KEY QUESTIONS

A Prevention/Education/Surveillance

1. Is there any evidence that screening patients with increased risk of malignant melanoma is effective?
2. Is there any evidence that primary prevention of malignant melanoma is effective?
3. Is there any evidence that public and /or professional education and early detection campaigns are effective?
4. What evidence is there regarding the information value of leaflets ,booklets and other published media e.g. websites?
5. What is most effective way of achieving early diagnosis at GP/ Primary care level/non-specialist doctors/ PAMS?

B Diagnosis

6. Is there any evidence that early diagnosis makes a difference to outcome
7. Is there evidence of who is most accurate in clinical recognition of melanoma
8. Is the evidence of benefit from non-surgical diagnostic aids e.g. dermatoscopy, computer images
9. What is best form of surgery to make diagnosis of melanoma?
10. What type of minor surgery can be done in primary care ?
11. At what stage is referral appropriate and to which specialty?
12. Is there any evidence that classifying malignant melanoma into histogenetic types influences prognosis or provides useful information?
13. Is there any evidence for value of these or other pathological measures
    • Clark Level
    • Breslow thickness
    • Inflammatory reaction/ regression
    • Radial vs. vertical growth phase
    • Lymphatic/ vascular involvement
    • Measuring surgical clearance
14. Is there any evidence that specialist path reporting is of value in melanoma diagnosis?

C Surgical management

15. What are the best methods of removal of melanoma – width of excision, depth, other techniques e.g. laser?
16. Is there evidence for benefit with individual specialty or multi disciplinary management?
17. What is optimal timing of post excision biopsy surgery?
18. What is the role of SNB in staging?
19. What is evidence for benefit / morbidity with elective / therapeutic lymph node dissection?

D Further management & investigation

20. What is role of non-surgical techniques in treatment of stage 1-3 malignant melanoma?
21. At what point(s) should the patient be staged for secondary disease?
22. What is evidence for different staging methods?
23. What are most appropriate imaging methods to use? MRI vs. Pet vs. CT
24. Is there any evidence that routine follow up is effective? Who should do follow-
25. Is there a role for routine imaging or blood tests in patients being followed up for malignant melanoma?
26. What information is needed for patients and their families to understand and cope with the diagnosis, treatment and outcome?
27. What evidence is there regarding the impact of verbal information from health professionals at initial diagnosis re treatment/ outcomes. How can this be made more effective?
28. Is there evidence that support groups aid patients and relatives to cope?

E Management of metastatic disease

29. What is primary care role in melanoma chemotherapy ?
30. Is there evidence of benefit in chemo-, biochemo- or biotherapy of metastatic melanoma? Is level of morbidity known?
31. Is there any evidence that multidisciplinary care/ specialization influences outcomes?
32. How often should patients being treated for metastatic malignant melanoma be imaged to assess response?
33. What is the role of radiotherapy, isolated limb perfusion or other techniques in metastatic melanoma?( Benefit vs. morbidity)
34. Is there evidence for a requirement for specialist palliative care for malignant melanoma? How best should this be harnessed to rest of melanoma management?

Database coverage:

The following databases will be searched for all or part of the list of key questions:

• Cancerlit
• CINHAL (for some areas)
• Cochrane Library
• Embase
• HEED
• Medline
• NEED

An initial search will be carried out using a search filter to identify guidelines and systematic reviews. Coverage of subsequent searches will depend on the results of this search, and the extent to which results answer the key questions. All searches will cover the period from 1993 onwards for Systematic Reviews in the first instance.

In addition a number of Internet sites will be searched for Systematic Reviews and Existing Guidelines.

• Cancernet
• National Guidelines Clearinghouse
• OMNI/Biome
• Other Medical Search Engines

Search strategies will be based on the following Medline strategy:

1. Exp Melanoma/
2. Melanoma.tw.
3. 1 or 2
4. Exp mass screening/
5. Screen$.tw.
6. Exp Sensitivity and specificity/
7. Family history.tw.
8. Exp Genetic predisposition to disease/
9. Exp Family Health/
10. Early detection.tw.
11. Follow up.tw.
12. Exp Aftercare/
13. Early diagnosis.tw.
14. Exp Palliative care/
15. Exp referral and consultation/
16. Self referral.tw.
17. Referral.tw.
18. Exp diagnostic imaging/
19. MRI.tw.
20. PET.tw.
21. CT.tw.
22. Or/4-21
23. Exp primary prevention/
24. Exp health education/
25. Exp health promotion/
26. Exp patient education/
27. Exp self-help groups/
28. Support group$.tw.
29. Exp Physician-patient relations/
30. Leaflet$.tw.
31. Exp pamphlet/
32. Exp Internet/
33. Booklet$.tw.
34. Exp Mass media/
35. Exp patient care team/
36. Multidisciplinary care.tw.
37. Exp professional education/
38. Professional education.tw.
39. Or/23-38
40. Exp hematologic tests/
41. Blood test$.tw.
42. Dermatoscopy.tw.
43. Exp microscopy/
44. Histogen$.tw.
45. Breslow.tw.
46. Clark level.tw.
47. Inflammatory reaction.tw.
48. Inflammatory regression.tw.
49. Lymphatic involvement.tw.
50. Vascular involvement.tw.
51. Exp lasers/
52. Exp lymph node excision/
53. Lymph node dissection.tw.
54. Sentinel node biopsy.tw.
55. Radial.tw.
56. Vertical.tw.
57. Surgical clearance.tw.
58. Exp neoplasm staging/
59. Or/40-58
60. Exp biopsy/
61. Punch biopsy.tw.
62. Excision.tw.
63. Exp Surgery/
64. Exp radiotherapy/
65. Exp perfusion, regional/
66. Isolated limb perfusion.tw.
67. Or/60-66
68. 22 or 39 or 59 or 67
69. 68 and 3

Set 69 will be combined with search filters for systematic reviews or other types of study as required.

Exclusions.

Search terms relating to drug or chemotherapy have been specifically excluded as it is expected that they would generate a large number of hits that are not relevant to the topic of this guideline.

Releated documents

• Guideline introduction
• Guideline proposal