May 27, 2024 • 24 mins
“Over half of all our referrals to dermatology are for suspected skin cancer. But this is the alarming thing, only 6% of those referrals turn out to be either a melanoma or a squamous cell carcinoma...” Dr George Moncrieff.
So, as primary care physicians, how can we help to reduce the percentage of benign melanoma referrals?
You can start by listening to this podcast where your hosts Dr George Moncrieff and Dr Roger Henderson discuss:
- The current incidence statistics for malignant melanomas and how these have changed over the past 5 decades
- Who is actually at risk? Looking at genetic make-up, age, gender, skin colour, hair colour and family history
- External risk factors, including ultraviolet light, explaining the difference between UVA and UVB
- Our approach to diagnosis, questioning if ABCDE is dangerously flawed.
“Everyone expects us to get this one right”, (Dr Moncrieff), so this podcast episode is not one to be missed!
Thank you to our kind sponsor AproDerm, who provide a comprehensive range of quality emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
To simplify the process of finding the most suitable emollient for each patient, they have developed a remarkable solution: the AproDerm Emollient Starter Pack. This pack conveniently combines all four of their emollients in a single prescription, enabling patients to identify their ideal emollient more efficiently, aiding both compliance and adherence.
Find out more: https://aproderm.com/aproderm-emollient-starter-pack/
LI: https://www.linkedin.com/company/fontus-health-ltd/
Got some feedback for us? Please rate and review Rash Decisions to help us keep creating educational podcasts for you.
Is there a dermatology topic you’d like us to explore? Email us at info@aproderm.com, and we’ll do our best to cover it.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
Episode Resources:
- International Prevalence of Indoor Tanning: A Systematic Review and Meta-analysis: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117411/
- An Exploration of the Use and Impact of Preventive Measures on Skin Cancer: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9025621/
- Association of UV Radiation Exposure, Diagnostic Scrutiny, and Melanoma Incidence in US Counties: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9531098/
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:08):
Hello, and welcome to this Rash Decisionspodcast, where we look at skin-related
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson, I'ma GP with a long-standing
interest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice and I was a past Chair
(00:30):
of the Dermatology Council for England.
So, in this podcast, Georgeand I are going to be
discussing malignant melanomas.
We're going to be looking at theircause and some figures as to how
common they are now, compared to someyears ago, and whether we're actually
approaching them the right way.
Now, I'll tell you a word to thewise here, to anyone listening,
George has got some pretty strongviews here on these topics.
(00:52):
So, it's going to be an absolutecracker of a series of podcasts.
Let me start off, I suppose, George,by thinking about the film, Jaws.
Spotting malignant melanomas hasrather become like the shark.
Everyone's afraid of it, everyone'stalking about it, and everyone's
(01:16):
keeping a constant lookout for it.
It does cause a lot ofanxiety, doesn't it?
And I think reasonably so,it's a nasty tumour, and it
affects young people as well.
So, why are we so afraid of it?
Well, I think for a start, we'renot forgiven when we miss it.
And that's borne out by the factthat we're ten times more likely
(01:36):
to be sued for missing a melanomathan missing any other cancer.
Society, our patients, the courts,journalists, they're ruthless when a
doctor fails to recognise a melanoma.
Everyone expects us to get this one right.
The other reason why I think it's worryingus more is, it's getting more common,
(01:58):
and it's getting more common quite fast,faster than any other cancer I know.
And the incidence of melanoma hasbeen doubling, every 10 years,
for the past 40 or 50 years.
You look back in 1998, the numberof cases was about five per 100,000.
Now it's over 20 per 100,000.
Admittedly, some of that increase indiagnosis, could be put down to changes
(02:24):
in our approach to making the diagnosis.
There are new histopathological teststhat are being used, that determine
that there are melanoma cells there,that would have been missed in the past.
And it's interesting that the vastmajority of melanomas are actually
in situ, which are almost benign.
(02:45):
Um, If you got a, a very, very earlymelanoma, we believe that some of those
don't do very much for a very long time.
And there's even a thought thatpeople might die with them, not
from them, that they won't changeto become invasive melanomas.
Unfortunately, no one's going tobe brave enough, rightly so, to
(03:06):
do the studies to find that out.
But I've certainly encounteredpatients who've had melanomas, that
haven't changed for a long time.
I vividly remember one particular patientwho had a melanoma, very obvious melanoma
when I first saw her, and she was adamantit had looked the same for many years, and
it was actually a 0.8 millimetre melanoma.
(03:27):
So, I used to say don't callthem malignant melanomas,
they're all malignant.
But I'm now coming around to thethought that there might be sometimes
some more benign melanomas, butnevertheless, if it's a melanoma, it's
a melanoma and it should be excised.
The current lifetime risk ofgetting a melanoma is about 1 in
(03:47):
36 in men and 1 in 47 in women.
So, roughly 3% of men and 2% of women.
Yeah, so not insignificant.
If I think back over the last 30/40 years,undoubtedly, as always, the vast majority
of patients presenting with malignantmelanomas are significantly, older people.
(04:12):
But I have seen, just on the backof an envelope calculation, a slowly
increasing trickle, over that time, ofyounger people, by which I'm thinking,
you know, under 30s, under 35s.
And we'll probably talk about someof the reasons for that shortly.
But we do see them in younger people too.
But we mustn't forget this ispredominantly, a skin lesion
(04:34):
of older people, isn't it?
It is.
Yeah.
If you look at the incidence, itincreases with increasing age.
And so the peak age is 85 to 89 years.
It's possibly more common perpopulation, in the over 90s, but
there are just fewer of them around.
But the cohort that has the highestnumber is 85 to 89 year olds.
(04:59):
But still, as you say, 4% occur inyoung adults, 15 to 34 years old.
And for them, at a prime stage intheir lives, a pretty terrifying
and catastrophic diagnosis.
This is terrifying foreverybody, but, I just thought
particularly difficult for them.
But these account for half of allreferrals to a two-week bureau.
(05:23):
Any two-week bureau are referralsto the skin dermatology, the
dermatology two-week bureau.
And these are vast numbers and they areoverloading the ability to secondary
care to give any other useful service.
Over half of all our referrals todermatology are for suspected skin cancer.
But this is the alarming thing, only 6%of those referrals turn out to be either
(05:48):
a melanoma or a squamous cell carcinoma,which is what the two-week bureau is for.
94% are benign.
And some information, informally gleanedfrom a number of trusts around the
country, that asked dermatologists, howmany they felt were obviously benign.
They said that the figure that cameback was 84% of our referrals from
(06:11):
primary care, to the two-week bureaufor skin cancer, are not just benign,
they are obviously benign, whichI think is pretty shocking really.
It means that we're not really makinggood use of that two-week bureau.
Yeah, I can't think of any othertwo-week, referral system where you've
got 84% which would be obviouslynot what you're referring them for.
(06:37):
So, if we've got such a huge numberof benign, harmless skin lesions
being referred to secondary care,obviously, especially in these times
of massive waiting lists anyway, andgetting worse, then it's this catch
22 because we're going to be furtheroverloading it, further compromising
the ability of dermatologiststo provide good service for us.
(06:57):
But, I do know many anecdotes wherecolleagues have been pressurised into
referring by patients, even when they were99% certain their skin lesion was benign.
And so I guess we come back to thatfear of both missing a skin cancer,
or in my view, perhaps an evenstronger driving force, the fear
(07:18):
of being sued if we do miss it, asyou said at the top of the podcast.
And I think this is where you've probablygot some pretty strong, even trenchant
views on the advice that we've beengiven as GPs in this area, haven't you?
Well, I have really.
Yes, it's very difficult, isn'tit, when your, your patient puts
you under that sort of pressure.
And you know, 99%, well, that's not100%, and, we will be sued, particularly
(07:42):
in that situation, if we're wrong.
So, it's as you say, you're in trouble ifyou do and you're in trouble if you don't.
Yes.
But, I think, our whole approach todiagnosing melanoma is dangerously flawed.
And, I think, it's I think thisis the whole approach supported
by NICE, and indeed by the BritishAssociation of Dermatologists.
(08:05):
They seem to be infatuated withwhat's called the ABCDE approach
to recognising a melanoma.
And I will be going into thatin a lot more detail next time.
But I think this ABCDE causes hugeanxiety with false positives, referring
lesions that are obviously benign andeven accounts for some of the false
(08:25):
negatives, i.e., failing to recogniseparticularly an early melanoma.
So, I think, we need to rethinkour whole approach to diagnosing
melanoma in primary care.
Yeah, I suspect there are quite a fewhealthcare professionals listening
to this nodding their heads at themoment about this, but there are also
others now wondering, what the Georgeapproach to melanomas is instead.
(08:48):
Now, my best guess here is that you willprobably start as I do with the general
perceptions around melanomas, and work upfrom there, to actually look at the actual
risk factors, across the whole area andnot just focusing on ultraviolet light.
That, to me, would be thecommon sense approach.
(09:08):
Do I win the goldfish?
You certainly do.
You know me too well.
Yeah, so what's my approach?
Well, the first thing I decide is,do I believe that this patient is a
potential candidate for a melanoma?
And it's much more than just down totheir behaviour in ultraviolet light.
(09:31):
Ultraviolet light has a part to play,but it is so much more important.
A number of people I ask andsay, "what causes melanoma?"
And they say, "sunlight."
Full stop.
But let's think about what are thereal and important risk factors.
Well, first of all, age.
I've already mentioned that itgets more common as we get older.
So you've got somebody 85 to 90, they'remuch greater risk than somebody 30, 35.
(09:55):
Turn that on its head.
Children, under 11, their riskof melanoma is vanishingly small.
There was a study from Bristol publisheda couple of years ago that looked at
all the referrals of children to theirtwo-week bureau, skin cancer, and there
were 79 children had been referred.
There wasn't one melanoma amongst them.
(10:17):
So, melanoma in children, and even youngadolescents, sort of early teens, the risk
is really very, very, very small indeed.
The things that really domatter are mainly genetic.
If you've had a history of a melanomain the past, you've got a 10% risk of
having another one, i.e., you've got thegenetic make-up for having a melanoma.
(10:40):
Similarly, if you've got a first degreerelative who had a melanoma, that doubles
your lifetime risk of having a melanoma.
And then patients with multiplemoles, they are at much greater risk.
If you've got more than 40 moles, andI'm not talking about solar lentigos
or pigmented seborrhoeic keratoses,I'm talking about melanocytic naevi.
(11:00):
If you've got more than 40, I used tosay more than five on the face, 20 on
an arm, or 40 in total, it doubles yourlifetime risk of getting a melanoma.
If you've got more than a hundred, yougot seven times the risk and if five
or more of them are unusual lookingmoles, they don't look like their
(11:23):
others, they're just, they're okaythemselves, but they're just atypical,
you have a six fold increased risk.
Now, that's not to saythat these moles themselves
constitute any significant risk.
They are a marker of your genetictendency to develop a melanoma.
The risk of one of these acquiredmelanocytic naevi becoming a
(11:44):
melanoma is one in 200,000.
It's tiny.
It's about the same as a patch ofskin that hasn't got a mole on it.
Moles are not the precursor for melanoma.
The only exception to thatperhaps is congenital naevi.
If you've got a congenital naevus,and the acquired naevi are the ones
that appear really from about the ageof eight, nine, upwards, and we go on
(12:07):
developing those in our early adult years.
They constitute virtually no individualrisk, but then a congenital naevus has
about a 0.8% risk of becoming a melanoma.
So there's a precursor lesion,it's the congenital naevus.
The vast majority of thoseeither disappear though, or
(12:28):
turn into intradermal naevi.
So, I wouldn't be worried about acongenital naevus, but they are a greater
risk than the acquired melanocytic naevus.
Skin type, yes, we will discuss that in abit more detail, but if you've got ginger
hair, for example, that doubles your risk,slightly, it's variable, it's between 1.5
and 3.6 times increased risk of havinga melanoma if you've got ginger hair.
(12:52):
On the other hand, if you've gotdark skin, Fitzpatrick Type IV to
VI, and I don't know about you, butI still use Fitzpatrick skin types,
rather than the Eumelanin Scale.
If you've got dark skin, brown,black, your risk of melanoma is
almost, of cutaneous melanoma,is almost non-existent.
Your risk of getting acral ormucosal melanoma is the same
(13:14):
as anyone with white skin.
It's not greater, it's not less.
Those aren't UV-related at all.
But in dark skin, the risk of getting acutaneous melanoma is almost non-existent.
So, I've really discussed geneticfactors there and none of those can
be changed, and these genetic factorsare the main thing that I focus on.
(13:37):
And, and obviously genetic medicine,and our understanding of genetics is
expanding at a phenomenally fast rate.
Am I right in reading recently aboutthe MC1R gene, with melanomas as well?
Yes, the MC1R gene is the gene that, givesyou, green eyes and, I think, ginger hair.
(14:01):
And if you've got that particular gene,you'll always freckle, and you'll always
burn, you'll never form a nice even tan.
And you have a 25 fold increasedrisk of developing a melanoma.
So, the MC1R gene is especially important.
And the phenotype for that, as you say,is this green eyes and, ginger hair.
(14:25):
Right.
Massive increased risk.
Yeah.
Yeah, I thought it was.
Before we look at this enormous topiccalled ultraviolet light, we've got to
also remember about, immune suppression.
And I think taking a history from apatient is really, really important.
What about the impact ofimmunosuppression when we're talking
to our patients about their risks ofpotentially developing a melanoma?
(14:51):
Well, it's estimated that each of us isproducing one new melanoma cell every day.
Right.
Our immune system is normally prettygood at clearing that, but if you
knock the immune system for whateverreason, steroids for polymyalgia
or chronic asthma or whatever, orazathioprine in particular, patients
with lymphoma or HIV, the immune systemis going to fail to pick that up.
(15:12):
So, if you take, for example,organ transplant patients, whose
immune system is pretty heavilysuppressed to prevent rejection.
Yes, they have a much increased risk ofsquamous cell carcinoma, as we all know,
and they're regularly managed for that.
But they have a two and a half foldincreased risk of developing a melanoma.
And so I think that they do need tobe given advice about ultraviolet
(15:32):
protection and regular skin checks.
So, if we move on to ultraviolet lightnow, then George, I think the one thing
that you and I definitely agree on, isthe risk of sunbed use, and I suppose
what has changed in the last 20 yearsis social media and the impact of social
media on image, in teens and young people.
(15:56):
Now I came across a statisticrecently when I was researching
this that surprised me so much.
I went away and double checkedit, still didn't believe it.
I went away and triple checkedit and it's actually correct.
And the stat was that, more skin cancercases are caused by a direct result
(16:16):
of sunbed use, than the number oflung cancer cases caused by smoking.
And if this surprises anyone listeningas much as it did with me, it's a study
published by the Journal of AmericanMedical Association Dermatology,
and it was, the InternationalPrevalence of Indoor Tanning.
It was a systematic review and a metaanalysis, and essentially, it came
up with a conclusion (16:39):
the number of skin cancer cases due to tanning, was
higher than the number of lung cancercases due to smoking, and I still find
that remarkable even just saying itnow, but, excessive intense bursts of
sunburn and sunbed usage are, to saysafely, not good for us, are they?
(17:04):
That is a really shocking and staggeringstatistic, but it is borne out, isn't it?
It really is.
Yeah, there are, there aretwo patterns of sun exposure.
There's chronic, low grade, cumulativesun exposure, without burning, and that
does give you a lifetime, cumulative,increasing risk of the keratotic cancers,
(17:25):
things like squamous cell carcinoma.
Then there's, as you say, intenseand occasionally burning, sunlight
exposure, which seems to be morerelated to the risk of melanoma.
With sunbeds, it's UVA,which doesn't burn.
They have pretty high doses of UVA.
But if you look at this,just think about this.
(17:47):
I think episodes of sunburn,really matters as far as melanoma
is concerned, especially inchildren under the age of 11.
Your melanocytes population, youracquired naevi tend to arrive in
your skin, sort of 8, 9, 10 onwards.
Your melanocytes haven't really maturedand got to the skin before the age of 11.
So, sun exposure then, isparticularly dangerous.
(18:09):
And we do know that, the sun exposureyou have in the first 11 years
of life to some extent dictatesyour lifetime risk of melanoma.
So, for example, if you're bornin Scandinavian countries and
migrate to Australia, after theage of 11, you take with you your
low lifetime risk of melanoma.
If you travel the other way, you takewith you your high lifetime risk, having
(18:30):
had your first 11 years in Australia.
So, the age of 11 is important.
Children under 11 shoulddefinitely be protected.
One episode of severe sunburn, enoughto cause blistering or peeling, doubles
the risk of melanoma, the lifetime risk.
Using a sunbed, ever, even justonce, increases your risk by 20%.
(18:53):
And in younger people, the ones whoare most keen to use it because of
their image, people under 35, usinga sunbed increases your risk by 59%.
In fact, it increases your risk ofsquamous cell carcinoma even more, by 67%.
So, yep.
Sunbeds are an absolute no-no in my book,and I'm delighted to feel that I was
(19:16):
part of the work done by the All-PartyParliamentary Group for Skin Disease,
back in about 2000 and, gosh, I thinkit's about 2011/12 now, where they managed
to get a law passed saying that it isillegal for, any outlet to allow somebody
under 18 to use a sunbed in the UK.
Well done.
(19:36):
UV exposure in adults isimportant because, it's the
one modifiable risk factor.
But in relative terms, compared tothe risk of, your genetic make-up
for getting a melanoma, it's notthe most important risk factor.
So, it is important, and it's somethingyou can do something about, but
(20:00):
I think it's almost overstressed.
Yes, melanomas do occur on sunexposed skin, typically on the
back in men, and the legs in women.
However, it's been estimated that if allCaucasians used total sunblock 24/7, we'd
only prevent about 34-38% of melanomas.
(20:23):
Two thirds would still happen.
And that also was published inthe JAMA [Journal of the American
Medical Association] 2022.
A paper last year looked at theincidence of melanoma, in the North of
America, in Puget Sound in WashingtonState, with the incidence of melanoma
in Orange County in California.
Two states with completelydifferent UV exposure experience.
(20:47):
And they matched the populations for everypossible variable they could come up with.
And they found that the incidencewas virtually identical.
72 cases in Puget Sound, and73 cases in Orange County.
And bear in mind that in California,they're going to be even more alert to
the possibility of melanoma, they're goingto be looking for them more vigorously,
(21:08):
and they only came out with one more.
And I agree with the conclusionthat they came to, that far
too much anxiety is stressed.
It's generated by stressing therisks of ultraviolet light in adults.
Yes, we must avoid getting burnt,we shouldn't let our skin go red,
but I think we need to take a muchmore balanced view of the risks and
(21:29):
the benefits of ultraviolet light.
So, yep, children, totalprotection, I think.
In fact, I say childrenshould be kept in the dark.
[Laughing]
And, I think that there'sa lot of sense there.
They are to be given vitamin D, butwhen they're out in the sun playing,
which is good for them, they should becovered up and protected with sunblock.
But I think in adults, we simply needto avoid sunbeds, where there's intense,
(21:53):
unregulated UVA, and avoid severe sunburn.
UVA is interesting because it penetrates,it penetrates the atmosphere, it
goes through cloud, it goes throughglass, 80% goes straight through
glass, and it penetrates deep into theskin, causing oxidative DNA damage.
(22:15):
But it doesn't burn.
UVB is a hundred timesmore burning than UVA.
So, UVA, and sunbeds have quite highintensity, UVA, Um, and I think that
might be part of the answer as to whythey're increasing the risk, with this
very penetrative ultraviolet light.
We're now talking about ultra longwave UVA, which is right next to
(22:38):
blue light in the visible, visiblelight, and that also penetrates very
deep and can cause oxidative damage.
And sunblocks, some sunblocks arenow coming out with very good,
ultra long wave, UVA protection.
But we know, for example, that,populations that live at very low
altitude, where there's virtually noUVB, but there's still intense UVA,
(23:03):
and they're out in the sun withoutany anxiety because they're not going
to burn, they're at a higher risk ofmelanoma than people living at sea level.
Wow.
One of the, the best examples I alwaysthink of, to highlight what you've just
said is an Australian dermatologist,you know, see these all the time, is
the Australian truck driver's arm.
So, your Australian truck driver driving,through 40 degree heat and incredible
(23:27):
sunshine in the Australian outback, isdriving along with his window down, and
yeah, sticks his arm out the side, andjust gets repeated, massively intense
bursts of sunburn and sun damage.
And that's where they tendto see their melanomas.
So I do hope that to everyone listening,and as I always say, thank you so much
(23:48):
for listening, George and I reallydo appreciate you spending your time
with us and we hope you found thisoverview about melanomas interesting,
helpful, and allowing you to havemore confidence in both understanding
them in your patient and also, theoverview of the risks involved, which
perhaps are slightly more nuancedthan you may have thought previously.
(24:09):
So, Roger and I hope you'll join usagain next time, when we'll be discussing
some of the potentially tricky areasabout how to diagnose a melanoma, some
of which you may not have considered.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
So, as always, until the nexttime, it's goodbye from George.
(24:31):
Goodbye.
And it's goodbye from me.
Goodbye.
Hello, and welcome to this Rash Decisionspodcast, where we look at skin-related
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson, I'ma GP with a long-standing
interest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice and I was a past Chair
(00:30):
of the Dermatology Council for England.
So, in this podcast, Georgeand I are going to be
discussing malignant melanomas.
We're going to be looking at theircause and some figures as to how
common they are now, compared to someyears ago, and whether we're actually
approaching them the right way.
Now, I'll tell you a word to thewise here, to anyone listening,
George has got some pretty strongviews here on these topics.
(00:52):
So, it's going to be an absolutecracker of a series of podcasts.
Let me start off, I suppose, George,by thinking about the film, Jaws.
Spotting malignant melanomas hasrather become like the shark.
Everyone's afraid of it, everyone'stalking about it, and everyone's
(01:16):
keeping a constant lookout for it.
It does cause a lot ofanxiety, doesn't it?
And I think reasonably so,it's a nasty tumour, and it
affects young people as well.
So, why are we so afraid of it?
Well, I think for a start, we'renot forgiven when we miss it.
And that's borne out by the factthat we're ten times more likely
(01:36):
to be sued for missing a melanomathan missing any other cancer.
Society, our patients, the courts,journalists, they're ruthless when a
doctor fails to recognise a melanoma.
Everyone expects us to get this one right.
The other reason why I think it's worryingus more is, it's getting more common,
(01:58):
and it's getting more common quite fast,faster than any other cancer I know.
And the incidence of melanoma hasbeen doubling, every 10 years,
for the past 40 or 50 years.
You look back in 1998, the numberof cases was about five per 100,000.
Now it's over 20 per 100,000.
Admittedly, some of that increase indiagnosis, could be put down to changes
(02:24):
in our approach to making the diagnosis.
There are new histopathological teststhat are being used, that determine
that there are melanoma cells there,that would have been missed in the past.
And it's interesting that the vastmajority of melanomas are actually
in situ, which are almost benign.
(02:45):
Um, If you got a, a very, very earlymelanoma, we believe that some of those
don't do very much for a very long time.
And there's even a thought thatpeople might die with them, not
from them, that they won't changeto become invasive melanomas.
Unfortunately, no one's going tobe brave enough, rightly so, to
(03:06):
do the studies to find that out.
But I've certainly encounteredpatients who've had melanomas, that
haven't changed for a long time.
I vividly remember one particular patientwho had a melanoma, very obvious melanoma
when I first saw her, and she was adamantit had looked the same for many years, and
it was actually a 0.8 millimetre melanoma.
(03:27):
So, I used to say don't callthem malignant melanomas,
they're all malignant.
But I'm now coming around to thethought that there might be sometimes
some more benign melanomas, butnevertheless, if it's a melanoma, it's
a melanoma and it should be excised.
The current lifetime risk ofgetting a melanoma is about 1 in
(03:47):
36 in men and 1 in 47 in women.
So, roughly 3% of men and 2% of women.
Yeah, so not insignificant.
If I think back over the last 30/40 years,undoubtedly, as always, the vast majority
of patients presenting with malignantmelanomas are significantly, older people.
(04:12):
But I have seen, just on the backof an envelope calculation, a slowly
increasing trickle, over that time, ofyounger people, by which I'm thinking,
you know, under 30s, under 35s.
And we'll probably talk about someof the reasons for that shortly.
But we do see them in younger people too.
But we mustn't forget this ispredominantly, a skin lesion
(04:34):
of older people, isn't it?
It is.
Yeah.
If you look at the incidence, itincreases with increasing age.
And so the peak age is 85 to 89 years.
It's possibly more common perpopulation, in the over 90s, but
there are just fewer of them around.
But the cohort that has the highestnumber is 85 to 89 year olds.
(04:59):
But still, as you say, 4% occur inyoung adults, 15 to 34 years old.
And for them, at a prime stage intheir lives, a pretty terrifying
and catastrophic diagnosis.
This is terrifying foreverybody, but, I just thought
particularly difficult for them.
But these account for half of allreferrals to a two-week bureau.
(05:23):
Any two-week bureau are referralsto the skin dermatology, the
dermatology two-week bureau.
And these are vast numbers and they areoverloading the ability to secondary
care to give any other useful service.
Over half of all our referrals todermatology are for suspected skin cancer.
But this is the alarming thing, only 6%of those referrals turn out to be either
(05:48):
a melanoma or a squamous cell carcinoma,which is what the two-week bureau is for.
94% are benign.
And some information, informally gleanedfrom a number of trusts around the
country, that asked dermatologists, howmany they felt were obviously benign.
They said that the figure that cameback was 84% of our referrals from
(06:11):
primary care, to the two-week bureaufor skin cancer, are not just benign,
they are obviously benign, whichI think is pretty shocking really.
It means that we're not really makinggood use of that two-week bureau.
Yeah, I can't think of any othertwo-week, referral system where you've
got 84% which would be obviouslynot what you're referring them for.
(06:37):
So, if we've got such a huge numberof benign, harmless skin lesions
being referred to secondary care,obviously, especially in these times
of massive waiting lists anyway, andgetting worse, then it's this catch
22 because we're going to be furtheroverloading it, further compromising
the ability of dermatologiststo provide good service for us.
(06:57):
But, I do know many anecdotes wherecolleagues have been pressurised into
referring by patients, even when they were99% certain their skin lesion was benign.
And so I guess we come back to thatfear of both missing a skin cancer,
or in my view, perhaps an evenstronger driving force, the fear
(07:18):
of being sued if we do miss it, asyou said at the top of the podcast.
And I think this is where you've probablygot some pretty strong, even trenchant
views on the advice that we've beengiven as GPs in this area, haven't you?
Well, I have really.
Yes, it's very difficult, isn'tit, when your, your patient puts
you under that sort of pressure.
And you know, 99%, well, that's not100%, and, we will be sued, particularly
(07:42):
in that situation, if we're wrong.
So, it's as you say, you're in trouble ifyou do and you're in trouble if you don't.
Yes.
But, I think, our whole approach todiagnosing melanoma is dangerously flawed.
And, I think, it's I think thisis the whole approach supported
by NICE, and indeed by the BritishAssociation of Dermatologists.
(08:05):
They seem to be infatuated withwhat's called the ABCDE approach
to recognising a melanoma.
And I will be going into thatin a lot more detail next time.
But I think this ABCDE causes hugeanxiety with false positives, referring
lesions that are obviously benign andeven accounts for some of the false
(08:25):
negatives, i.e., failing to recogniseparticularly an early melanoma.
So, I think, we need to rethinkour whole approach to diagnosing
melanoma in primary care.
Yeah, I suspect there are quite a fewhealthcare professionals listening
to this nodding their heads at themoment about this, but there are also
others now wondering, what the Georgeapproach to melanomas is instead.
(08:48):
Now, my best guess here is that you willprobably start as I do with the general
perceptions around melanomas, and work upfrom there, to actually look at the actual
risk factors, across the whole area andnot just focusing on ultraviolet light.
That, to me, would be thecommon sense approach.
(09:08):
Do I win the goldfish?
You certainly do.
You know me too well.
Yeah, so what's my approach?
Well, the first thing I decide is,do I believe that this patient is a
potential candidate for a melanoma?
And it's much more than just down totheir behaviour in ultraviolet light.
(09:31):
Ultraviolet light has a part to play,but it is so much more important.
A number of people I ask andsay, "what causes melanoma?"
And they say, "sunlight."
Full stop.
But let's think about what are thereal and important risk factors.
Well, first of all, age.
I've already mentioned that itgets more common as we get older.
So you've got somebody 85 to 90, they'remuch greater risk than somebody 30, 35.
(09:55):
Turn that on its head.
Children, under 11, their riskof melanoma is vanishingly small.
There was a study from Bristol publisheda couple of years ago that looked at
all the referrals of children to theirtwo-week bureau, skin cancer, and there
were 79 children had been referred.
There wasn't one melanoma amongst them.
(10:17):
So, melanoma in children, and even youngadolescents, sort of early teens, the risk
is really very, very, very small indeed.
The things that really domatter are mainly genetic.
If you've had a history of a melanomain the past, you've got a 10% risk of
having another one, i.e., you've got thegenetic make-up for having a melanoma.
(10:40):
Similarly, if you've got a first degreerelative who had a melanoma, that doubles
your lifetime risk of having a melanoma.
And then patients with multiplemoles, they are at much greater risk.
If you've got more than 40 moles, andI'm not talking about solar lentigos
or pigmented seborrhoeic keratoses,I'm talking about melanocytic naevi.
(11:00):
If you've got more than 40, I used tosay more than five on the face, 20 on
an arm, or 40 in total, it doubles yourlifetime risk of getting a melanoma.
If you've got more than a hundred, yougot seven times the risk and if five
or more of them are unusual lookingmoles, they don't look like their
(11:23):
others, they're just, they're okaythemselves, but they're just atypical,
you have a six fold increased risk.
Now, that's not to saythat these moles themselves
constitute any significant risk.
They are a marker of your genetictendency to develop a melanoma.
The risk of one of these acquiredmelanocytic naevi becoming a
(11:44):
melanoma is one in 200,000.
It's tiny.
It's about the same as a patch ofskin that hasn't got a mole on it.
Moles are not the precursor for melanoma.
The only exception to thatperhaps is congenital naevi.
If you've got a congenital naevus,and the acquired naevi are the ones
that appear really from about the ageof eight, nine, upwards, and we go on
(12:07):
developing those in our early adult years.
They constitute virtually no individualrisk, but then a congenital naevus has
about a 0.8% risk of becoming a melanoma.
So there's a precursor lesion,it's the congenital naevus.
The vast majority of thoseeither disappear though, or
(12:28):
turn into intradermal naevi.
So, I wouldn't be worried about acongenital naevus, but they are a greater
risk than the acquired melanocytic naevus.
Skin type, yes, we will discuss that in abit more detail, but if you've got ginger
hair, for example, that doubles your risk,slightly, it's variable, it's between 1.5
and 3.6 times increased risk of havinga melanoma if you've got ginger hair.
(12:52):
On the other hand, if you've gotdark skin, Fitzpatrick Type IV to
VI, and I don't know about you, butI still use Fitzpatrick skin types,
rather than the Eumelanin Scale.
If you've got dark skin, brown,black, your risk of melanoma is
almost, of cutaneous melanoma,is almost non-existent.
Your risk of getting acral ormucosal melanoma is the same
(13:14):
as anyone with white skin.
It's not greater, it's not less.
Those aren't UV-related at all.
But in dark skin, the risk of getting acutaneous melanoma is almost non-existent.
So, I've really discussed geneticfactors there and none of those can
be changed, and these genetic factorsare the main thing that I focus on.
(13:37):
And, and obviously genetic medicine,and our understanding of genetics is
expanding at a phenomenally fast rate.
Am I right in reading recently aboutthe MC1R gene, with melanomas as well?
Yes, the MC1R gene is the gene that, givesyou, green eyes and, I think, ginger hair.
(14:01):
And if you've got that particular gene,you'll always freckle, and you'll always
burn, you'll never form a nice even tan.
And you have a 25 fold increasedrisk of developing a melanoma.
So, the MC1R gene is especially important.
And the phenotype for that, as you say,is this green eyes and, ginger hair.
(14:25):
Right.
Massive increased risk.
Yeah.
Yeah, I thought it was.
Before we look at this enormous topiccalled ultraviolet light, we've got to
also remember about, immune suppression.
And I think taking a history from apatient is really, really important.
What about the impact ofimmunosuppression when we're talking
to our patients about their risks ofpotentially developing a melanoma?
(14:51):
Well, it's estimated that each of us isproducing one new melanoma cell every day.
Right.
Our immune system is normally prettygood at clearing that, but if you
knock the immune system for whateverreason, steroids for polymyalgia
or chronic asthma or whatever, orazathioprine in particular, patients
with lymphoma or HIV, the immune systemis going to fail to pick that up.
(15:12):
So, if you take, for example,organ transplant patients, whose
immune system is pretty heavilysuppressed to prevent rejection.
Yes, they have a much increased risk ofsquamous cell carcinoma, as we all know,
and they're regularly managed for that.
But they have a two and a half foldincreased risk of developing a melanoma.
And so I think that they do need tobe given advice about ultraviolet
(15:32):
protection and regular skin checks.
So, if we move on to ultraviolet lightnow, then George, I think the one thing
that you and I definitely agree on, isthe risk of sunbed use, and I suppose
what has changed in the last 20 yearsis social media and the impact of social
media on image, in teens and young people.
(15:56):
Now I came across a statisticrecently when I was researching
this that surprised me so much.
I went away and double checkedit, still didn't believe it.
I went away and triple checkedit and it's actually correct.
And the stat was that, more skin cancercases are caused by a direct result
(16:16):
of sunbed use, than the number oflung cancer cases caused by smoking.
And if this surprises anyone listeningas much as it did with me, it's a study
published by the Journal of AmericanMedical Association Dermatology,
and it was, the InternationalPrevalence of Indoor Tanning.
It was a systematic review and a metaanalysis, and essentially, it came
up with a conclusion (16:39):
the number of skin cancer cases due to tanning, was
higher than the number of lung cancercases due to smoking, and I still find
that remarkable even just saying itnow, but, excessive intense bursts of
sunburn and sunbed usage are, to saysafely, not good for us, are they?
(17:04):
That is a really shocking and staggeringstatistic, but it is borne out, isn't it?
It really is.
Yeah, there are, there aretwo patterns of sun exposure.
There's chronic, low grade, cumulativesun exposure, without burning, and that
does give you a lifetime, cumulative,increasing risk of the keratotic cancers,
(17:25):
things like squamous cell carcinoma.
Then there's, as you say, intenseand occasionally burning, sunlight
exposure, which seems to be morerelated to the risk of melanoma.
With sunbeds, it's UVA,which doesn't burn.
They have pretty high doses of UVA.
But if you look at this,just think about this.
(17:47):
I think episodes of sunburn,really matters as far as melanoma
is concerned, especially inchildren under the age of 11.
Your melanocytes population, youracquired naevi tend to arrive in
your skin, sort of 8, 9, 10 onwards.
Your melanocytes haven't really maturedand got to the skin before the age of 11.
So, sun exposure then, isparticularly dangerous.
(18:09):
And we do know that, the sun exposureyou have in the first 11 years
of life to some extent dictatesyour lifetime risk of melanoma.
So, for example, if you're bornin Scandinavian countries and
migrate to Australia, after theage of 11, you take with you your
low lifetime risk of melanoma.
If you travel the other way, you takewith you your high lifetime risk, having
(18:30):
had your first 11 years in Australia.
So, the age of 11 is important.
Children under 11 shoulddefinitely be protected.
One episode of severe sunburn, enoughto cause blistering or peeling, doubles
the risk of melanoma, the lifetime risk.
Using a sunbed, ever, even justonce, increases your risk by 20%.
(18:53):
And in younger people, the ones whoare most keen to use it because of
their image, people under 35, usinga sunbed increases your risk by 59%.
In fact, it increases your risk ofsquamous cell carcinoma even more, by 67%.
So, yep.
Sunbeds are an absolute no-no in my book,and I'm delighted to feel that I was
(19:16):
part of the work done by the All-PartyParliamentary Group for Skin Disease,
back in about 2000 and, gosh, I thinkit's about 2011/12 now, where they managed
to get a law passed saying that it isillegal for, any outlet to allow somebody
under 18 to use a sunbed in the UK.
Well done.
(19:36):
UV exposure in adults isimportant because, it's the
one modifiable risk factor.
But in relative terms, compared tothe risk of, your genetic make-up
for getting a melanoma, it's notthe most important risk factor.
So, it is important, and it's somethingyou can do something about, but
(20:00):
I think it's almost overstressed.
Yes, melanomas do occur on sunexposed skin, typically on the
back in men, and the legs in women.
However, it's been estimated that if allCaucasians used total sunblock 24/7, we'd
only prevent about 34-38% of melanomas.
(20:23):
Two thirds would still happen.
And that also was published inthe JAMA [Journal of the American
Medical Association] 2022.
A paper last year looked at theincidence of melanoma, in the North of
America, in Puget Sound in WashingtonState, with the incidence of melanoma
in Orange County in California.
Two states with completelydifferent UV exposure experience.
(20:47):
And they matched the populations for everypossible variable they could come up with.
And they found that the incidencewas virtually identical.
72 cases in Puget Sound, and73 cases in Orange County.
And bear in mind that in California,they're going to be even more alert to
the possibility of melanoma, they're goingto be looking for them more vigorously,
(21:08):
and they only came out with one more.
And I agree with the conclusionthat they came to, that far
too much anxiety is stressed.
It's generated by stressing therisks of ultraviolet light in adults.
Yes, we must avoid getting burnt,we shouldn't let our skin go red,
but I think we need to take a muchmore balanced view of the risks and
(21:29):
the benefits of ultraviolet light.
So, yep, children, totalprotection, I think.
In fact, I say childrenshould be kept in the dark.
[Laughing]
And, I think that there'sa lot of sense there.
They are to be given vitamin D, butwhen they're out in the sun playing,
which is good for them, they should becovered up and protected with sunblock.
But I think in adults, we simply needto avoid sunbeds, where there's intense,
(21:53):
unregulated UVA, and avoid severe sunburn.
UVA is interesting because it penetrates,it penetrates the atmosphere, it
goes through cloud, it goes throughglass, 80% goes straight through
glass, and it penetrates deep into theskin, causing oxidative DNA damage.
(22:15):
But it doesn't burn.
UVB is a hundred timesmore burning than UVA.
So, UVA, and sunbeds have quite highintensity, UVA, Um, and I think that
might be part of the answer as to whythey're increasing the risk, with this
very penetrative ultraviolet light.
We're now talking about ultra longwave UVA, which is right next to
(22:38):
blue light in the visible, visiblelight, and that also penetrates very
deep and can cause oxidative damage.
And sunblocks, some sunblocks arenow coming out with very good,
ultra long wave, UVA protection.
But we know, for example, that,populations that live at very low
altitude, where there's virtually noUVB, but there's still intense UVA,
(23:03):
and they're out in the sun withoutany anxiety because they're not going
to burn, they're at a higher risk ofmelanoma than people living at sea level.
Wow.
One of the, the best examples I alwaysthink of, to highlight what you've just
said is an Australian dermatologist,you know, see these all the time, is
the Australian truck driver's arm.
So, your Australian truck driver driving,through 40 degree heat and incredible
(23:27):
sunshine in the Australian outback, isdriving along with his window down, and
yeah, sticks his arm out the side, andjust gets repeated, massively intense
bursts of sunburn and sun damage.
And that's where they tendto see their melanomas.
So I do hope that to everyone listening,and as I always say, thank you so much
(23:48):
for listening, George and I reallydo appreciate you spending your time
with us and we hope you found thisoverview about melanomas interesting,
helpful, and allowing you to havemore confidence in both understanding
them in your patient and also, theoverview of the risks involved, which
perhaps are slightly more nuancedthan you may have thought previously.
(24:09):
So, Roger and I hope you'll join usagain next time, when we'll be discussing
some of the potentially tricky areasabout how to diagnose a melanoma, some
of which you may not have considered.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
So, as always, until the nexttime, it's goodbye from George.
(24:31):
Goodbye.
And it's goodbye from me.
Goodbye.
Popular Podcasts
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
NFL Daily with Gregg Rosenthal
Gregg Rosenthal and a rotating crew of elite NFL Media co-hosts, including Patrick Claybon, Colleen Wolfe, Steve Wyche, Nick Shook and Jourdan Rodrigue of The Athletic get you caught up daily on all the NFL news and analysis you need to be smarter and funnier than your friends.
The Joe Rogan Experience
The official podcast of comedian Joe Rogan.