Melanoma is increasing in frequency. This is probably due to increasing sun exposure without using sunscreen, as well as use of tanning lamps, beds and salons, all of which increase exposure to UV radiation (astonishingly, 35 percent of adults and 59 percent of college students in America use these tanning sources).
We are all reminded of this increasingly common cancer by President Jimmy Carter's recent disclosure of his challenge facing widespread melanoma. In May, his doctors discovered a spot on his liver. When attempting to remove the lump surgically, they discovered that it was a melanoma that had probably spread from previously undiagnosed skin melanoma. As a routing part of the evaluation, the physicians performed a brain MRI, which showed four unsuspected metastatic deposits.
Courageously, President Carter shared his news with the public and rapidly began radiation treatments to his brain and received a new immunotherapy pembrolizumab. He is continuing to teach Sunday school at Maranatha Baptist Church in Plains, GA, so the side effects of his treatments have not prevented him from continuing his productive life.
An interesting part of President Carter's story is his strong family history of pancreatic cancer. Among his family members, pancreatic cancer has been diagnosed in three siblings and his father and mother. Like other familial cancer syndromes, the familial atypical multiple mole melanoma syndrome (FAMMM) and also the familial atypical multiple mole melanoma and pancreatic cancer syndrome (FAMMM-PC) are associated with a mutation in a gene called CDKN2A associated with melanoma as well as pancreatic cancer (and even other cancers). We do not know if President Carter has this gene mutation for the familial atypical multiple mole melanoma pancreatic cancer (FAMMM-PC) syndrome. But this observation emphasizes how much progress medicine has made in understanding how gene mutations can lead to different types of cancer, and how important it is for people to share their family history with their physicians.
So here are my tips about melanoma:
• Prevention: You can help prevent melanoma by reducing sun exposure. Remember the international recommendations: slip, slop, slap and wrap. This cute expression reminds us to slip on a shirt (many more melanomas occur also on the arms and chest), slop on high SPF sunscreen (water resistant of course, and repeat the application frequently, it makes you more attractive!), slap on a hat (many melanomas occur on the forehead and scalp), and wrap on UV protective glasses to protect your eyes. Also, do not use tanning lamps, beds or salons.
• Screening: Does your doctor ask you to disrobe and examine all your skin, nail beds, and mouth? If not ask for a dermatology consultation to screen you for melanoma and other skin cancers (basal cell carcinoma and squamous cell carcinomas as well as precancerous dysplastic nevi which should be removed). For more information on second opinions with doctors who will do the complete exam, see my book Surviving American Medicine.
• Diagnosis: If you have a mole that has any suspicious feature make sure you have a biopsy. These suspicious features are "ABCDE" which describes Asymmetry (uneven areas in a mole), Border (irregular edges in a mole), Color (variable color lighter and darker in a mole), Diameter (a mole larger than ¼ inch), or Evolving (any mole that changes in size or color or border). If any one of these is observed (and have your spouse, significant other, or family member check the areas you cannot see like your back), then have your doctor or dermatologist check it at once.
• Genetic testing: If you have a family history of melanoma, especially multiple melanomas in 1 or more individuals, or other cancers as well as melanoma, ask your doctor for a gene test to see if you have the FAMMM syndrome (familial atypical multiple mole melanoma). If your doctor does not know about this, ask for a second opinion with an oncologist or genetic counselor to get the gene test for a CDK2A mutation performed. If you have a melanoma, certain gene tests can predict for effective therapy. Ask your oncologist for a test for a BRAF mutation and if she/he does not know about it, get a second opinion.
• Treatment for melanoma: Ask you surgeon if your melanoma resection has met the current guidelines and if you need a sentinel node biopsy to be sure you do not have any spread of the cancer. And if the melanoma has spread to other organs, be sure to ask you doctor if you are eligible for one of the new effective treatments. Like President Carter, immunotherapy drugs have been favored for some treatments, so ask your oncologist about pembrolizumab, nivolumab and ipilimumab. Targeted chemotherapy may be appropriate for patients whose cancer has a target mutation, so ask if you have BRAF mutation and if drugs like vemurafenib, trametanib or dabrafenib might be good treatments. And ask if you should have a brain MRI, like President Carter, to detect any spread that needs to be treated with newer radiation techniques.
Your skin is your link with the outside world, so keep it cancer-free and melanoma-free. I am sure President Carter wants your never to have a melanoma, and these tips will help you.