By Jan Bowers, contributing writer
A diagnosis of advanced melanoma marks the beginning of a difficult journey for patients. Dermatologists are increasingly involved with the care of these patients, in collaboration with oncologists and other specialists. Some of these dermatologists specialize in advanced melanoma and serve as critical members of a multispecialty care team. Others seek the expertise of surgical and medical oncologists when they discover melanoma in one of their patients.
Dermatology World spoke with three dermatologists who collaborate with other specialists to care for patients with advanced melanoma, and one who treats a variety of disorders in a pediatric cancer clinic. They explored the role of the dermatologist in a multidisciplinary care team, how the teams function, and how community dermatologists can connect their patients with oncology specialists.
Team dynamics and the dermatologist’s role
At the University of Wisconsin-Madison School of Medicine and Public Health, a diagnosis of Stage IB melanoma or higher typically triggers the involvement of specialties beyond dermatology, said Yaohui Gloria Xu, MD, associate professor of dermatology. “Those patients deserve to hear whether they’re a candidate for sentinel lymph node biopsy, which might be done by a surgical oncologist, or — if it’s on the head or neck — an ENT who specializes in head and neck cancer.” Patients who are elderly or have significant comorbidities may decline the biopsy and opt for local excision only; then “they might still come back to us for their care,” said Dr. Xu. A medical oncologist would normally be consulted for a patient at stage III or IV, but “there is a little gray zone. A patient could be lower than stage III, maybe IIB, but have a high risk of local/regional recurrence. Then we might still involve the medical oncologist to see if adjuvant therapy should be considered. While systemic adjuvant therapy is currently only approved by the FDA for patients with resected melanoma that is stage IIIA or greater, there are clinical trials currently in progress to study the potential benefit of adjuvant therapy for patients with resected stage IIB melanoma.”
The melanoma tumor board at UW tackles particularly complicated cases of advanced melanoma, where the optimal path for treatment isn’t clear, said Dr. Xu. After one unsuccessful attempt to establish a board when she first arrived, in 2014 she succeeded in her efforts to persuade other specialists that rapid advances in the treatment of advanced melanoma would yield enough cases to support twice-monthly meetings. “My medical oncologist is the main driver now, but in the beginning, he needed a little push,” she remarked. “I approached him and a few other key players in surgical oncology, radiation oncology, radiology, and pathology. As junior faculty, I didn’t have an established relationship with these colleagues, but after a few years navigating the system, they knew me as more than a colleague because we share patients together — more like a friend.”
Dr. Xu describes the dermatologist’s role on the board as supportive. “We follow the patients for general skin checks and treat cutaneous side effects. We’re in the car, but not the driver.” In one recent case, however, she alerted the group that small reddish nodules a half-inch away from a skin graft (performed after excision of pigmented melanoma) could be amelanotic melanoma. “I said we needed to biopsy those as well. It was an in-transit mass, a local-regional recurrence, so not an ordinary recurrence, but worse. The surgeon said based on these biopsies, this is way beyond the graft site, so not a good case for surgery. These are the cases that present routinely on the tumor board. Sometimes nobody knows what to do, there’s not enough data, but at least you have a reasonable consensus.”
The melanoma tumor board at the University of Texas MD Anderson Cancer Center typically reviews patients “whose disease is progressing, and we’re having a multidisciplinary evaluation as to whether they could be surgically cleared; if not, then what combination of radiation therapy and systemic therapy is appropriate for the next step in their care,” said Kelly C. Nelson, MD, associate professor of dermatology. “We’ve also discussed patients who have subtle tumors for which the surgeons may be having trouble clearing the margins. That’s really where the dermatologist becomes very engaged, to help define the extent of disease involvement.” Outside of the tumor board, Dr. Nelson’s role in team care varies by patient, she explained. “We care for patients who have advanced cancer of all different types. Over time, I’ve served in a role of almost a palliative dermatologist. Patients may have metastatic deposits from any cancer on their skin, and sometimes those can be a challenge from a bleeding standpoint. We also serve in this role of trying to optimize patients’ quality of life, even when they are at an advanced stage of disease.”
Like Dr. Nelson, Jennifer Huang, MD, helps manage the complications of cancer treatment, but her patients are children seen at the Jimmy Fund Clinic, the pediatric oncology department at Dana-Farber Cancer Institute. “I take care of rashes that patients get from chemotherapy, and more and more I’m seeing rashes from targeted anti-cancer therapy,” she said. “Another subset of patients that I see are those with graft-versus-host-disease (GVHD) who have received bone marrow transplants. The skin is the most common organ involved in GVHD, and both acute and chronic GVHD can be quite severe. I also take care of cancer survivors, doing regular skin checks on patients exposed to radiation and immunosuppression.”
Dr. Huang runs a monthly dermatology clinic at the Jimmy Fund Clinic and often sees patients with a medical oncologist, an arrangement she characterized as “really rewarding. We’re learning from each other, and the patient gets one single message, which is nice.” She said she views the oncologists as the “primary care providers, responsible for taking care of the patient as a whole,” but emphasized that the specialists have a lot to teach each other. “Often I will be in a situation where the oncologist wants to stop treatment because the patient has some sort of skin reaction,” she remarked. “As dermatologists, we can identify what skin conditions are and are not life-threatening, and guide the oncologist in managing the patient’s oncologic therapy.”
Collaboration with oncologists was the topic of a popular session at the most recent AAD annual meeting. Jason C. Sluzevich, MD, dermatologist and dermatopathologist at the Mayo Clinic in Jacksonville, Florida, said his talk focused on how dermatologists can facilitate collaboration in the management of patients with advanced melanoma and cutaneous T-cell lymphoma. “The landscape has changed because medical treatment for melanoma has become much better, so there’s an increasing role for adjuvant therapy,” he noted. In an integrated health practice like the Mayo Clinic, “it’s very easy to send people to other specialists. However, a lot of dermatologists either practice solo or they’ll just be in a group of dermatologists. Many are not associated with a hospital system, so we discussed how, as an independent dermatology practitioner, you can build a go-to team that you can refer patients to and know they will get the right type of care in the long term.” One approach is to attend CME events that are focused on melanoma treatments. “That’s a good way to learn something new and also meet many of the specialty providers who treat melanoma,” Dr. Sluzevich said. “Another strategy is to develop a relationship with an integrated practice group that either has a certification as a cancer center, or certain people who specialize in melanoma.”
When a primary care dermatologist refers a patient, “I try to reach out to those providers to thank them and let them know that I will keep them abreast of developments in the patient’s care, so they’re not left in the dark,” said Dr. Nelson. “Some of them are comfortable in watching for recurrence and treating complications, and some are not. If they are, and it saves the patient from having to always travel to MD Anderson, we want to take advantage of that knowledge.”
Ongoing care
Although they provide expert opinion and care as needed, the dermatologists said their primary responsibility in a multidisciplinary care team is to conduct regular skin checks and manage complications of treatment, a challenge that is becoming more complex as new therapeutic drugs gain FDA approval. Guidelines from the National Comprehensive Cancer Network dictate the frequency of follow-up exams according to the stage of the patient’s melanoma. However, some patients require more active surveillance, said Dr. Nelson. “Patients with stage IIC, patients who have very aggressive tumors that have developed ulceration, or patients with stage III and greater typically have some sort of body imaging on a regular basis,” she noted. “Those patients will usually see a dermatologist along with the medical oncologist in the same visit, because when melanoma spreads to the skin as a metastatic deposit, it can be much harder for the scans to show that. You need a skilled dermatologist to examine the skin, palpate the lymph nodes, and try to find those areas that may have come back on the skin as early as possible.” Dr. Huang follows her pediatric patients “as long as they want to be followed. Because I see cancer survivors, I’ve had a few patients who are in their 30s. At some point they feel like it’s time to transition to adult care, but as long as they’re still coming to the Jimmy Fund Clinic, I see them.” For young patients beginning targeted anti-cancer therapy, Dr. Huang meets with them “before they start treatment” and does “some counseling about what to expect.” During treatment, she sees them every three months “because so many of them develop reactions.”
To a large extent, dermatologists rely on each other to stay abreast of the complications that can result from medical and radiation therapy. “I learn from my adult-patient dermatology colleagues, because drugs come into use a lot more slowly for kids,” said Dr. Huang. Dr. Nelson pointed to “some really great lectures at the AAD meetings that provide overviews of the current spectrum of cutaneous adverse events related to targeted immunotherapeutics. Plus, I’m grateful to have Dr. Anisha Patel, who’s an expert in this space, right down the hall from me. If I see something that I’m not sure about, I just ask her.” Dr. Sluzevich maintained that most cutaneous side effects of melanoma treatment “are pretty well documented, so if you’re up to date with the literature, you’ll find they’re well described.” What bears watching, he noted, is that “the threshold for using these medicines is probably going to get lower and lower, so I would keep a particular eye out for when will these adjuvant therapies start being applied to patients outside of known metastatic disease, but with other clinical features that are considered very high risk.” Dr. Nelson agreed that dermatologists need to be aware of changing indications. In addition, she noted, new combinations of existing targeted therapies are yielding, in some cases, side effects that are different from those resulting from either agent used alone. “Sometimes the reactions are worse, but in the case of [BRAF inhibitor] dabrafenib and [MEK inhibitor] trametinib, the skin reactions are actually improved by adding in the MEK inhibitor. It’s kind of its own little neighborhood when we start making these combinations.”
Keys to successful collaboration
All four dermatologists agreed that multispecialty care is a win-win for physicians and patients. “Where I see the advantage is that we’re able to work with the oncologist to manage skin reactions to systemic therapy in a way that lets patients stay on their therapy longer,” said Dr. Nelson. “Our eyes are trained to see things that other physicians may find hard to see, like recurrent amelanotic melanoma, or syphilis of the skin. Also, I think it makes patients feel cared for and reassured. They enjoy seeing the camaraderie and respect that we have for each other.” Dr. Sluzevich maintained that “you can’t really effectively treat advanced melanoma patients without having some sort of interdisciplinary process at work. Sooner is better than later, and you should try to involve more players as early on as possible. It’s good to give people a heads-up, especially if the case is very complicated.” For community dermatologists who may feel “a bit siloed,” building collaborative relationships can yield benefits beyond helping their melanoma patients, he noted. “It gets a very favorable reception, and you may think that you’re just collaborating on difficult melanoma cases, but then it opens up doors to all kinds of different areas that can touch dermatology.”
Not surprisingly, the dermatologists emphasized the importance of clear communication with their colleagues in a multidisciplinary care setting. Empathy is also critical, said Dr. Huang, adding that she learned “the hard way” how best to collaborate. “I was really excited to develop an initiative to work with these patients and with the oncologist, and I had a vision of how it could be done. I learned that it really helps to understand someone else’s needs and someone else’s perspective before developing a model. It’s incredible how much more you can do if you start the conversation with ‘what do you need’ as opposed to ‘here’s my idea.’ Also, recognize that the oncologists are, in essence, primary care providers, and that that’s where they’re coming from, so while you have an important role, they’re ultimately the ones who are in charge and responsible for their patient.”
Dr. Xu advised that anyone seeking to establish a tumor board should ensure that participants have expertise and interest in melanoma, and that members will work well together as a group. In Dr. Nelson’s view, working well together means that “if I detect a new metastasis with one of our mutual patients, I’m going to walk down the hallway and say to my colleague, ‘I’m looking at this gentleman who’s our patient, and I think I found a new metastatic deposit. How can I best help you? Can I order his imaging? Can I do a biopsy today? Does he qualify for a study now that he has a new deposit of measurable disease?’ And from a patient care standpoint, the closeness of those relationships is only beneficial.”
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