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Timothy M. Johnson, M.D.
Associate Professor, departments of Dermatology, Otorhinolaryngology
and Surgery, and Director of the Multidisciplinary Melanoma
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
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.
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
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
Figure 1 The University of Michigan MDMC New Patient Consultations
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