Multidisciplinary care in the management of melanoma

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Background

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.

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Evidence

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.[1] This is largely based on extrapolation from non-trial data in other cancers, where it is associated with improved survival.[2][3]

Current guidelines for melanoma management in the United States[4] and Europe[5] 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[6] but provide no evidence to support this recommendation.

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Evidence summary and recommendations

Evidence summary Level References
Multidisciplinary care improves quality of life in melanoma patients. I, II [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]
Evidence-based recommendationQuestion mark transparent.png Grade
Multidisciplinary care should be considered in the management of all patients with stage III and stage IV melanoma.
C

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References

  1. Marsden JR, Newton-Bishop JA, Burrows L, Cook M, Corrie PG, Cox NH, et al. Revised UK guidelines for the management of cutaneous melanoma 2010. J Plast Reconstr Aesthet Surg 2010 Sep;63(9):1401-19 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20728418.
  2. Kesson EM, Allardice GM, George WD, Burns HJ, Morrison DS. Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women. BMJ 2012 Apr 26;344:e2718 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22539013.
  3. Sainsbury R, Haward B, Rider L, Johnston C, Round C. Influence of clinician workload and patterns of treatment on survival from breast cancer. Lancet 1995 May 20;345(8960):1265-70 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7746056.
  4. Coit DG, Thompson JA, Algazi A, Andtbacka R, Bichakjian CK, Carson WE 3rd, et al. Melanoma, Version 2.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2016 Apr;14(4):450-73 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27059193.
  5. Dummer R, Hauschild A, Lindenblatt N, Pentheroudakis G, Keilholz U, ESMO Guidelines Committee. Cutaneous melanoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015 Sep;26 Suppl 5:v126-32 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26314774.
  6. National Collaborating Centre for Cancer (UK). 2015 Jul Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26334080.
  7. Campolmi E, Mugnai F, Riccio M, Santosuosso U, Saccardi A, Giove S, et al. Simultaneous care and melanoma: preliminary report about the psychoncological approach. G Ital Dermatol Venereol 2011 Dec;146(6):425-30 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22095174.
  8. Chua TC, Saxena A, Morris DL. Surgical metastasectomy in AJCC stage IV M1c melanoma patients with gastrointestinal and liver metastases. Ann Acad Med Singapore 2010 Aug;39(8):634-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20838706.
  9. Clark MM, Rummans TA, Atherton PJ, Cheville AL, Johnson ME, Frost MH, et al. Randomized controlled trial of maintaining quality of life during radiotherapy for advanced cancer. Cancer 2013 Feb 15;119(4):880-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22930253.
  10. Cubitt JJ, Khan AA, Royston E, Rughani M, Middleton MR, Budny PG. Melanoma in buckinghamshire: data from the inception of the skin cancer multidisciplinary team. J Skin Cancer 2013;2013:843282 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24163771.
  11. Field S, Deady S, Fitzgibbon J, Murphy M, Comber H. Improved malignant melanoma prognosis at a consultant-delivered multidisciplinary pigmented lesion clinic in Cork. Ir Med J 2010 Feb;103(2):40-3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20666053.
  12. Gutman H, Ben-Ami E, Shapira-Frommer R, Schachter J. Multidisciplinary management of very advanced stage III and IV melanoma: Proof-of-principle. Oncol Lett 2012 Aug;4(2):307-310 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22844375.
  13. Khan F, Amatya B, Pallant JF, Rajapaksa I, Brand C. Multidisciplinary rehabilitation in women following breast cancer treatment: a randomized controlled trial. J Rehabil Med 2012 Sep;44(9):788-94 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22858869.
  14. Khan F, Amatya B, Ng L, Demetrios M, Zhang NY, Turner-Stokes L. Multidisciplinary rehabilitation for follow-up of women treated for breast cancer. Cochrane Database Syst Rev 2012 Dec 12;12:CD009553 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23235677.
  15. Lee SJ, Lim HJ, Kim HY, Song CH, Kim BS, Lee WJ, et al. The feasibility of sentinel lymph node biopsy with a multidisciplinary cooperative team approach for the management of koreans with cutaneous malignant melanoma. Ann Dermatol 2010 Feb;22(1):26-34 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20548877.
  16. Lin JX, Chen XW, Chen ZH, Huang XY, Yang JJ, Xing YF, et al. A multidisciplinary team approach for nutritional interventions conducted by specialist nurses in patients with advanced colorectal cancer undergoing chemotherapy: A clinical trial. Medicine (Baltimore) 2017 Jun;96(26):e7373 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28658162.
  17. McCorkle R, Jeon S, Ercolano E, Lazenby M, Reid A, Davies M, et al. An Advanced Practice Nurse Coordinated Multidisciplinary Intervention for Patients with Late-Stage Cancer: A Cluster Randomized Trial. J Palliat Med 2015 Nov;18(11):962-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26305992.
  18. Meani RE, Pan Y, McLean C, Haydon A, Leung M, Kelly JW. The Victorian Melanoma Service: A 20-year review of an Australian multidisciplinary cancer service. Australas J Dermatol 2016 Aug;57(3):235-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26559638.
  19. Murchie P, Nicolson MC, Hannaford PC, Raja EA, Lee AJ, Campbell NC. Patient satisfaction with GP-led melanoma follow-up: a randomised controlled trial. Br J Cancer 2010 May 11;102(10):1447-55 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20461089.
  20. Voruganti T, Grunfeld E, Jamieson T, Kurahashi AM, Lokuge B, Krzyzanowska MK, et al. My Team of Care Study: A Pilot Randomized Controlled Trial of a Web-Based Communication Tool for Collaborative Care in Patients With Advanced Cancer. J Med Internet Res 2017 Jul 18;19(7):e219 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28720558.

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Appendices