPs wanted prompt access to melanoma specialists when suspicious lesions were found.

CONCLUSION

Psychosocial aspects of follow-up impact on patient well-being and potential adherence to schedules, and may influence clinician practice. If follow-up schedules or personnel are to be revised, psychosocial impacts on patients must be explicitly addressed, as well as guidance and specialist support for clinicians.

Cachrys pungens Jan inhibits human melanoma cell proliferation through photo-induced cytotoxic activity

OBJECTIVE

To date, plants belonging to the genus Cachrys have not been amply studied. In the present study, aerial components of Cachrys pungens Jan from Italy, were examined to assess their free radical-scavenging and antioxidant activity, and their phototoxicity on A375 melanoma cells. In view of potential pharmaceutical applications, a relationship between antioxidant, phototoxic activities and polyphenolic composition has also been investigated.

MATERIALS AND METHODS

Content of sterols, terpenes, fatty acids and coumarins was assessed by gas chromatography-mass spectrometry and GC. Total phenolic content was also determined. Antioxidant activity of the methanol extract and fractions of C. pungens Jan was assessed using DPPH scavenging assay and β-carotene bleaching test. Plant phototoxicity was also investigated in this human tumour cell line (amelanotic melanoma).

RESULTS

  Analysis of the chloroform extract was particularly interesting, as it led to identification of many coumarins, of which five were linear and one angular furanocoumarins. Methanol and ethyl acetate fractions exhibited substantial antioxidant activity. Moreover, chloroform extract and isolated coumarin fraction had strong phototoxic activity on UVA-induced A375 cells after irradiation at UVA dose of 1.08 J/cm.

CONCLUSIONS

Plant-derived natural compounds are an important source for development of cancer-fighting drugs. This study has demonstrated strong phototoxic activity of the coumarin fraction of C. pungens, a plant which, to our knowledge, has never been studied before. This investigation offers a new perspective for developing other formulations potentially useful in photodynamic therapy for treatment of non-melanoma skin cancers as well as melanomas.

Melanoma survivors: health behaviors, surveillance, psychosocial factors, and family concerns

BACKGROUND

Little research has been conducted on melanoma survivors and important opportunities exist for research in this understudied population. The study objective was to examine experiences of melanoma survivors regarding sun protection, surveillance practices, psychosocial and family concerns using focus groups.

METHODS

We identified patients (≥ 18 years) treated at Memorial Sloan-Kettering Cancer Center (USA) during 1996-2005 with invasive primary cutaneous melanoma, stages I-III. We stratified focus groups by age (<50 vs ≥ 50 years) and years since diagnosis (1 to <5 years vs 5-10 years). We performed qualitative thematic text analysis, which involved independent data review by multiple analysts (n = 2) followed by interpretation of key findings via consensus work.

RESULTS

Forty-eight survivors composed the final sample. Most did not conduct routine skin self-examinations. Survivors became more conscious of sun exposure and expanded their sun protection; some experienced anxiety if caught unprotected in the sun. Survivors were aware of the increased melanoma risk for family members, yet many did not discuss risk reduction. Melanoma diagnosis elevated the importance of retaining health insurance and purchasing life insurance for younger survivors. We did not identify significance difference between those diagnosed more or less recently.

CONCLUSIONS

We identified areas of high priority to melanoma survivors: skin self-examination, anxiety associated with sun exposure, familial risk communication, and maintaining health insurance benefits. The implications for cancer survivors are that these behavioral data will help to design health promotion and prevention programs that are tailored to melanoma survivors' risk status.

The antimitogenic effect of the cannabinoid receptor agonist WIN55212-2 on human melanoma cells is mediated by the membrane lipid raft

Here are reported the antiproliferative effects of the cannabinoid agonist WIN upon human melanoma cells expressing mRNA and protein for both CB1 and CB2 receptors. While WIN exerted antimitogenic effects, selective CB1 or CB2 agonists were unable to reproduce such effects and selective CB1 and CB2 antagonists did not inhibit WIN-induced cell death. Cells treated with WIN, preincubated with the lipid raft disruptor methylcyclodestrin, were rescued from death. WIN induced activation of caspases and phosphorylation of ERK that were attenuated in cultures treated with methylcyclodestrin. Membrane lipid raft complex-mediated antimitogenic effect of WIN in melanoma could represents a potential targets for a melanoma treatment.

The in vitro PDT efficacy of a novel metallophthalocyanine (MPc) derivative and established 5-ALA photosensitizing dyes against human metastatic melanoma cells

BACKGROUND AND OBJECTIVE

Numerous worldwide clinical trials have shown that photodynamic therapy (PDT) represents an effective and safe modality for various skin disorders, but little research has been done in terms of its effect on malignant melanomas (MM). Thus, the aim of this study was to compare the effect of both established porphyrin photosensitizer 5-aminolevulinic acid (5-ALA) and novel metallophthalocyanine (MPc) photosensitizer on human metastatic skin cells which produce a MM.

MATERIALS AND METHODS

The cellular responses following PDT were assessed using changes in cell morphology, cell viability, cytotoxicity, apoptosis, and proliferation.

RESULTS

Findings reported that in vitro human MM cell line A375 (EACC no: 88113005) are highly sensitive to growth inhibition and apoptosis induction by the cytotoxic side-effects induced by MPc and 5-ALA photosensitizing treatments post-laser irradiation at 680 and 636 nm, respectively. The decrease of cell viability accompanied by an increased cytotoxicity and apoptotic and necrotic levels, with a time-dependant decrease in cellular proliferation was found to be far more significant for MPc-treated cells than 5-ALA-treated cells, since MPc was applied in far lower concentrations and exhibited far less photoxicity to control cells.

CONCLUSION

Hence, novel MPc proved to be the better photosensitizing dye for metastatic melanoma tumor destruction in combination with laser irradiation and is a particularly attractive photosensitizer since it exhibits so many ideal properties of a photosensitizing agent, thus further research of this possible anticancer agent could contribute to its potential application in PDT cancer treatment of MMs.

Melanoma prevention using topical PBISe

Malignant melanoma is the deadliest form of skin cancer, known for its drug resistance and high metastatic potential. Deregulated PI3 and mitogen activated protein (MAP) kinase pathways promote early melanocytic lesion development and confer drug resistance. No agent exists to target these deregulated pathways to prevent cutaneous noninvasive melanocytic cells or invasive melanomas from developing into more aggressive widely disseminated metastatic disease. In this study, a selenium containing isosteric analogue of PBIT [S, S'-1,4-phenylenebis(1,2-ethanediyl)bis-isothiourea] called PBISe [Se, Se'-1,4-phenylenebis(1,2-ethanediyl)bis-isoselenourea] is shown to moderate these 2 major signaling pathways to prevent cutaneous melanocytic lesion or melanoma development. Topical application of PBISe retarded melanocytic lesion development in laboratory-generated skin by 70% to 80% and in animal skin by approximately 50%. Mechanistically, prevention of lesion development occurred due to decreased Akt3 signaling, which increased MAP kinase pathway activity to inhibitory levels. The combined effect of targeting these pathways led to decreased cell proliferation and increased apoptotic cell death thereby preventing melanoma development. Thus, topically applied PBISe treatment has potential to prevent noninvasive melanocytic lesion and invasive metastatic melanoma development in skin.

[Long-term survival of adult cancer patients from a psychosomatic perspective - literature review and consequences for future research]

OBJECTIVES

The increasing survival of cancer patients is the result of early detection, improved treatment, and demographic change. This poses urgent questions regarding the stresses and needs for care long-term survivors face.

METHODS

A literature survey (PubMed, Scopus) was conducted based on all publications with a psychooncological background from 2004 to 2008 concerning long-term survivors.

RESULTS

Of the 164 publications found, 74 referred to breast cancer; 62 % came from the United States and only 4 % from Germany. Although overall quality of life among long-term survivors appears to be good, considerable adverse somatic effects (long-term effects, late consequences, recidivism, second tumors) and mental effects (e.g., fear of recurrence) persist. Somatic and psychosocial determinants of long-term adjustment, health behaviour, health care needs and utilization, and the quality of life of next-to-kin have hardly been studied. The effects of psychotherapy on survival remain controversial.

CONCLUSIONS

In light of the growing number of long-term surviving cancer patients, it is necessary to study their strains and needs for care under a lifespan perspective.

[Psycho-oncological aspects of malignant melanoma. A systematic review from 1990-2008]

BACKGROUND AND METHODS

Despite the increasing prevalence of malignant melanoma, psychosocial aspects have found little attention. A systematic review was conducted in order to identify psycho-oncological articles on patients with malignant melanoma.

RESULTS

Out of a total of 31 studies, 12 examine quality of life in malignant melanoma patients and 6 studies monitor quality of life in the course of therapy. Most studies originate from English-speaking countries (USA, UK, AU); few German studies have been published. Methodological limitations of the studies include cross-sectional assessment, unreported return rate, small sample sizes and comparability (heterogeneous or non-standardized psychosocial measures).

CONCLUSIONS

In addition to the tumor stage, psychosocial characteristics (coping with disease, social support) have a substantial effect on quality of life. Results from psychotherapy trials with malignant melanoma patients are encouraging. Given the overall high survival rates of malignant melanoma, quality of life and needs for care of long-term survivors need to be assessed.

Patterns of photoprotection following CDKN2A/p16 genetic test reporting and counseling

BACKGROUND

The impact of melanoma genetic testing and counseling on photoprotective behaviors is unknown.

OBJECTIVE

To determine if genetic testing and counseling alter compliance with photoprotection recommendations.

METHODS

Reported use of sunscreen, protective clothing, and sun avoidance by 59 members of CDKN2A/p16-mutation positive pedigrees was assessed as a function of mutation status and melanoma history, before, immediately after, and 1 month following test reporting.

RESULTS

Intentions to practice all photoprotective behaviors increased in all participant groups (P < .0001). At 1 month, 33% of participants reported the adoption of a new photoprotective behavior. Subpopulation analyses identified different patterns of change in photoprotection relative to baseline (P < .005), with no net decline in any group.

LIMITATIONS

This initial study of CDKN2A/p16 families is small and awaits replication in a larger sample.

CONCLUSION

Melanoma genetic testing and counseling enhanced intentions to implement photoprotective strategies and did not result in reduced compliance in the CDKN2A/p16-subpopulation.