Identification and management of high-risk individuals

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Clinical practice guidelines for the diagnosis and management of melanoma > Identification and management of high-risk individuals


Introduction

This chapter of the Guidelines considers the evidence underlying the identification and management of individuals at high risk of melanoma.

The Australian Clinical Practice Guidelines for Management of Cutaneous Melanoma (2010) recommended that people at high risk of melanoma have ongoing surveillance, and be educated about skin self-examination and appropriate sun protection. However, Australia has no population-based melanoma screening program, and neither the main observable risk factors, such as fair skin, sun-sensitivity and naevus (mole) count, nor the genomic variations that underlie them, are currently used systematically to stream high-risk individuals for targeted prevention, screening or early detection programs. A recent evidence synthesis for the US Preventive Services Taskforce concluded: “Future research on skin cancer screening should focus on evaluating the effectiveness of targeted screening in those considered to be at higher risk for skin cancer”.[1]

The 2010 edition of these Guidelines highlighted the strong evidence that individual melanoma risk is influenced by a range of risk factors: some demographic (e.g. age, sex, geographic location), some marked by skin phenotype (e.g. pigmentation, melanocytic naevi), some only signalled by personal or family history of melanoma (e.g. a high-risk genetic background). It concluded that genetic testing of CDKN2A mutations had a role in highly selected familial melanoma kindred's. It provided guidance on the appropriate surveillance of individuals at high risk, from whatever cause.

In the current guideline, evidence and recommendations have been updated in three areas:

  • the genetic basis of high melanoma risk,
  • integrated risk assessment, considering all relevant risk factors, and
  • evidence for benefit of identification and systematic surveillance of individuals at high risk of future melanoma.

Taken together, there is evidence that clinical practice should change in both the areas of risk assessment and surveillance.

References

  1. Wernli KJ, Henrikson NB, Morrison CC, Nguyen M, Pocobelli G, Blasi PR. Screening for Skin Cancer in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2016 Jul 26;316(4):436-47 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27458949.