Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand
Cancer Council Australia, Australian Cancer Network, Ministry of Health, New Zealand
These guidelines were developed for use in 2 countries with a very high incidence of melanoma1. From 1998 to 2002, the age-standardized incidence rate of melanoma in Australia and New Zealand ranged from 21.7 to 55.8 per 100,000 population, depending on sex and region2. Comparatively, the age-standardized incidence of skin melanoma in Canada was 15.7 per 100,000 in 20073.Most melanomas are the result of exposure to ultraviolet radiation from the sun4, and survival has been associated with depth of invasion, which suggests a role for early detection1. Therefore, this guideline focuses on prevention, screening, and identification and management of individuals at high risk of melanoma.
RELEVANCE TO CTFPHC MANDATE
The following sections of this guideline are applicable to the CTFPHC mandate of prevention in primary care:
- Section 1: Prevention
- Section 2: Population-based whole-body skin screening for melanoma
- Section 3: Identification of high-risk individuals
The target population for this guideline is not clearly stated; however, on the basis of the recommendations, it can be inferred that it applies to people of all ages and all ethnic backgrounds.
EVIDENCE REVIEW METHODS
The following databases were searched from mid-2006 to early 2007: MEDLINE, Embase, PubMed, CINAHL, Cochrane Library, AUSThealth, Clinical Evidence, and PsycINFO. Reference lists of relevant articles were hand searched. The specific research questions are unknown. GRADING SYSTEM Each recommendation was assigned a grade of A to D, based on features of the body of evidence, including volume, consistency, generalizability, applicability and clinical impact1. “Good practice points” refer to statements made by the developer that could not be graded (Table 2). METHODOLOGICAL QUALITY The CTFPHC assessed the methodological quality of the guideline using the Appraisal of Guidelines Research & Evaluation (AGREE II) criteria (Table 1).This guideline scored above 60% on the domains of Scope and Purpose, Rigour of Development, and Editorial Independence; therefore, the CTFPHC has classified it as a high-quality guideline. Concordance among reviewers, as measured through standard deviation of AGREE II scores, was high (SD < 1.5) for all domains except Editorial Independence.
|AGREE II domain||Domain score||Standard deviation|
|Scope and purpose||83%||1.4|
|Rigour of development||70%||1.3|
|Clarity of development||86%||0.7|
The scope and purpose of this guideline are clearly described, with good separation of screening from diagnosis and case-finding. The recommendations are presented clearly, with links to the supporting evidence. Further, the guideline development group included individuals from all relevant disciplines, as well as a consumer representative, and the views and preferences of patients were sought through public review.
However, the rigour of development scored relatively low, primarily because methodological details (research questions, inclusion and exclusion criteria) were only available upon request (information not received), making it difficult to determine whether the included evidence is appropriate. There is also a lack of discussion about facilitators and barriers to the application of these recommendations, which would have been helpful for family physicians. Although these recommendations are based on evidence obtained in early 2007, the guideline states that updates will be posted online if needed6. Methods are provided for addressing conflicts of interest, but the CTFPHC did not identify any evidence of such conflicts.
Overall, this guideline provides clear and concise recommendations for prevention, screening and identification of individuals at high risk of melanoma. Although the incidence of melanoma is lower in Canada than in Australia and New Zealand, the recommendations seem sensible and applicable for use in Canadian practice.
ORIGINAL GUIDELINE RECOMMENDATIONS
The full guideline can be found at cancer.org.au.
Prevention of melanoma
- Sunburn be avoided and UV protection (physical methods complemented by sunscreens) adopted. (Grade B)
- Sunscreens be used to complement but not to replace physical methods of UV protection. (Grade C)
- Risks associated with exposure to tanning booths and sunbeds be explained. (Grade C)
- As brief sun exposures are needed to maintain vitamin D levels, total lack of sun exposure is not advised without vitamin D supplementation. (Grade C)Population screening for melanoma
- In the absence of substantive evidence as to its effectiveness in reducing mortality from melanoma, population-based skin screening cannot be recommended.
(Grade C)Identification and management of high-risk individuals
- Clinical assessment of future risk of melanoma take into account:
- person’s age and sex
- history of previous melanoma or non-melanoma skin cancer
- family history of melanoma
- number of naevi (common and atypical)
- skin and hair pigmentation
- response to sun exposure
- evidence of actinic skin damage(Grade B)
- Individuals at high risk of melanoma and their partner or carer be educated to recognise and document lesions suspicious of melanoma, and to be regularly checked by a clinician with six-monthly full body examination supported by total body photography and dermoscopy as required. (Grade C)
- Prophylactic removal of non-suspicious lesions is not recommended since it is unlikely to increase survival and therefore may incur unnecessary procedures and give false reassurance as many new melanomas in high-risk individuals will occur outside pre-existing naevi. (Good practice point)
- Screening for a genetic mutation such as the CDKN2A gene be contemplated only after a thorough clinical risk assessment (the patient is at personal high risk of melanoma), confirmation of a strong family history of melanoma (there is a significant probability of a family mutation), and appropriate genetic counselling. (Grade C)
- Clinical assessment of future risk of melanoma take into account:
- Australian Cancer Network Melanoma Guidelines Revision Working Party. Clinical practice guidelines for the management of melanoma in Australia and New Zealand. Sydney, Australia, and Wellington, New Zealand: Cancer Council Australia, Australian Cancer Network, New Zealand Guidelines Group; 2008.
- World Health Organization, International Agency for Research on Cancer. Cancer incidence in five continents. Vol. 1 to 9. Online analysis, Table by population. Lyon, France: IARC; 2010. Available at: http://ci5.iarc.fr/CI5i-ix/ci5i-ix.htm. Accessed 2013 May 29.
- Chronic disease infobase data cubes. Ottawa, ON: Public Health Agency of Canada; 2013. Available at: http://22.214.171.124/cubes/intro-e.html. Accessed 2013 May 28.
- IARC monographs on the evaluation of carcinogenic risks to humans. Vol. 55: Solar and ultraviolet radiation. Lyon, France: International Agency for Research on Cancer; 1992.
- Skin cancer clinical guidelines. Cancer Council Sydney, Australia; 2008. Available at: http://www.cancer.org.au/health-professionals/clinical-guidelines/skin-cancer.html. Accessed 2013 May 29.