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Michigan Oncology Journal Summer 2000

The Multidisciplinary Melanoma Clinic

Timothy M. Johnson, M.D. Timothy M. Johnson, M.D.
Associate Professor, departments of Dermatology, Otorhinolaryngology and Surgery, and Director of the Multidisciplinary Melanoma Clinic

The incidence of melanoma continues to rise at a greater rate than any other human cancer (1,2). Melanoma currently is the fifth most common type of cancer - the most common type in women 25 to 29 years of age, and the most common type in Caucasian men 25 to 44 years of age in Michigan. One person dies of melanoma in the United States approximately every hour (1). Melanoma is one of the leading cancer types in terms of average years of life lost per person. At the present rate, the estimated cost of treatment of melanoma in the United States by Medicare alone is projected to exceed $5 billion by the year 2010 (3).

The escalating incidence in melanoma has resulted in the need to optimize patient care, while at the same time support and promote the growth of melanoma basic and clinical research. As a result the Multidisciplinary Melanoma Clinic (MDMC) evolved during the last decade at the University of Michigan Cancer Center in partnership with a large network of Midwest regional community physicians, not only to manage patients with melanoma but also to attempt to develop an optimal melanoma care delivery system (3, 4).

Melanoma care remains the province of several medical and surgical disciplines that all lay claim to expertise. The diagnosis of melanoma often results in the need for a spectrum of care that simply cannot be totally provided by a single discipline. The full continuum of care includes prevention, patient and family education, screening, staging and work-up, initial and subsequent treatment, follow-up, psycho-social services, and possibly palliative and hospice care. The challenge is to create a multidisciplinary melanoma care delivery system that can coordinate care among specialists with maximum utilization of provider time and resources, deliver quality care, reduce practice variation, define and measure outcomes, reduce costs, and promote education and research. A cost-outcome analysis study of multidisciplinary melanoma specialty care done at the University of Michigan Cancer Center demonstrated that coordinated multidisciplinary care that follows consensus and evidence-based clinical practice guidelines can provide the most cost-efficient care based on outcomes (3). It is important to recognize that the University of Michigan MDMC includes the entire network of community providers working in partnership and support with each other.

The strength of the melanoma clinic lies in the partnership between multiple disciplines including dermatology, dermatopathology, surgical and medical oncology, otorhinolaryngology, plastic surgery, nuclear medicine, psychiatry, ophthalmology, obstetrics and gynecology, radiation oncology, genetics, nursing, social work, and data management. Overcoming the potential destructive hurdle of "turf" is accomplished by striving for a single mission: "each and every patient should be treated like your own family member." The multidisciplinary team is characterized by a pure enthusiasm for melanoma knowledge; a desire for internal interdisciplinary and external community education and sharing; and a common interest in outstanding, compassionate patient care.

A patient with a melanoma may be referred by a health care provider or self-referred for an initial consultation appointment. The purpose of the first consultation visit is to educate the patient and family, perform a melanoma-focused history and physical examination, and develop a comprehensive treatment plan. Nurse coordinators act as liaisons for patients, community health providers and multidisciplinary melanoma team members. Organized, coordinated and easy access is gained with contact to the Cancer AnswerLine™ 800-865-1125. Prior to the initial visit, the nurse coordinators counsel the patient, schedule an appointment and mail a packet of information and a melanoma video to the patient. The melanoma video is a professionally produced product that introduces the patient and family to the MDMC, with discussion regarding what to expect at the initial consultation visit. In addition, the video contains basic melanoma education with graphic design answers to: What is melanoma? How common is it? Who is at risk? What does melanoma look like? And how is it treated? The video is given to the patient to keep.

Each patient, independent of stage of disease, is assessed in much the same way. A comprehensive history and total body skin and lymph node examination is performed. The patient is educated regarding the importance of monthly self-skin and lymph node examinations. Every other Wednesday, the multidisciplinary tumor board conference is held in the afternoon. Each patient requiring multidisciplinary input is presented followed by discussion and consensus treatment plan agreement. The most appropriate physician(s) is assigned to each patient depending on the specialties needed. In addition, follow-ups and patients requiring new disciplines due to change in disease status are discussed and triaged to the most appropriate service(s).

Using this model, in one clinic visit, a comprehensive treatment plan is developed with direct input from all specialists needed (4). The patient may elect to have treatment at the University of Michigan or return to their referring provider(s). The melanoma clinic works closely with the community providers and attempts to coordinate initial and follow-up care close to home when possible and if desired.

One obvious strength of a team-oriented multidisciplinary clinic is patient care. Specialists with a focus and interest in melanoma can provide the most up-to-date care for a disease for which guidelines are continually changing due to new knowledge and advances (5 - 9). One area in particular that is recognized as critically important to have a high level of experience and expertise is the histopathologic interpretation of melanoma (4). Errors in diagnosing melanoma both clinically and histopathologically unfortunately now top the list of malpractice claims against dermatologists. Utilizing the MDMC database, roughly 20% of all patients seen in the MDMC have a significant alteration in diagnosis or micro-staging based on review of the histologic material by two melanoma dermatopathology specialists. Roughly half of these discordant findings involve a complete change in diagnosis while the other half results in significant changes in microstaging that alters prognosis, treatment and follow-up guidelines. Our dermatopathology specialists appreciate the difficulty of interpreting pigmented lesions. The luxury of two specialists who review over 1,000 cases of melanoma per year with clinical follow-up is highly beneficial for a disease based on accurate histopathologic interpretation (Figure 1).

Another benefit of a multidisciplinary melanoma clinic is research. Research opportunities in melanoma are enormous. No satisfactory stage IV or adjuvant therapy exists. Many research areas of melanoma are still in the frontier stage including biology, prevention, psychosocial issues, evidence-based treatment, epidemiology, and even etiology. A multidisciplinary program fosters collaboration among many clinical specialists in clinical and basic research sciences. A high volume caseload facilitates accrual and development of clinical trials and provides tissue for basic research studies. Numerous multi-center and internal novel clinical trials are available at the University of Michigan (4). One example of a novel trial involves the investigation of immunotherapy strategies with gene modification. In fact, the first gene therapy trial for melanoma was performed at the University of Michigan in a patient from the MDMC (10). This would not have occurred without a successful multidisciplinary melanoma clinic model involving the combination of University and community providers. Those who benefit from the MDMC are the patients and families, team members, providers in training and community providers.

References

1. Johnson TM, Smith JW, Nelson BR, Chang A. Current therapy for cutaneous melanoma. J Am Acad Dermatol 1995;32:689-707.

2. Chang AE, Karnell LH, Menck HR. The national cancer database report on cutaneous and non-cutaneous melanoma: a summary of 84,836 cases from the past decade. Cancer 1998;8:1664-78.

3. Fader DJ, Wise C, Normolle D, Johnson TM. The multidisciplinary melanoma clinic: A cost outcomes analysis of specialty care. J Am Acad Dermatol 1998;38:742-52.

4. Johnson TM, Chang A, Redman B, et al. Management of melanoma using a multidisciplinary melanoma clinic model. [In Press] J Am Acad Dermatol 2000.

5. Johnson TM, Yahanda AM, Chang AE, Fader DJ, Sondak VK. Advances in melanoma therapy. J Am Acad Dermatol 1998;38:731-41.

6. Macfarlane DJ, Sondak V, Johnson TM, Wahl RL. Prospective evaluation of FDG-PET in staging regional lymph nodes in patients with cutaneous malignant melanoma. J Clin Oncol 1998;165:1770-6.

7. Johnson TM, Headington JT, Baker SR, Lowe L. Usefulness of the staged excision for lentigo maligna and lentigo maligna melanoma: the "square" procedure. J Am Acad Dermatol 1997;37:758-64.

8. Johnson TM, Hamilton TA, Lowe L. Multiple primary melanomas. J Am Acad Dermatol 1998;39:422-7.

9. Terhune MH, Swanson N, Johnson TM. The utility of chest x-rays in the initial evaluation of patients with localized melanoma. Arch Dermatol 1998;134:569-72.

10. Nabel GJ, Nabel EG, Yang ZY, et al. Direct gene transfer with DNA-liposome complexes in melanoma: Expression, biologic activity, and lack of toxicity in humans. Proc Natl Acad Sci USA 1993;90:11307-11.

Figure 1 The University of Michigan MDMC New Patient Consultations

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