Sancy Leachman, MD, PhD, is director of the Melanoma and Skin Cancer Program at Knight Cancer Institute; professor and chairwoman of the department of dermatology at Oregon Health & Science University; co-chair of the Southwest Oncology Cooperative’s Melanoma Prevention Working Group; and principal investigator of the WarOnMelanomaTM. She met with The Dermatologist to discuss skin cancer—particularly focusing on melanoma—and other related cutaneous cancers.
Read Dr Leachman’s first interview with The Dermatologist, as seen in the April/May 2021 print issue!
Your group tested a pilot interventional program on sun protection practices.1 What elements contributed to its success, acceptability, and effectiveness with caregivers and children?
This study was led by a talented young behavioral psychologist from the University of Utah, Yelena Wu. She is very interested in understanding how to better educate young people about skin cancer risks in a way that will motivate them to better follow photosafety and screening recommendations. For the study, she used children whose parents had suffered a melanoma because they are at higher risk of getting melanoma at some point in their lives. Their parents are also very motivated to try to make sure that their kids are following prevention guidelines because they don't want them to have to go down the same path that they had to in getting a melanoma.
It is important to address why some kids are resistant to using prevention behaviors, because we could probably reduce the number of lethal melanomas that occur if we knew how to motivate them to comply with prevention recommendations. As a pilot, it was only testing to see whether or not the parents and the children found that they were amenable to doing it, but it sets you up to understand what messaging works. It's a fancy way of figuring out how to talk to kids in a way that they can understand and then inspire them to implement real behavior change.
What does the future of treating melanoma—and other related cutaneous cancers—hold for dermatologists?
Within skin cancer, we are in a time where we are just exploding with new technology. We have vivo confocal microscopy, photoacoustic, and optical coherence tomography that are coming out. We also have high-frequency ultrasound, and multiphoton microscopy—and those are only imaging technologies!
Additionally, we have gene expression profiling and electrical impedance technology. We have all these technologies that are coming together to be able to better diagnose things. What they boil down to is technology allowing us to detect something that we would never be able to see with our eyes. That is cool because now you can start to objectively identify what is and what is not a melanoma at a much earlier stage, when it is treatable. The gold standard for treatment is still surgery, but these technologies can tell you earlier which people need surgery and which people do not.
We also have this influence of technology and a major shift towards telehealth or e-health. This perfect storm enables patients and providers to be able to send digital images electronically. Providers can do an e-visit directly, just like what everyone is doing on video-based conferences. Patients and providers can also send pictures to a dermatologist at any time of day and the provider can evaluate the images at their convenience as well.
All of this is leading to a transition in the way we accomplish health care. In the beginning, we need to become comfortable using more technology and telehealth and then, artificial intelligence can start to be applied (at least to the straightforward cases). Ultimately, if we do things right, we are going to be able to safely shift a lot of the responsibility for screening and diagnosis to machine algorithms and empower the public to take more and more responsibility for their own care. For example, an individual will have an app on their phone where they can take a picture of their mole. Instead of calling up and making an appointment with the dermatologist to wait for evaluation, they can call up and say, "Hey, I just used the melanoma detector super-app, and it says that I have an 85% chance of having a melanoma. I need to set up an excision right now."
This approach saves money, and it saves time. It basically empowers the individual to do the right thing for themselves. If you can empower them to do something and convince them that it is the right thing to do, you have got an unbeatable combination.
Aside from technology, the future of treatment is going to stay with excisions. Excisions are the way that you cure. The diagnostics are going to help us to do better at the surgery. That is going to become important to do better with the surgery that we already do.
If you keep going further, dermatologists are going to have a real chance to help treat people who have more advanced disease. There are a lot of immunotherapies now that can be administered by injection. You still get a systemic effect of the immunotherapy, but without having all the side effects of the systemic drugs. As injectable and systemic therapies become more safe, effective, and easy to use, it is not unreasonable to think that dermatologists may be able to administer them.
Recent evidence2 has shown a decrease in skin cancer diagnoses during the pandemic. How can dermatologists improve this trend?
The decrease in diagnosis is most likely because people aren't coming in to be diagnosed—it's not because the skin cancers aren’t developing. In fact, the important thing to pay attention to is whether, when they do come in, the skin cancer and outcome are worse than if they came in earlier. I have seen a few cases of delayed melanoma diagnosis. It is tragic when someone worried about a possible melanoma defers their exam because of COVID, and has a more deadly melanoma. That is a very depressing situation when that happens because it could have been different.
There is another group led by Rebecca Hartman, along with Susan Swetter, Clara Curiel, and several other colleagues, to extract data about what happened during COVID with respect to melanoma. We have just started the project, and the results aren't known yet. It is going to be a very important study to be able to balance the risks that people take by not going in during COVID when they had a melanoma with the risk of contracting COVID.
While delays in basal cell and squamous cell carcinomas are not likely to be lethal, they may get a little bit bigger as slow-growing cancers. A year may not make that much difference. However, if that nonmelanoma skin cancer is on the face, then even a small growth increase could be cosmetically devastating. It could be so disfiguring that it is an impact nonetheless, even though it did not kill the patient. There are other things with skin cancer on the face that make them important. The fact is that people's livelihoods are dependent on their appearance. People don't like to talk about that, but it is often the case. If you have been disfigured, your opportunities for being hired in virtually any job is less. Your ability to be successful in any job that involves interacting with other people becomes restricted. It's not trivial, but it's not survival. It's not as much life and death as it is with melanoma.
References
1. Wu YP, Boucher K, Hu N, et al. A pilot study of a telehealth family-focused melanoma preventive intervention for children with a family history of melanoma. Psychooncology. 2020;29(1):148-155. doi:10.1002/pon.5232
2. Asai Y, Nguyen P, Hanna TP. Impact of the COVID-19 pandemic on skin cancer diagnosis: A population-based study. PLoS One. Published online March 31, 2021;16(3):e0248492. doi:10.1371/journal.pone.0248492
