BJD BAD GUIDELINES British Journal of Dermatology Revised U.K. guidelines for the management of cutaneous melanoma 2010 J.R. Marsden, J.A. Newton-Bishop,* L. Burrows, M. Cook,à P.G. Corrie,§ N.H. Cox,– M.E. Gore,** P. Lorigan, R. MacKie,àà P. Nathan,§§ H. Peach,–– B. Powell*** and C. Walker University Hospital Birmingham, Birmingham B29 6JD, U.K. *University of Leeds, Leeds LS9 7TF, U.K. Salisbury District Hospital, Salisbury SP2 8BJ, U.K. àRoyal Surrey County Hospital NHS Trust, Guildford GU2 7XX, U.K. §Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 2QQ, U.K. –Cumberland Infirmary, Carlisle CA2 7HY, U.K. **Royal Marsden Hospital, London SW3 6JJ, U.K. The Christie NHS Foundation Trust, Manchester M20 4BX, U.K. ààUniversity of Glasgow, Glasgow G12 8QQ, U.K. §§Mount Vernon Hospital, London HA6 2RN, U.K. ––St James’s University Hospital, Leeds LS9 7TF, U.K. ***St George’s Hospital, London SW17 0QT, U.K. Correspondence Disclaimer Jerry Marsden. These guidelines reflect the best published data available at the time the report was E-mail: [email protected] prepared. Caution should be exercised in interpreting the data; the results of future Accepted for publication studies may require alteration of the conclusions or recommendations in this report. 24 May 2010 It may be necessary or even desirable to depart from the guidelines in the interests of Key words specific patients and special circumstances. Just as adherence to the guidelines may not evidence, guideline, investigation, melanoma, treatment constitute defence against a claim of negligence, so deviation from them should not necessarily be deemed negligent. Conflicts of interest None declared. These guidelines are published simultaneously in the British Journal of Dermatology This is an updated guideline prepared for the British Association of (DOI 10.1111/j.1365-2133.2010.09883.x) and the Journal of Plastic, Dermatologists (BAD) Clinical Standards Unit, made up of the Therapy & Reconstructive & Aesthetic Surgery (DOI 10.1016/j.bjps.2010.07.006). Guidelines Subcommittee (T&G) and the Audit & Clinical Standards Sub- committee (A&CS). Members of the Clinical Standards Unit are: H.K. Bell (Chairman T&G), L.C. Fuller (Chairman A&CS), N.J. Levell, M.J. Tidman, P.D. Yesudian, J. Lear, J. Hughes, A.J. McDonagh, S. Punjabi, N. Morar, S. Wagle (British National Formulary), S.E. Hulley (British Dermatological These guidelines for the management of cutaneous melanoma Nursing Group), K.J. Lyons (BAD Scientific Administrator) and M.F. present evidence-based guidance for treatment, with identifica- Mohd Mustapa (BAD Clinical Standards Manager). tion of the strength of evidence available at the time of Guidelines produced in 2002 by the British Association of Dermatolo- gists; reviewed and updated 2009. preparation of the guidelines, and a brief overview of epide- Guidelines review process miology, diagnosis, investigation and follow up. These guidelines were initially reviewed at a multidisciplinary meeting on Contribution to these guidelines has been made by a large 8 November 2007. Those attending were the authors plus: Dermatology: V. Doherty, D. Roberts, F. Wojnarowska, H. Bell, D. de Berker, number of clinicians. They have also been endorsed by, or C. Harwood, S. Bailey, R. Barlow, V. Bataille, L. Rhodes have had input from, representatives of the following groups Surgery: A. Hayes, J. Kenealy, G. Perks, M. Timmins or organizations: the U.K. Melanoma Study Group, the British Specialist nursing: H. Williams, C. McGarr, M. Sherman, J. Davenport, C. Wheelhouse Association of Dermatologists, the British Association of Histopathology: N. Kirkham, H. Rigby, J. Theaker Plastic, Reconstructive and Aesthetic Surgeons, the Royal Col- Imaging: J. Smith, P. Guest, A. Dancey Oncology: N. Steven, P. Patel, A. Goodman, C. Kelly, P. Lawton, A. Dalgleish lege of Physicians, London, the Association of Cancer Physi- Lay representative: T. Fay cians, the Royal College of Radiologists, London, the Royal Palliative care: J. Speakman, F. Calman National Institute for Health and Clinical Excellence: N. Summerton College of Surgeons of England, the Royal College of Patholo- Scottish Intercollegiate Guidelines Network: S. Qureshi gists (pathology section only), the Royal College of General Primary care: P. Murchie Practitioners, London, and the Department of Health. DOI 10.1111/j.1365-2133.2010.09883.x These consensus guidelines have been drawn up by a multi- disciplinary working party with membership drawn from a NHS Evidence has accredited the process used by the British Association of Dermatologists to produce guidelines. Accreditation is valid for three years from May 2010 and is applicable to guidance produced using the processes described in the British variety of groups and coordinated by the U.K. Melanoma Association of Dermatologists’ guidelines development manual (Bell & Ormerod, 2009). More information on accreditation can be viewed at www.evidence.nhs.uk. Study Group and the British Association of Dermatologists. Ó 2010 British Association of Dermatologists 238 Journal Compilation Ó British Association of Dermatologists • British Journal of Dermatology 2010 163, pp238–256 Guidelines for management of cutaneous melanoma 2010, J.R. Marsden et al. 239 The guidelines deal with aspects of the management of mela- promptly referred for investigation and treatment from an noma from its prevention, through the stages of diagnosis and LSMDT to an SSMDT (Table 1). initial treatment to palliation of advanced disease. PubMed literature searches for this guidelines revision Prevention of melanoma were carried out to identify publications from 2000 to April 2010, with search terms including: melanoma genetics, epi- Individuals, and particularly children, should not get sunburnt demiology, early diagnosis, risk factors, clinical features, (Level I).6–9 Meta-analysis of case–control studies provides good pathology, surgery, chemotherapy and clinical trials. Relevant evidence that melanoma is caused predominantly by intermit- materials were also isolated from reviews and other publica- tent intense sun exposure; fair-skinned individuals should there- tions identified from the PubMed searches, independent fore limit their recreational exposure through life (Level I).10 searches carried out by the authors, as well as materials col- People with freckles, red or blond hair, skin which burns in the lected by the authors as part of their ongoing professional sun, increased numbers of naevi, and those with a family history interest in the latest developments in this clinical area. Levels of melanoma are at increased risk and should heed this advice. of evidence to support the guidelines are quoted according Adequate sun exposure to allow vitamin D synthesis, or to the criteria stated in Appendix 1. The consultation process sufficient dietary intake of vitamin D3, is essential to human for British Association of Dermatologists guidelines and their health; insufficiency of vitamin D is now recognized to be compliance with guideline recommendations have been pub- common.11 It would therefore be inappropriate to greatly limit lished elsewhere.1,2 There are arguments in favour of newer sun exposure in people without the risk factors listed above. guideline grading methods, such as those of GRADE,3 but Recent studies have shown that in the U.K. vitamin D levels the authors believe that the system used here allows greater are often suboptimal in melanoma patients, and are lower in potential for consensus in areas of conflicting evidence or fair-skinned people.12,13 Fair-skinned people who avoid the where evidence sources are not directly comparable. In some sun rigorously to reduce the risk of melanoma should consider instances, this is not due to an absence of high quality supplementing their intake of vitamin D3 in the absence of (Level Ib) trials but because different entry criteria or end- medical contraindications. points preclude direct comparison of results; in other cases There is evidence from a recent meta-analysis that sunbed interpretation of the clinical significance of results has been usage does increase the risk of melanoma, particularly under challenged. To assist production of unified guidelines taking the age of 35 years, and therefore it is recommended that this account of these issues, the ‘quality of evidence’ grading should be avoided (Level Ia).14 used in these guidelines differs slightly from that used in other British Association of Dermatologists current guidelines; Referral and clinical diagnosis the ‘strength of recommendations’ grading is the same as used in many other publications. Where no level is quoted Melanoma remains relatively uncommon and therefore the the evidence is to be regarded as representing Level IV (i.e. opportunity to develop diagnostic skills is limited in primary a consensus statement). The intention of the working party was to agree best prac- tice for the management of melanoma in the belief that this Table 1 Melanoma patients who must be referred from a Local Skin will promote good standards of care across the whole country. Cancer Multidisciplinary Team to a Specialist Skin Cancer Multidisciplin- However, they are guidelines only. Care should be individual- ary Team (SSMDT) (National Institute for Health and Clinical Excellence 5 ized wherever appropriate. These guidelines will be revised as Improving Outcomes for People with Skin Tumours including Melanoma, 2006 ) necessary to reflect changes in practice in light of new evi- dence. • Patients with melanoma