Scientific highlights: Day 1
Controversies in Dermato-oncology 1
Prevention campaign will prevent skin cancer - Yes | Alexander STRATIGOS (Greece)
In his lecture on the impact of prevention campaigns, Alexander STRATIGOS stresses that despite these major campaigns, especially in countries where the incidence of cancer and skin cancer are important, there is no reduction in the incidence of these problems. Only stable mortality reflects the positive effects of efforts in early detection.
Primary prevention campaigns aim to reduce sun exposure and recommend a sun protection strategy. After many years of contradictory studies on the protective role of sunscreens, an Australian study showed that the regular use of sunscreens reduces the risk of melanoma by 50% and invasive melanoma by 73%.
The strong messages of prevention since childhood for children born after 1980 contrast clearly with continuously increasing amounts of pathologies in elderly people. In Whiteman's historical study, in Australia, there will be a nearly 0.5% decline in invasive melanoma observed each year since 2005, thanks to long-term campaigns and to a proliferation of indoor recreational activities. Behavioral changes obviously have a major impact on sun exposure.
The AAD’s SPOT program allowed to detect melanomas in 47% of patients who never had a skin test. The economic burden will likely lead to a review of prevention campaigns and more support for this type of program in the future.
Prevention campaign will prevent skin cancer - No | Claus GARBE (Germany)
Professor Claus GARBE questioned the German situation relating to prevention campaigns, during his conference on Wednesday, April 24th. In Germany, a very strong prevention campaign consists of screening every German. Yet, the number of skin cancers continues to increase.
Professor Claus GARBE recalls the results of several studies relating to the use of sunscreens and their protective action, which is not significant to counteract the appearance of skin cancers, not even if it is applied on the whole body. The frequency of application has no impact either, nor does the sun protection factor of sunscreens.
On the other hand, wearing a t-shirt as a form of protection has a real effect, just like wearing shorts; the maximum protective effect being obtained by simultaneously wearing a t-shirt, shorts and a cap.
For Professor Claus GARBE, prevention messages are not effective. It would be necessary to clarify the messages by stating that sunbathing is the cause of cancer, that sunscreens do not protect against skin cancer and that sunbathing promotes the appearance of wrinkles.
This last message appears to be the most important because the increase of skin cancers, in Germany as elsewhere, seems linked to fashion phenomena above all. This message becomes a priority in our time when low-cost planes allow the lightest skin-tones to go tanning in hot countries.
Will lymph node surgery remain a main therapy in melanoma? - Yes | David MORENO-RAMIREZ (Spain)
Dr. MORENO-RAMIREZ questions MSLT-I and MLST-II results in the use of lymph node surgery in patients with melanoma. After a more detailed examination of certain trials, it seems legitimate to dive deeper into these conclusions.
Tests have shown that all patients with lymph node complications have undergone lymph node surgery, whether it is a sentinel lymph node biopsy alone or followed by complete or delayed dissection. Of the 4000 patients in the study, all without exception underwent nodal surgery. So far, it has not been demonstrated that failure to operate on nodal metastases is preferable to timely surgical removal of these metastases. For patients with regional nodal metastases, the best way to avoid LND is to have SLNB performed and to replace complete dissections with sentinel node biopsies in patients with melanoma.
Dr. MORENO-RAMIREZ also advocated the use of SLNB as a standard procedure for nodal staging, providing essential prognostic information and improving decision-making regarding adjuvant therapy.
Will lymph node surgery remain a main therapy in melanoma? - No | Axel HAUSCHILD (Germany)
Although the search for the sentinel lymph node remains a frequent practice, Professor Axel HAUSCHILD puts in question the real interest of this practice, which no longer needs to be indicated.
When a melanoma has a Breslow score of 1 mm, the sentinel lymph node test is generally performed to check for the presence or absence of cancer cells. If there are, some teams carry out an additional CLNS. However, several recent studies show that the realization of this CNLS is of no use, not affecting the survival of the patient or its treatment.
Contrary to what seemed logical at the beginning of this practice, we now know that the removal of these cancerous cells does not have the slightest impact on the evolution of the disease by the patient, giving only prognostic information to the medical staff, without more utility.
Professor Axel HAUSCHILD, on the other hand, supports the use of adjuvant and neoadjuvant treatment, the results of which are already promising. The possibilities of these treatments are becoming more diversified in recent years and could be more relevant to the needs.
Adjuvant therapy should be moved to primary melanoma stage II - Yes | Jean-Jacques GROB (France)
For Jean-Jacques GROB, adjuvant Stage III treatments should be applied when patients are still in stage II.
Indeed, some melanomas are naturally very aggressive and can kill very quickly, while others have much slower kinetics and are not aggressive with a low probability of leading to patient death. Unfortunately, it is particularly difficult to differentiate them despite the need to focus current research on their detection.
A Breslow test or sentinel lymph node test does not differentiate these variable behaviors. In addition, early detection alone cannot be enough to reduce mortality. Whether the melanoma is stage II-A, II-B or II-C, adjuvant therapy is therefore justified from stage II.
Therefore, instead of taking the risk of letting a dragon egg in the stage II pass to a true dragon in stage III, it is better to apply an adjuvant treatment from stage II, as long as the dragon is still in the egg.
Adjuvant therapy should be moved to primary melanoma stage II - No | Paul LORIGAN (United Kingdom)
To counterbalance Professor Jean-Jacques GROB's vision, Professor Paul LORIGAN took time this Wednesday, April 24th to present his wish that treatments be limited to patients in stage II.
For him, it has not been shown that adjuvant treatment in stage II would be effective because no study proves that there is a better response to adjuvant treatment if the disease is treated at an earlier stage.
There is also no evidence that adjuvant treatment would be better tolerated, but the toxicity of treatment causes sequelae and harms patients' lives.
In addition, studies to date have shown that only a few melanomas in stage II pass to stage III, while these treatments are primarily indicated for stage III.
Finally, the cost of these treatments is particularly important, justifying their use in specific cases only.