Melanoma: Prevention, Detection and Treatment - Stephanie Badalamenti, MD - Library of the Chathams - 6.10.2021

Sun safety needs to start at an early age, and continue throughout life, in order to reduce the risk for skin cancer. Learn about prevention and ways to reduce your risk, screening for skin cancer and innovations in treatments.

1. Melanoma Prevention, Detection & Treatment Presented by: Stephanie Badalamenti, MD, PhD, Dermatology June 10, 2021

2. Melanoma Define Melanoma Magnitude of Problem Prevention Detection Diagnosis/Staging Treatment 2

3. What is Melanoma? 3

4. What is Melanoma? 4

5. Melanoma Survival by Depth 5

6. Melanoma Survival Stage of Diagnosis Stage of Distribution 5-year Survival Localized (primary site) 84% 99% Regional spread (nodes) 9% 66% Distant spread organs 4% 27% 6

7. r 7 Magnitude of the Problem Melanoma

8. Magnitude of the Problem 8

9. Magnitude of the Problem 120,000 cases detected each year 8,700 deaths per year Most early detectable cancers: colorectal, breast, cervical and prostate have demonstrated substantial declines over the past 3 decades; however, melanoma mortality rates have continued to rise 9

10. 10 Melanoma Risk Factors Prevention

11. Melanoma Risk Factors Ultra-Violet Radiation (Tanning Salons, Sun Light) Personal history of Melanoma Family history of Melanoma Dysplastic nevi  More than 50 moles Age/Gender Skin type Occupation Socioeconomic Status 11

12. Energy – UV Rays 12

13. Sunshine Rays 13

14. Ultraviolet Light 14

15. Tanning Salons 15

16. Tanning Salons In a quest to get a “sunless” tan, almost 30 million Americans visit indoor tanning salons each year. On an average day, more than 1 million Americans visit tanning salons. Of these, 70% are Caucasian girls and women between the ages of 16 and 49. More than 25% of teen girls have used tanning salons three or more times in their lives.  "Ever-use of indoor tanning services is associated with a 20% increase in lifetime melanoma risk, and this risk doubles if use begins before age 35 years." 16

17. Percentage of U.S. High School Students Who Reported Indoor Tanning in the Past Year 17

18. Natural Sunlight 18

19. Natural Sunlight Five sunburns doubles your risk of melanoma Cumulative and intermittent sun exposure High altitudes increase exposure Reflection off sand and snow increase exposure 19

20. Seek Shade 20

21. Sun Protective Clothing 21

22. Sunscreen 22

23. Sunscreen 23

24. Sunscreen 1-2 ounce 30 minutes prior exposure Reapplied every 2 hours SPF 30- 50 Creams Lotions Gels Sprays 24

25. Sun Protection Slip Slap Slop 25

26. Do public health campaigns that are aimed at modifying sun exposure work? Increased use of sun protection Decreased the number of sunburns  Decreased the number of squamous cell and basal cell skin cancer   Decreased thickness of melanoma at diagnosis 26

27. 27 Early detection saves lives!! Detection

28. Detection Increase the detectors General Public Spot the Spot ABCDEs High Risk Patient Improve the detectors Education Technology Dermoscopy Full Body Photography Eye on future technology Telemedicine-MoleSafe, iPhone Apps Confocal Microscopy  Non- invasive DNA technology DermTech 28

29. 29 ABCDEs Melanoma

30. A -Asymmetry Benign Mole - Symmetrical 30

31. A symmetry- These are Melanomas - Asymmetrical 31

32. B  -Boarder Benign Mole – Sharp Boarder 32

33. B -Border These are Melanomas – Uneven Borders 33

34. C  -Color Benign Mole – One Color 34

35. C -Color These are Melanomas – Two or More Colors 35

36. D Diameter Benign Mole – 6mm or Smaller 36

37. D - Diameter These are Melanomas – Larger than 6mm 37

38. E volving This is Melanoma – a Mole that Changes 38

39. 39 Remember: A symmetry B order C olor D iameter E volving Get ready spot detectors?

40. Is this Melanoma? 40

41. Is this Melanoma? 41

42. Is this Melanoma? 42

43. Is this Melanoma? 43

44. Is this Melanoma? 44

45. Is this Melanoma? 45

46. Is this Melanoma? 46

47. Is this Melanoma? 47

48. 48 Because screening saves lives! Screening

49. Screening High Risk Patients New or Changing Mole ABCDEs Personal History of Melanoma Family History of Melanoma History of Tanning Salon Use Older Light Skin Men* 49

50. 50 Improving the Detectors

51. Dermoscopy Studies show this tool improves our accuracy at identifying Melanomas   This tool gives us another pattern to correlate with the ABCDEs of Melanoma 51

52. Dermoscopy 52

53. Full Body Photograph 53

54. 54 Future technologies 

55. Future-Confocal Microscopy 55

56. Future-Telemedicine 56

57. Future-Non-invasive DNA technology-DermTech 57

58. 58 Diagnosis/Staging Melanoma

59. Biopsy 59

60. Excisional Biopsy 60

61. Skin Sample 61

62. Skin Tissue Processed 62

63. Dermatopathologist 63

64. Dermatopathologist Essential Tumor thickness Ulceration Mitotic rate Margins Anatomic level Microsatellitosis Optional Angiolymphatic invasion Histologic subtype Neurotropism Regression T stage Tumor infiltrating lymphocytes and vertical growth phase 64

65. Melanoma Staging 65

66. Sentinel Node Biopsy 66 Sentinel lymph node

67. Sentinel Lymph Node Biopsy: Lymphoscintigraphy 67 Sentinel lymph node Injection of radiotracer around melanoma

68. 68 Treatment                 Surgical                 Medical

69. Surgical Treatment – NCCN-Recommended Surgical Margins for Melanoma Tumor Thickness Recommended Margin In situ 0.5 cm < 1.0 mm 1.0 cm 1.01 – 2 mm 1—2 cm 2.01 – 4 mm 2.0 cm > 4 mm 2.0 cm 69

70. Surgical Treatment 70

71. Surgical Treatment 71

72. Surgical Treatment 72

73. Surgical Treatment What about patients who have Melanoma in their sentinel lymph nodes? Until 2017:  Completion lymph-node dissection was standard for all patients. MSLT-II Clinical Trial  -provided prognostic information -did not increase melanoma-specific survival  73

74. Medical Treatment Radiation therapy Chemotherapy Biologic therapy 74

75. Treatment of Advanced Melanoma 75

76.  Immune checkpoints and their inhibitors in advanced melanoma. 76

77. Dysregulation of the MAPK signaling pathway in melanoma 77

78. Month Day, Year 78

79. Decreasing the Mortality Rate of Melanoma 79

80. 80 Prevention Detection Well informed patients Well trained dermatologists Diagnosis Dermatopathologist Treatment Integrated team dermatologists, oncologic surgeons, oncologists Summit Health

81. Learn more about Summit Health’s Dermatology Team at summithealth.com Thank You! 81

82. References Jenkins, R. W. & Fisher D. E. ( 2021) Treatment of Advanced Melanoma in 2020 and Beyon d.  Journal Investigative Dermatology  141, 23-31 Welch, H. G., Mazer, B.L., and Adamson A. A.(2021)  The Rapid Rise in Cutaneous Melanoma Diagnoses .  New England Journal of Medicine . 384(1): 72-79. Qian, Y., Johannet, P., Sawyers, A., Yu., Osman, I., and Zhong, J.(2020) The Ongoing Racial Disparities in Melanoma: An analysis of the Surveillance, Epidemiology, and End Results (SEER) database (1975-2016). Journal of the American Academy of Dermatology .08.097 Paulson, K.G., Gupta, D., Kim, T. S., Veatch, J. R., Byrd, D. R., ... Gardner, J.M. (2020) Age-Specific Incidence of Melanoma in the United States ,  Journal of American Medical Association Dermatology . 156(1): 57-64. Leonardi, G.C., Candido, S., Falzone,L., Spandidos, D.A., ….Libra, M.(2020)  Cutaneous Melanoma and the Immunotherapy Revolution .  International Journal of Oncology  57: 609-618 Trucco, L.D., Mundra, P.A., Hogan, K.  et al. (2019)  Ultraviolet radiation–induced DNA damage is prognostic for outcome in melanoma .  Nature Medicine   25,  221–224  Kann, L., Mc Manus, T., Harris, W. A.,Shanklin, S. L., Flint, K. H.,...Ethier, K. A. (2108)  Youth Risk Behavior Surveillance- United States, 2017 .  Morbidity and Mortality Weekly Report  .67(8) 1-114. 82

83. References Faries, M. B, Thompson, J.F., Cochran, R. H, Andtback, N., Mozzillo, J.S., ...Elashoff, R. M (2017)  Completion Dissection or Observation for sentinel-Node Metastasis in Melanoma .  New England Journal of Medicine  376; (23) :2211-2222. Gershenwald, J. E., Scolyer, R. A., Hess, K. R, Sondak, V. K, Long, G. V.,...Thompson, J.F. (2017)  Melanoma Staging: Evidence-Based Changes in the American Joint Committee on Cancer Eighth Edition Cancer Staging Manual .  Cancer Journal Clinics  67(6):472-492. Trip, M.K., Watson, M., Balk, S. J., Swetter, S. M.,... Gershenwald, J.E. (2016)  State of the Science of Prevention and Screening to Reduce Melanoma Incidence and Mortality:   The Time is Now .  Cancer Journal Clinics . 66(6):460-480. Boniol M, Autier P, Boyle P, Gandini S.(2012) Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis .  British Medical Journal .345:e4757. Riegel, D.S., Russak, J., & Friedman. R. (2010)  The Evolution of Melanoma Diagnosis: 25 Years Beyond the ABCD's . CA a Cancer Journal For Clinicians. 60(5): 301-16 Abbasi NR, Shaw HM, Rigel DS, Friedman R. J., McCarthy W. H., ...Polsky. D. (2004) Early diagnosis of cutaneous melanoma: revisiting the ABCD criteria .  Journal of American Medical Association  292:2771–2776. 83

84. How to find out if your dermatologist did a dermatology residency FAAD Fellow of the American Academy of Dermatology https://find-a-derm.aad.org/ Routine dermatologist-performed full-body skin examination and early melanoma detection. Kantor J, Kantor  DE.Arch  Dermatol. 2009 Aug;145(8):873-6.  doi : 10.1001/archdermatol.2009.137.PMID: 19687416 84

85. Questions? 85