Dr Sancy Leachman Outlines a “Spectrum of Problems” Between Melanoma Detection and Treatment

There is a “spectrum” of problems and obstacles in a patient’s way once melanoma has been detected before that patient sees the right physician and receives treatment, said Sancy Leachman, MD, PhD, professor and chair in the Department of Dermatology and director of the Melanoma Research Program at the Knight Cancer Institute at Oregon Health and Science University.

Transcript

Early detection of melanoma is important, but patients need to get access to providers and treatments once it has been identified. What challenges are there with that conversion?

I think about it as a spectrum of problems. There is a whole series of steps that a person has to go through that have the potential to be an obstacle. You have to make sure that the whole chain works. For example, early detection is the first step, but just because you've seen it doesn't mean that you're aware that anything needs to be done about it. You need to recognize that it's something of concern.

Then, once you've recognized that it's something of concern, you have to say, “Which doctor do I need to go to, or which provider?” And most people will start with their primary care provider [PCP], whoever that is. They'll start with that, and maybe they can get in or maybe they can't. Maybe there's an obstacle there, maybe not. They get into the PCP, and then maybe the PCP, who only had probably 1 to 2 weeks maximum of dermatology education in their whole medical school career, and they've been out in practice, maybe they haven't seen many melanomas. They may or may not know what a melanoma looks like. And they may or may not decide to refer them to somebody who does, if they don't know. That's an obstacle right there.

Then, there's not a lot of PCPs around relative to the number of people who may need to be seen. They're in a very busy, busy practice. It may be that they come in, and they don’t really have time to be able to look at [the patient’s] skin as well as they should—even if they know that this is a person who's potentially high risk, who should have a good check on their back or somewhere where they can't see very well, but they don't really have time to do it. They've got other more pressing matters. Maybe the person is there for diabetes or hypertension or some infectious disease. And so that's an obstacle.

Let's say they do get to dermatology, and sometimes the dermatologist might not recognize that it's melanoma. They might make a mistake there. Or if you think getting into a PCP is hard, getting into dermatologist is even harder. There are a lot less dermatologists to go around. There are all kinds of things that we've been doing to try to get to the point where we get a real diagnosis.

But then, let's say they think it might be melanoma, they take a biopsy—it still has to go through another process to the dermatopathologist or the pathologist. Sometimes the pathologist may or may not recognize it. It's a spectrum of disease. When you look at it, it's anything from being atypical to an early melanoma to a thicker melanoma. The thicker melanomas are usually pretty easily caught, they know those. But there's this whole gray zone of melanoma diagnosis with a pathologist that then has to get back to the either the dermatologist or the PCP who did the biopsy.

There are possibilities there for mistakes every step of the way. Unfortunately, we're all human and our processes aren't 100%. Getting that diagnosis finalized is really important. We now are trying to do a lot of really great molecular testing and better imaging on the skin that can enhance our ability to diagnose, but it's still not 100%.