Close monitoring and lifetime follow-up is optimal for patients with a history of melanoma

A Digital Intervention to Improve Skin Self-Examination Among Survivors of Melanoma: Protocol for a Type-1 Hybrid Effectiveness-Implementation Randomized Trial

BACKGROUND

Although melanoma survival rates have improved in recent years, survivors remain at risk of recurrence, second primary cancers, and keratinocyte carcinomas. The National Comprehensive Cancer Network recommends skin examinations by a physician every 3 to 12 months. Regular thorough skin self-examinations (SSEs) are recommended for survivors of melanoma to promote the detection of earlier-stage, thinner melanomas, which are associated with improved survival and lower treatment costs. Despite their importance, less than a quarter of survivors of melanoma engage in SSEs.

OBJECTIVE

Previously, our team developed and evaluated a web-based, fully automated intervention called mySmartSkin (MSS) that successfully improved SSE among survivors of melanoma. Enhancements were proposed to improve engagement with and outcomes of MSS. The purpose of this paper is to describe the rationale and methodology for a type-1 hybrid effectiveness-implementation randomized trial evaluating the enhanced MSS versus control and exploring implementation outcomes and contextual factors.

METHODS

This study will recruit from state cancer registries and social media 300 individuals diagnosed with cutaneous malignant melanoma between 3 months and 5 years after surgery who are currently cancer free. Participants will be randomly assigned to either enhanced MSS or a noninteractive educational web page. Surveys will be collected from both arms at baseline and at 3, 6, 12, and 18 months to assess measures of intervention engagement, barriers, self-efficacy, habit, and SSE. The primary outcome is thorough SSE. The secondary outcomes are the diagnosis of new or recurrent melanomas and sun protection practices.

RESULTS

Multilevel modeling will be used to examine whether there are significant differences in survivor outcomes between MSS and the noninteractive web page over time. Mixed methods will evaluate reach, adoption, implementation (including costs), and potential for maintenance of MSS, as well as contextual factors relevant to those outcomes and future scale-up.

CONCLUSIONS

This trial has the potential to improve outcomes in survivors of melanoma. If MSS is effective, the results could guide its implementation in oncology care and nonprofit organizations focused on skin cancers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/52689.

Follow-up in melanoma patients

Due to lack of evidence from prospective clinical trials, the diagnostic procedures, their frequency, as well as the length of the follow-up period in cutaneous melanoma patients should be based on the individual risk of disease recurrence, which is strongly dependent on the stage of disease at the time of diagnosis. In the paper we propose the current recommendations for follow-up strategy. Nowadays, new effective treatment options with biological agents justify the closer monitoring of high risk melanoma patients.

Serum CEACAM1 Correlates with Disease Progression and Survival in Malignant Melanoma Patients

The search for melanoma biomarkers is crucial, as the incidence of melanoma continues to rise. We have previously demonstrated that serum CEACAM1 (sCEACAM1) is secreted from melanoma cells and correlates with disease progression in metastatic melanoma patients. Here, we have used a different cohort of melanoma patients with regional or metastatic disease (N = 49), treated with autologous vaccination. By monitoring sCEACAM1 in serum samples obtained prior to and after vaccination, we show that sCEACAM1 correlates with disease state, overall survival, and S100B. The trend of change in sCEACAM1 following vaccination (increase/decrease) inversely correlates with overall survival. DTH skin test is used to evaluate patients' anti-melanoma immune response and to predict response to vaccination. Importantly, sCEACAM1 had a stronger prognostic value than that of DTH, and when sCEACAM1 decreased following treatment, this was the dominant predictor of increased survival. Collectively, our results point out the relevance of sCEACAM1 in monitoring melanoma patients.

Outpatient Follow-up and Secondary Prevention for Melanoma Patients

Health care providers and their patients jointly participate in melanoma prevention, surveillance, diagnosis, and treatment. This paper reviews screening and follow-up strategies for patients who have been diagnosed with melanoma, based on current available evidence, and focuses on methods to assess disease recurrence and second primary occurrence. Secondary prevention, including the roles of behavioral modification and chemoprevention are also reviewed. The role of follow-up dermatologist consultation, with focused physical examinations complemented by dermatoscopy, reflectance confocal microscopy, and/or full-body mapping is discussed. Furthermore, we address the inclusion of routine imaging and laboratory assessment as components of follow-up and monitoring of advanced stage melanoma. The role of physicians in addressing the psychosocial stresses associated with a diagnosis of melanoma is reviewed.

Systemic dysregulation of CEACAM1 in melanoma patients

It was previously shown that CEACAM1 on melanoma cells strongly predicts poor outcome. Here, we show a statistically significant increase of serum CEACAM1 in 64 active melanoma patients, as compared to 48 patients with no evidence of disease and 37 healthy donors. Among active patients, higher serum CEACAM1 correlated with LDH values and with decreased survival. Multivariate analysis with neutralization of LDH showed that increased serum CEACAM1 carries a hazard ratio of 2.40. In vitro, soluble CEACAM1 was derived from CEACAM1(+), but neither from CEACAM1(-) melanoma cells nor from CEACAM1(+) lymphocytes, and directly correlated with the number of CEACAM1(+) melanoma cells. Production of soluble CEACAM1 depended on intact de novo protein synthesis and secretion machineries, but not on metalloproteinase function. An unusually high percentage of CEACAM1(+) circulating NK and T lymphocytes was demonstrated in melanoma patients. CEACAM1 inhibited killing activity in functional assays. CEACAM1 expression could not be induced on lymphocytes by serum from patients with high CEACAM1 expression. Further, expression of other NK receptors was impaired, which collectively indicate on a general abnormality. In conclusion, the systemic dysregulation of CEACAM1 in melanoma patients further denotes the role of CEACAM1 in melanoma and may provide a basis for new tumor monitoring and prognostic platforms.

[Post-treatment surveillance for potentially curable malignancies]

Through an enormous research effort over the past five decades and especially due to early screening, an increasing number of cancers are potentially curable. Patients expand immeasurable energy in adhering to treatment plans and supportive care. Unfortunately, nothing prepares them for the anxiety that often comes with completion of therapy. More importantly, physicians are not properly equipped with data from controlled trials to define appropriate post-treatment surveillance, data with which they could educate patients and allay their fears. The goal of post-treatment surveillance is to enable the early detection of relapses and thus enhance the possibility of subsequent cure. Accordingly special follow-up is appropriate only for patients who can receive a second-line therapy. Clinical trials support conservative, rather than aggressive, surveillance to detect curable local relapse of breast tumors and potentially surgically curable metastases (mainly in the liver) of colon cancer. For germ-cell tumors, second-line treatments are potentially curative in nearly all instances. Follow-up for other cancers depends on patients' anxiety levels and on the costs of surveillance.

Surgical management of distant metastases

Although the location of metastases is of prognostic importance in stage IV melanoma, as seen in the revised AJCC staging classification system and other studies, certain guiding principles apply to patients who have any stage IV disease. Close follow-up of any patient who has melanoma may identify surgically resectable metastatic disease, although this method is controversial. Components of this monitoring may include careful questioning to determine symptoms, such as cough, abdominal pain, or headaches; physical examination for evidence of skin, soft tissue, and lymph node metastases; and screening tools, such as radiographs and laboratory tests. Identifying patients who have metastatic disease at the earliest stage possible is crucial for surgical resection to be an option. Patients should also be thoughtfully evaluated for the possibility of a complete surgical re-section. Complete metastectomy, regardless of the anatomic site, confers survival advantages not seen with other treatment modalities. This aggressive surgical approach should be tempered with the knowledge that incomplete resections put patients at increased risk without any proven survival benefit, and should be reserved only for palliation of symptoms. Systemic adjuvant therapies for stage IV melanoma are evolving, but do not yet confer the survival advantage of complete surgical resection. Until novel drug therapies show efficacy and significantly prolong survival in patients who have stage IV disease, careful consideration should be given to a complete metastectomy if technically feasible.

Health profiles of 996 melanoma survivors: the M. D. Anderson experience

BACKGROUND

The incidence and survival of melanoma are increasing, but little is known about its long-term health effects in adult survivors.

METHODS

A health survey was available from 996 melanoma survivors (577 treated with surgery alone, and 391 with combined treatments). Their medical/physiologic and psychosocial responses were analyzed and compared with those of the survivors from other cancers.

RESULTS

The melanoma survivors were 44.8 +/- 12.8 years of age at diagnosis (significantly younger than the survivors of other cancers) and 63.7 +/- 12.8 years at survey. Melanoma survivors were less likely to report that cancer had affected their health than survivors of other cancers (15.8% vs. 34.9%). The 577 individuals treated with surgery alone reported arthritis/osteoporosis, cataracts, and heart problems most frequently (less often than survivors of other cancers). The 391 individuals who had undergone combined treatments reported circulation problems and kidney problems generally as often as survivors of other cancers. Health problems were not associated with number of decades since diagnosis but with age at diagnosis, treatment modality, and family relationships.

CONCLUSION

We present information from a large cohort of long-term survivors of melanoma. As a group, they were less likely to report that cancer had affected their overall health than survivors of other cancers; a number of disease related and psychosocial factors appear to influence their health profiles.

Risk of second primary cancers, other than melanoma, in an Italian population-based cohort of cutaneous malignant melanoma patients

A population-based study has been carried out in central Italy to investigate the risk of further non-melanoma primary cancers in a cohort of cutaneous malignant melanoma (CMM) patients. We considered 1835 invasive CMM cases (93.4% histologically verified) diagnosed between 1985 and 1999 by the Tuscany Cancer Registry, central Italy (1 200000 inhabitants) and actively followed up to the end of 1999 for vital status and for the occurrence of a second primary. Only cases diagnosed after 2 months (metachronous) from CMM diagnosis were considered. During 7758 person-years of observation, 94 cancers were observed (93.6% histologically verified) versus 73.8 expected, corresponding to a standardized incidence ratio (SIR) of 1.27 (95% confidence interval (CI) 1.03-1.56). The risk was similarly increased in both sexes, males SIR=1.31 and females SIR=1.23, and it was statistically significant among subjects younger than 60 years (SIR=1.76) but not among those of 60 years and older (SIR=1.14). Significant increased risks were observed for non-melanoma skin cancers (SIR=3.26) and non-Hodgkin's lymphoma (SIR=2.74). Physicians should be aware of the higher risk for non-Hodgkin's lymphoma and clinical follow-up should include lymph node palpation. However, the risk for extranodal lymphomas should also be kept in mind.