|In the context of a high suspicion of melanoma, any one feature from the seven point checklist (see practice point below) is adequate to prompt urgent referral to a regional melanoma service; excision in primary care should be avoided.||C|
|In the context of a low suspicion of melanoma, GPs should use the seven point checklist (see practice point below) to carefully monitor for change at the initial examination to be repeated at eight weeks.||D|
GPs should use the seven point checklist (Table 1) in the assessment of pigmented lesions to determine referral. Suspicion is greater for lesions scoring 3 points or more (based on major features scoring 2 points each and minor features scoring 1 point each).
Symptoms and signs
Clinical features of melanoma in adolescents and young adults (AYAs) are similar to those in adults. Melanomas usually present as a change in the size, shape, colour or feel (itchiness) of a skin lesion; ulceration or bleeding may also be present.
General practitioners (GPs) assessing for melanoma should examine the whole skin surface under good lighting.
AYAs with a lesion suggestive of melanoma should be urgently referred for investigation to a regional melanoma service (based in some public and private hospitals); locally advanced melanoma should be referred without biopsy. Excision in primary care should be avoided. GPs should consider reviewing unexpected pathology results with the reporting pathologist.
Seven point checklist
GPs should assess pigmented lesions using the seven point checklist (Table 1). Suspicion is greater for lesions scoring 3 points or more. However, if there is a high suspicion of melanoma, any one feature is adequate to prompt urgent referral. Low-suspicion lesions should be carefully monitored for change using the checklist for eight weeks.
Table 1. Seven point checklist for melanoma
| Major features
(score 2 points each)
| Minor features |
(score 1 point each)
Change in size
Diameter >7 mm
Oozing, crusting or bleeding
Change in sensation
Melanomas often present with an initial flat phase (superficial spreading melanoma, lentigo maligna melanoma and acral lentiginous melanoma) which are summarised by the ABCD(E) rule (Asymmetry, Border irregularity, Colour variation, large Diameter [and Evolution]). This can also be a useful tool for GPs to assess melanoma.
Detection of melanoma may be aided by dermoscopy (hand-held magnifying device used in combination with liquid applied between the transparent plate of the device and the skin or used with cross-polarised light). Training and utilisation of dermoscopy is recommended for GPs routinely examining pigmented skin lesions.
Exposure to ultraviolet radiation (UVR) from the sun or other source (e.g. solaria) is the primary risk factor for melanoma; other known risk factors include having fair skin or blond/red hair colour, freckles, a large number of moles (particularly abnormal moles), previous melanoma/other skin cancer/premalignant lesion (such as actinic keratoses), family history of melanoma or being female.
However, melanoma can occur in AYAs without any of these risk factors.
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- Bleyer A. CAUTION! Consider cancer: common symptoms and signs for early detection of cancer in young adults. Semin Oncol 2009 Jun;36(3):207-12 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19460578.
- Adolescent and Young Adult Working Party of the Statewide Cancer Clinical Network. South Australian Adolescent and Young Adult Cancer Care Pathway: Optimising outcomes for all adolescent and young adult South Australians with a cancer diagnosis. Adelaide: South Australia Department of Health; 2010.
- Australian Cancer Network Melanoma Guidelines Revision Working Party. Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand. Sydney: Cancer Council Australia and Australian Cancer Network and Wellington: New Zealand Guidelines Group; 2008.
- New Zealand Guidelines Group. Suspected cancer in primary care: guidelines for investigation, referral and reducing ethnic disparities. Wellington: New Zealand Guidelines Group; 2009.
- National Collaborating Centre for Primary Care. Referral Guidelines for Suspected Cancer. Clinical guideline 27. London: National Institute for Health and Clinical Excellence; 2005.
- Higgins EM, Hall P, Todd P, Murthi R, Du Vivier AW. The application of the seven-point check-list in the assessment of benign pigmented lesions. Clin Exp Dermatol 1992 Sep;17(5):313-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1458634.
- Friedman RJ, Rigel DS, Kopf AW. Early detection of malignant melanoma: the role of physician examination and self-examination of the skin. CA Cancer J Clin 2018 Feb 21;35(3):130-51 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3921200.
- Hamm H, Höger PH. Skin tumors in childhood. Dtsch Arztebl Int 2011 May;108(20):347-53 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21655460.