Updated melanoma guidelines stress consensus, clear safety margins

German experts came together to update guidelines on melanoma management and create consensus out of fragmented standards of care by experts across multiple fields.

“Unfortunately, there are no international standards of care for melanoma,” said Dr. Axel Hauschild of the University Hospital Schleswig-Holstein in Campus Kiel, Germany, who is one of the collaborators on the updated guidelines. “The current standards of care vary from country to country, and international guidelines by the European Dermatology Forum and European Society for Medical Oncology are truly expert opinions with a low evidence level.”

The guidelines, prepared over 2 years, include 124 recommendations and statements for the diagnosis, treatment and follow-up of melanoma by professionals representing 24 different disciplines, as well as patients.

One of the most basic criteria, Hauschild said, was to agree on safety margins for excision. “For these, there already existed a true international consensus. There is only evidence for a maximum 2 cm safety margin for tumor thickness at all stages, even for stage IV tumors thicker than 4 mm.”

Another key recommendation was to eliminate the practice of amputation in all but the most necessary cases.

“In many countries it’s like a reflex to say it’s melanoma on the toe, and the toe needs to be removed,” Hauschild said.

However, amputation does not increase the probability of survival compared with conservative treatment. In the revised guidelines, amputation is only indicated if the cancer has spread to the bone.

The updated guidelines also touched on when to perform sentinel node biopsy, which types of diagnostic imaging tests are the most effective, the impact of adjuvant chemotherapy, and how to do genetic testing. The guidelines also stated that eligible patients should be made aware of their options for enrollment in clinical trials.

Follow-up recommendations emphasized self-examination of skin and lymph nodes by patients as an essential part of early detection, particularly for relapses and secondary melanomas. “About half of such metastases were usually detected by patients or by relatives,” said Hauschild.

Psychological support, especially for stage IV melanoma patients, and early involvement of palliative care were also important changes.