Pauline Funchain:
Welcome to the ASCO Post Roundtable Series on Evolving Skin Cancer Management. I'm Dr. Pauline Funchain. I am a Medical Oncologist at Stanford University where I am co-director of the Skin Cancer Genomics Program and Co-director of the Immunotherapy Toxicity Program. I have two wonderful panelists with me today and I will have them introduce themselves. Dr. Vidimos?
Allison Vidimos:
Hello, I'm Allison Vidimos. I'm the Chairman of the Department of Dermatology at the Cleveland Clinic. I am a dermatologic surgeon and Mohs surgeon, and my practice is cutaneous oncology.
Pauline Funchain:
And Dr. Zaba?
Lisa Zaba:
My name is Dr. Zaba, and I run the Merkel cell carcinoma multidisciplinary clinic at the Stanford Cancer Center.
Pauline Funchain:
Well, thank you for joining me today. Today, we are discussing the treatment of skin cancer with four patient cases. Our final installment, we'll focus on the treatment of melanoma in younger patients. Let me introduce to you case four.
Case four is a 32-year-old woman, Mrs. Anderson, who recently gave birth to her first child. Shortly after childbirth, she noticed a suspicious pigmented lesion on her thigh looking something like this. A biopsy confirms the diagnosis of melanoma with a breast load depth of 3 millimeters.
There's no ulceration, but there is a mitotic rate of 8/mm2. Let me just start with initial thoughts about this. Here's a young person who has a melanoma right after childbirth. We're definitely seeing increases in melanoma in the young, and certainly we know that melanoma is common in young women. What are your experiences of melanoma in young women and what are your thoughts about the increases that we're seeing in melanoma diagnosis?
Allison Vidimos:
I think some of it is people are coming in for skin checks, so we're catching them more. I definitely think tanning beds play a role, and we are doing a lot of education in the community level and legislative advocacy efforts at the state level to try to restrict access by minors to them. Because I'm sure in your practices, when a patient comes with a melanoma and you're taking their history, many of them say, "Yes, I did tanning beds. I did a lot of tanning bed sessions when I was a teenager." And that just breaks my heart, because it's something preventable in many cases.
Lisa Zaba:
I completely agree, Dr. Vidimos. It is utterly heartbreaking when someone has a potentially lethal diagnosis due to tanning beds. I'm so grateful that many states are now taking action and preventing tanning of minors. I'll also say about this case that potentially, the reason that the patient is coming in after childbirth is because there does tend to be a hesitancy amongst general dermatologists to biopsy a patient when they're pregnant.
And there are guidelines for this, that lidocaine, even with epi, we typically remove the epinephrine when we perform a biopsy in a pregnant patient just with the lidocaine. But if there is a concerning pigmented lesion, regardless of the trimester of the pregnant patient, please just biopsy that patient. Early diagnosis is key in melanoma, and therefore, even a pregnant patient should be biopsied even if it's just with lidocaine.
Pauline Funchain:
There's some literature about pregnant women or the perinatal period and melanoma. Do you do anything different in terms of screening? I hear that. I think it's good to say that there should be no reason to not biopsy a pregnant woman, and there are ways around using the epinephrine, but we know that there are more pigmented lesions, that sort of benign pigment lesions that happen during pregnancy. Should there be more surveillance of pregnant women or pregnant women with a history of melanoma? Is there anything that you would do differently or advise a young woman to do?
Allison Vidimos:
I'd say if they've had a history of melanoma or atypical nevi, we'd watch them closer. And I think again, this is an opportunity for us to educate our gynecology, OB-GYN colleagues as well, to mention it to the patient, mention that they should be doing self-skin exams once a month. Is anything new? Is anything changing? You can tell them that the moles on their abdomen and breasts are going to look funky because of tissue stretching, and that's to be anticipated and not be overly alarmed, but keep an eye on them and bring them to the attention of your doctor. So I would say, but a patient with no nevi, less worry.
Pauline Funchain:
Don’t worry?
Allison Vidimos:
Right.
Pauline Funchain:
Okay. When you say more closely, let's say someone has a history of melanoma, you're usually seeing them every 3 to 6 months anyway, right? Would you see them more than that or do something different?
Allison Vidimos:
I'd probably stay at that frequency with the caveat that you're educating them to call or MyChart message you if there's something concerning.
Lisa Zaba:
Completely agree.
Pauline Funchain:
All right. The other thing, I think that we think about in all of our patients, just varying degrees but usually younger people, I think we get more nervous about prognosticating. Is this melanoma harmful? Is there anything that needs to be done? Is there some reason, let's say for systemic surveillance? There are these commercial gene expression profiling panels that are out there for melanoma that would like to put risk categories on melanomas that are outside of staging. And we know there's a lot of controversy about these panels, so I'd love to hear both of your thoughts on gene expression panels and prognostication in melanoma. Don't all jump up at once.
Allison Vidimos:
Since you were at Cleveland Clinic and you were running our tumor board, I'm going to turn that back on you, because you kind of drove the boat about this. Seriously, you and Dr. Gassman.
Pauline Funchain:
Yeah, and we had slightly different opinions.
Allison Vidimos:
Yes.
Lisa Zaba:
I'd like to point out one thing though. This patient has a mitotic rate of 8/mm2. In the genetic tests that are performed, many of them actually look at the driver, the genes that are related to cell proliferation, and those are the driving things. And so a mitotic rate of 8/mm2 is highly concerning no matter which way you skin this cat. This one's a problem. Take it away, Dr. Funchain, and talk about the genetics of this, the genomic test.
Pauline Funchain:
I will say that I like, as a scientist before, before I was a physician, I'll take any data I can, and I really love to have more data. And I have been known to get biomarkers of questionable or potential future use into use now, just because I want to have any more information than I can get. And I think patients like that, and I think that is the appealing thing of gene expression profiling is you feel like you're getting more data. I think the hard thing about gene expression profiling is that we really haven't shown as a field, I don't think we have shown that it is hugely different than things like mitotic rate or staging. I think that there have been some studies that show maybe a small additive effect over staging potentially, but it's hard to know. And that in particular, a lot of the data are retrospective.
I think as a field, I think there's controversy for a reason. I guess I would say there's probably not a strong argument that it must be used and there's not a strong argument that it can't be used. But what you do with it then becomes very challenging, and I think a lot of us feel that it's difficult to interpret to patients, because it looks so black and white. But if it does have a true additive effect or separate effect, it's not as big as what it looks like on the paper, and that becomes very hard to explain to patients. And most of us don't really want to deal with, and this is just being realistic as a practitioner, most of us don't want to deal with fine shades of gray if we don't have to, because there's so many other things that are really important to explain the fine shades of gray to patients about, "Did you get radiation?" or "Should you get a sentinel lymph node?", or whatever it is.
I will say personally, I do not use this regularly in practice. I will deal with it if my colleague orders it or really wants to order it. But yeah, because it's controversial and it's in wide use, it was a topic. And I appreciate you letting me be a sounding board or hearing your thoughts about it, because it sounds like nobody wants to really say one way or the other, which is fair. The takeaways, really, for melanoma, we could have gone really long into adjuvant therapy, new adjuvant therapy, but just went on to touch on some of the more controversial spaces and spaces where melanoma has movement and changes, like the incidents in young people.
I think our takeaways from this discussion are really that for gene expression profiling, I think that practices are all over the place, that its benefit is still quite controversial. I would importantly point out that NCCN, it's not currently recommended for routine use. And in terms of melanoma in young adults, I am hearing no reason to have open access to a carcinogenic exposure through tanning beds in young adults. And that for pregnant patients who have had a history of melanoma, certainly to follow closer or more closely, and that we are seeing melanoma in young people. Young people should be aware of skin changes that may be melanoma.
And that, I think, brings us to the end of this case. For more titillating discussions on the latest in skin cancer, see our other segments or visit ascopost.com.
