Multidisciplinary care in the management of melanoma
Patients with melanoma can experience very different clinical courses, with the requirements for appropriate treatment and support dependent on their stage of disease. The great majority present with early (stage I or stage II) melanoma and their care is usually provided by a general practitioner, a dermatologist or a surgeon, with critically important input from a pathologist. If sentinel node biopsy is undertaken, a nuclear medicine physician is also involved.
A much smaller group of patients present with or develop advanced (stage III and stage IV) melanoma and their care can involve further medical and allied health specialists – surgical oncologists, medical oncologists, radiation oncologists, specialty site surgeons (e.g. neurosurgeons, upper gastrointestinal tract surgeons), radiologists (both diagnostic and interventional), oncology nurses, physiotherapists, clinical trial staff, palliative care providers and psychologists. In some settings this care is provided in a sequential manner, where each specialty independently makes a recommendation but then interacts with other specialties, with written communication between care providers.
A more satisfactory alternative to this process for patients with stage III and stage IV melanoma is fully integrated multidisciplinary care, in which all involved specialists (including pathologists) meet to discuss treatment options and any uncertainties relating to their cases, share the latest evidence and consider patient suitability for clinical trials. The outcome of the multidisciplinary discussion can then be fed back to the patient directly, or via their primary care provider. This coordinated multidisciplinary approach has been shown to lead to more carefully considered care decisions, fewer missed opportunities for better care or clinical trial involvement, and greater collaboration across specialties. Multidisciplinary clinics tend to exist in large cancer treatment facilities and feasibility usually excludes attendance by general practitioners, however detailed information should always be fed back to primary care providers. Based on limited clinical trial evidence but many reported non-trial assessments and case series, it appears that, as would be expected, multidisciplinary clinics lead to better health outcomes for cancer patients and enhanced clinical trial recruitment.
Is multidisciplinary care of value in the management of melanoma?
Despite the absence of good quality randomised trials of multidisciplinary care in melanoma patients, there is strong support from expert bodies for a multidisciplinary approach. This is largely based on extrapolation from non-trial data in other cancers, where it is associated with improved survival.
Current guidelines for melanoma management in the United States and Europe do not include recommendations in relation to multidisciplinary care. Guidelines from the United Kingdom recommend referral to a multidisciplinary team for management of oligometastatic stage IV melanoma but provide no evidence to support this recommendation.
Evidence summary and recommendations
|Multidisciplinary care improves quality of life in melanoma patients.||I, II||, , , , , , , , , , , , , |
|Multidisciplinary care should be considered in the management of all patients with stage III and stage IV melanoma.||C|
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