NICE UK issues a new guideline which covers the full pathway of care in melanoma. It focusses on staging, identifying treatments for each stage of the disease including when the disease has spread, and outlines the best follow-up care after treatment. It also includes recommendations on managing low vitamin D levels, and the use of sentinel lymph node biopsy for staging.
NICE recommendations for management of stage IV melanoma
Management of oligometastatic stage IV melanoma
NICE recommends referral to the specialist skin cancer multidisciplinary team (SSMDT) for recommendations about staging and management.
NICE advises considering surgery or other ablative treatments (including stereotactic radiotherapy or radioembolisation) to prevent and control symptoms of oligometastatic stage IV melanoma in consultation with site‑specific MDTs (such as an MDT for the brain or for bones).
NICE recommends discussing the care with the SSMDT.
NICE recommends referral of patients with melanoma and brain metastases that might be suitable for surgery or stereotactic radiotherapy to the brain and other central nervous system tumours MDT for a recommendation about treatment.
Systemic anticancer treatment
For adult patients, NICE recommends consulting its technology appraisal guidance on dabrafenib for treating unresectable or metastatic BRAF V600 mutation-positive melanoma.
For adult patients, “vemurafenib is recommended as an option for treating BRAF V600 mutation‑positive unresectable or metastatic melanoma only if the manufacturer provides vemurafenib with the discount agreed in the patient access scheme”. This recommendation is from NICE's technology appraisal guidance on vemurafenib for treating locally advanced or metastatic BRAF V600 mutation-positive melanoma.
NICE recommends for adult patients its technology appraisal guidances on ipilimumab for previously treated and untreated advanced (unresectable or metastatic) melanoma.
NICE recommends considering dacarbazine for patients with stage IV metastatic melanoma if immunotherapy or targeted therapy are not suitable.
It also recommends not routinely offering further cytotoxic chemotherapy for stage IV metastatic melanoma to patients previously treated with dacarbazine except in the context of a clinical trial.
Melanoma accounts for more deaths from cancer than all other skin cancers combined
The disease is linked to exposure to ultraviolet (UV) light which is emitted by the sun and by sunbeds. Estimates suggest that up to 86% of melanomas could be caused by exposure to UV light.
Over the past 30 years rates of melanoma have risen faster than any of the current ten most common cancers. Studies have linked the rising incidence with the increased sun exposure people are experiencing through repeated holidays abroad.
Measure vitamin D levels at diagnosis
Since melanoma is linked to sun exposure, and around 10% of patients with melanoma have a subsequent melanoma, clinicians often ask patients to reduce their contact with the sun at diagnosis.
However, in the UK where people get limited sun exposure, avoiding the sun can hamper the uptake of vitamin D. Vitamin D is important for keeping bones and teeth healthy, and a lack can lead to deformities such as rickets in children, and osteomalacia in adults which causes pain and tenderness.
Consequently, the NICE guideline recommends that all patients with melanoma should have their vitamin D levels measured at diagnosis in secondary care.
Measuring vitamin D levels at diagnosis allows doctors to identify patients with melanoma whose vitamin D levels are low and who might benefit from supplements in line with UK national policies. It will also help identify people with high vitamin D levels who do not need supplementation and in whom supplementation might be harmful.
Knowing a person’s vitamin D level will also improve the accuracy of the advice given to them about the risks and benefits of sunlight exposure.
Use sentinel lymph node biopsy for staging rather than treatment
The NICE guideline also recommends that doctors should consider using sentinel lymph node biopsy as a staging rather than a therapeutic procedure for people with stage IB–IIC melanoma with a Breslow thickness of more than 1 mm. Patients should also be given detailed verbal and written information about the possible advantages of using the procedure.
Clinicians should explain that there are no clear survival benefits to using the procedure. However, it can be used to predict what might happen in the future and people who have had the operation may be able to take part in clinical trials of new treatments for melanoma.