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Melanoma: Diagnosis and Treatment

Rebecca Lauters, MD
Ashley Dianne Brown, MD, MPH
Kari-Claudia Allen Harrington, MD, MPH

American Family Physician. 2024;110(4):367-377.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Cutaneous malignant melanoma accounts for 5% of cancer diagnoses and is the fifth most common cancer diagnosed in the United States. Risk factors for cutaneous malignant melanoma include ultraviolet radiation from sun exposure, Fitzpatrick skin type I or II, a history of dysplastic nevi, indoor tanning, older age, and a personal or family history of melanoma. The U.S. Preventive Services Task Force recommends counseling with patient education on minimizing early ultraviolet radiation exposure, including the use of protective clothing and sunscreen, especially for patients 6 months to 24 years of age. Tools to aid in the diagnosis of cutaneous malignant melanoma and the decision to biopsy include the ABCDE mnemonic, ugly duckling sign, and dermoscopy. Any suspicious pigmented lesion should be biopsied. Biopsy with a deep scoop shave, saucerization, punch biopsy, or full-thickness excision is preferred to ensure the entire lesion is removed to obtain an accurate measurement of Breslow depth. Breslow depth is important in staging, treatment consideration, and prognosis. Wide local excision by a dermatologist or surgeon with appropriate margins is the primary treatment of choice. Thin lesions with a Breslow depth of less than 0.8 mm usually do not need further treatment after wide local excision and have an excellent prognosis. Lesions with a Breslow depth greater than 0.8 mm may need further diagnostic tests or procedures, including sentinel lymph node biopsy, complete lymph node dissection, gene mutation analysis, and possible treatment with systemic immunotherapy. Use of systemic immunotherapies has improved the prognosis for advanced melanoma (stages III and IV), with 5-year survival rates of 74.8% and 35%, respectively, compared with 62.6% and 16% from 1975 to 2011 before immunotherapy was available.

Cutaneous malignant melanoma is the most lethal type of skin cancer accounting for 5% of all cancers and 1% of all skin cancer diagnoses in the United States.1,2 Malignant transformation of melanocytes, the melanin-producing cells in cutaneous tissue, is the underlying cause of melanoma. Risk factors for cutaneous malignant melanoma include increased exposure to ultraviolet (UV) radiation from indoor tanning and sun exposure and genetic susceptibility (Table 1).2

WHAT'S NEW ON THIS TOPIC

Cutaneous Malignant Melanoma
Dermoscopy performed by an experienced clinician increases diagnostic sensitivity from 76% to 92% and specificity from 75% to 95% for cutaneous malignant melanoma compared with visual inspection alone, with a reduction in the number of melanomas missed.
Despite an increase in the incidence of melanoma over the past 10 years, the death rate has decreased 3.5% per year for adults, on average.
The incidence of cutaneous malignant melanoma in Fitzpatrick skin types V and VI is 1.0 per 100,000, although this population has the highest percentage of late-stage melanoma at the time of diagnosis, likely related to differences in presentation, delayed diagnosis, and social factors, all of which contribute to increased melanoma mortality in Black patients.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
The USPSTF recommends counseling young adults, adolescents, children, and parents about minimizing exposure to UV radiation for people 6 months to 24 years of age with fair skin types to reduce their risk of skin cancer.6 B Large body of evidence and moderate net benefit (USPSTF grade B); shows improved sun protection but limited data on decreased sunburns or melanoma rates
Physicians should consider counseling for adults older than 24 years with fair skin about minimizing their exposure to UV radiation to reduce the risk of skin cancer, but there is insufficient evidence for a visual screening examination in asymptomatic patients without risk factors.6,7 C Minimal benefit with minimal risk (USPSTF grade C); insufficient evidence for skin cancer screening (USPSTF grade I)
Dermoscopy, performed by a trained clinician, aids in differentiating melanoma from benign skin lesions during a clinical examination.16,17 C Large body of disease-oriented evidence, although evidence in primary care is limited
All suspicious pigmented lesions should be biopsied with an excisional biopsy deep enough to prevent transection of the base of the lesion with 1- to 3-mm circumferential margins excising the entire lesion.18,19 C Consensus guidelines

USPSTF = U.S. Preventive Services Task Force; UV = ultraviolet.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

REBECCA LAUTERS, MD, FAAFP, DipABLM, is the associate program director of the Eglin Family Medicine Residency, Eglin Air Force Base, Fla., and an assistant professor of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.

ASHLEY DIANNE BROWN, MD, MPH, FAAFP, is a faculty family physician at the Offutt Air Force Base/University of Nebraska Medical Center Family Medicine Residency, Omaha; an assistant professor of Family Medicine at the University of Nebraska, Omaha; and an assistant professor of Family Medicine at the Uniformed Services University of the Health Sciences.

KARI-CLAUDIA ALLEN HARRINGTON, MD, MPH, is a faculty family physician at the Prisma Health/USC Family Medicine Residency Program, Columbia, S.C., and an assistant professor at the University of South Carolina School of Medicine, Columbia.

Address correspondence to Rebecca Lauters, MD, FAAFP, DipABLM, at becca.lauters@gmail.com.

Author disclosure: No relevant financial relationships.

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