Surgical progress and understanding in the treatment of the melanoma epidemic

The honoree of this lecture is a towering figure in contemporary American surgery, and so it is highly appropriate that the Southwestern Surgical Congress honor him and his family with this distinguished Novartis lecture. Dr. Claude Organ’s contributions have been numerous, but he also is noted for his leadership, imagination, and integrity. Most of all, he has been the most formidable and consistent advocate of the breadth of general surgery in this country for more than a decade. He may be somewhat better known for his unswerving efforts to encourage, promote, advocate, and secure mainstream appointments for African-American surgeons throughout the rubric of leading academic centers in our country. It is fitting that he be so recognized, and I submit that the subject of this lecture provides an appropriate scientific parallel as the result of my lifetime of interest and commitment to the understanding and care of the melanoma patient. Science includes geography, epidemiology, outcomes research (before it was fashionable), both public and professional education, preventive medicine, and currently molecular oncology. Much of what we know about melanoma at present can be found, at least in its seeds, from the early work of the Queensland Melanoma Project under the leadership of Neville Davis. The clinical experiment of transporting sandy-haired, fair-complexioned prisoners to a subtropical location was not understood at the time, but it has created the highest attack rate for melanoma in the world. Uniquely, under Davis’s leadership, with that of other colleagues in practice in the Queensland area, many aspects of the disease have been defined, and a unique geographic approach to the illness is now well understood. This project has also been a model for public education and professional involvement, which is only now being emulated in the United States. Annually, some 32,000 patients are known to develop melanoma in the United States. The frequency of melanoma has been rising dramatically since 1980, with conservative suggestions that as many as 1 in 75 Americans will develop invasive melanoma within the next year. What is even more sobering is the fact that these estimates are subject to vast under-reporting, with the many patients in dermatologists’ offices and surgicenters seldom being reported through the traditional conduits of hospital tumor registries. The American Academy of Dermatology suggests that only half of all melanomas are reported, and our early experience with compulsory reporting of melanoma in Kentucky suggests that this is indeed the case. Notwithstanding the escalating frequency of melanoma, a vast majority of these new patients have favorable thin melanomas that are amenable to cure. Indeed, the death rate for melanoma has inched up only slightly over the past 20 years (Figure 1). The real progress here has been the early diagnosis by primary care practitioners and dermatologists. We can point with pride to the fact that more than 80% of all melanomas are diagnosed today in a localized condition and, of those, 90% are cured. Furthermore, more than half of patients with regionally confined disease (ie, nodal and/or satellite or in-transit disease) are cured. In fact, one can examine national data for the 5-year cure rate of melanoma and see that it has statistically improved in the period from 1960 to 1989, from 60% to 83%. This is not the epidemiologic impact of dramatically improved surgical care, but of remarkable improvements in diagnosis. Keys to the diagnosis have been the simplistic protocols evolved by the Queensland Melanoma Project, and now promulgated by the American Cancer Society. Suspicious moles show ABCD: A) Asymmetry; B) Borders that are irregular; C) Coloration that is uneven; and D) Diameter greater than 6 mm. Any mole with any of those characteristics deserves biopsy. If one combines the ABCD rules with the Australian data regarding change in size, change in color, itching, or bleeding, then one can recognize which moles deserve biopsy with great accuracy. We must especially be alert to the scalp melanoma, which causes the poorer prognosis of many patients with head and neck melanoma that is inevitably detected somewhat late. Detailed prognostic breakdowns for melanoma are included in the Table, but in fact, the greater lesson is to appreciate that the meaningful prognostic variables are gender, age, site, and depth of invasion in millimeters, and that the other significant characteristics are largely functions of depth of invasion. The contributions of Wallace Clark in developing levels of invasion as a significant prognostic variable were important at one time. However, Clark’s levels are highly subject to interpretation by even the best dermatopathologist, and the suggestion by Breslow that this is better approached by simply measuring millimeters of thickness by ocular micrometry has greatly improved objectivity. It is no longer appropriate to care for patients based on Clark’s level of Am J Surg. 1999;178:443–448. From the Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky. Requests for reprints should be addressed to Hiram C. Polk, Jr., MD, Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292. This work was supported in part by the Mary and Mason Rudd Surgical Endowment of Jewish Hospital, and the Center for Advanced Surgical Technologies of Norton Healthcare, Louisville, Kentucky. Presented at the 51st Annual Meeting of the Southwestern Surgical Congress, Coronado, California, April 18–21, 1999. CLAUDE H. ORGAN, JR., NOVARTIS LECTURE