National Institute for Health and Clinical Excellence (NICE)
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NICE publishes new guideline on most deadly form of skin cancer

Guidelines aim to reduce variations in practice and help the NHS deliver the very best in melanoma care.

NICE has today (29 July) published its first guideline on melanoma which aims to reduce the numbers of people dying from the disease, and addresses the wide variations across the country in diagnosis and treatment.

Melanoma is the third most common skin cancer in the UK and accounts for more cancer deaths than all other skin cancers combined. In 2012, there were over 2000 deaths from melanoma, and over the last thirty years, rates of malignant melanoma in Britain have risen faster than any of the current ten most common cancers.  Incidence rates have also increased more than five-fold since the mid 1970si.

Melanoma is a type of skin cancer which can spread to other parts of the body. It is most common in people who have pale skin, tend to burn in the sun or have many moles. It occurs when some cells in the skin begin to develop abnormally and is thought to be caused by exposure to ultraviolet (UV) light from natural or artificial sources.  However, this risk is more strongly linked to intermittent exposure to high-intensity sunlight rather than to chronic or continuous sunlight exposure.

The new NICE guideline focuses on assessing and managing melanoma, working out how far it has progressed (staging), identifying treatments for each stage of the disease, including when the cancer has spread, and outlines the best follow-up care after treatment.

Recommendations include:

  • Improved, preferably nationally standardised information should be made available to all patients with melanoma. Information should be appropriate to the patients’ needs at that point in their diagnosis and treatment, and should be repeated over time. The information given must be specific to the type of lesion, type of treatment, local services and any choice within them, and should cover both physical and psychosocial issues.
  • Dermoscopyii and other visualisation techniques: Assess all pigmented skin lesions that are either referred for further assessment or identified during follow-up in secondary or tertiary care, using dermoscopy carried out by healthcare professionals trained in this technique.
  • The guideline also makes recommendations about the use of sentinel lymph node biopsy and subsequent lymph node removal where the biopsy shows evidence that the disease has spread.
  • Include the brain as part of imaging for people with suspected stage 4 melanoma.  Consider whole-body MRI for children and young people (from birth to 24 years) with stage 3 or stage 4 melanoma. 
  • Follow-up after treatment for melanoma: Perform a full examination of the skin and regional lymph nodes at all follow-up appointments.  Consider personalised follow-up for  people who are at increased risk of further primary melanomas (for example people with atypical mole syndrome, previous melanoma, or a history of melanoma in first-degree relatives or other relevant familial cancer syndromes).  Consider including the brain for people having imaging as part of follow-up after treatment for melanoma.

Commenting on the new guideline, Professor Mark Baker, Centre for Clinical Practice director at NICE, said: “At this time of year, we all want to get out there and enjoy the sun, and there are plenty of ways to do that safely: using a sunscreen with a high SPF, spending time in the shade between 11am – 3pm, ensuring you don’t burn, and covering up with a hat, t-shirt and sunglasses. But, overexposure to ultraviolent light from the sun can have very serious repercussions.

“Melanoma causes more deaths than all other skin cancers combined. Its incidence is rising at a worrying rate – faster than any other cancer. If it is caught early, the melanoma can be removed by surgery. If it is not diagnosed until the advanced stages, it may have spread, so it is harder to treat. However, there are a number of options available to help slow the progress of the disease and improve quality of life.

“This new guideline addresses areas where there is uncertainty or variation in practice, and will help clinicians to provide the very best care for people with suspected or diagnosed melanoma, wherever they live.”

The new guideline will be available on the NICE website from 00:01hrs on Wednesday 29 July at: http://www.nice.org.uk/guidance/ng14

For more information call the NICE press office on 0300 323 0142 or out of hours on 07775 583 813.

Notes to Editors

References

1. Cancer Research UK cancer statistics. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/skin-cancer#heading-Zero

2. Dermoscopy is a non-invasive, widely used diagnostic tool that aids the diagnosis of skin lesions and is proven to increase the accuracy of melanoma diagnosis.

About the guideline

  1. The new guideline will be available at /guidance/ng14 from Wednesday 29 July 2015.  Embargoed copies of the guidance are available from the NICE press office on request.
  2. Related NICE guidance:

       a. Cancer service guidance on improving outcomes for people with skin tumours including Melanoma - /guidance/CSGSTIM. Cancer Service Guidance is a series of recommendations for the organisation and delivery of care for individuals in specific clinical conditions or circumstances – from prevention and self-care through to primary and secondary care and onto more specialised services

        b. Public health guidance on skin cancer prevention: information, resources and environmental changes - /guidance/PH32

        c. The draft public health guideline on sunlight exposure: communicating the benefits and risks to the general public - /guidance/gid-phg77/resources/sunlight-exposure-benefits-and-risks-draft-guideline2 (which includes a partial update of PH32) .

3. The stages of melanoma can be described as:

Stage 0 – the melanoma is on the surface of the skin. 

Stage 1A – the melanoma is less than 1mm thick.

Stage 1B – the melanoma is 1-2mm thick, or the melanoma is less than 1mm thick and the surface of the skin is broken (ulcerated) or its cells are dividing faster than usual (mitotic activity).

Stage 2A – the melanoma is 2-4mm thick, or the melanoma is 1-2mm thick and is ulcerated.

Stage 2B – the melanoma is thicker than 4mm, or the melanoma is 2-4mm thick and ulcerated.

Stage 2C – the melanoma is thicker than 4mm and ulcerated.

Stage 3A – the melanoma has spread into one to three nearby lymph nodes, but they are not enlarged; the melanoma is not ulcerated and has not spread further.

Stage 3B – the melanoma is ulcerated and has spread into one to three nearby lymph nodes but they are not enlarged, or the melanoma is not ulcerated and has spread into one to three nearby lymph nodes and they are enlarged, or the melanoma has spread to small areas of skin or lymphatic channels, but not to nearby lymph nodes.

Stage 3C – the melanoma is ulcerated and has spread into one to three nearby lymph nodes and they are enlarged, or the melanoma has spread into four or more lymph nodes nearby.

Stage 4 – the melanoma cells have spread to other areas of the body, such as the lungs, brain or other parts of the skin.

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.

Our products and resources are produced for the NHS, local authorities, care providers, charities, and anyone who has a responsibility for commissioning or providing healthcare, public health or social care services.

To find out more about what we do, visit our website:www.nice.org.uk and follow us on Twitter: @NICEComms.

 

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