Identifying Symptoms Most Significantly Associated With Melanoma Recurrence

The landscape for treatment of melanoma metastases has changed significantly in a short period of time. There are currently 14 FDA-approved systemic treatments for metastatic disease that have been shown to prolong survival, while in 2010, there were zero. But if physicians are not aware that the patient has a metastasis, treatment cannot be initiated.Therefore, we need to be on the lookout for patient-reported signs and symptoms that could indicate recurrent disease.

This paper looked at melanoma patients seen by an oncologist within a multidisciplinary melanoma clinic at a major academic medical center. The authors found that some patient-reported signs and symptoms were more common in patients who had melanoma recurrence compared with patients who did not, with a mnemonic for those most strongly associated with melanoma recurrence: Appetite loss/change, Tiredness/fatigue, Lymph node enlargement, Abdominal pain, and Shortness of breath, or ATLAS if one uses the initial letters of each sign or symptom. The symptoms identified in the paper, such as loss of appetite or fatigue, are common markers of cancer metastases, and it is not surprising that they are associated with melanoma recurrence.

The emphasis of the paper is on which patient-reported signs and symptoms are more strongly associated with melanoma recurrence, while I would argue that the more important issue for us as dermatologists is to keep in mind which signs and symptoms are more commonly found in patients with a metastasis so that those patients can be screened appropriately and, if needed, seen by an oncologist. Whether there are false-positives is less relevant in my view than making sure we identify as many patients with metastatic disease as possible. From the article’s supplemental data, I created the below table of the patient-reported signs and symptoms found most often by the authors in patients with melanoma recurrence:

(I should note that having a “new bump” was commonly reported, but it was found in the exact same proportion in both groups and therefore was not associated with recurrence.)

Going over the review of systems (ROS) for a patient can take a while, but it is important. One time-saver that I institute in my own clinic is that the staff gives melanoma patients a lengthy list of ROS questions on paper that they can check off as “yes” or “no” while waiting to be seen. This is much more efficient and less labor-intensive than having a staff member read each question to a patient and type in each response into the electronic health record. Almost all of the answers will be “no,” and the doctor can quickly zero in on the few “yes” answers.

It is also important to keep in mind that the likelihood of a specific relatively thin melanoma leading to metastases is low, but there are so many more thin melanomas than thick melanomas that the proportion of metastases developing from thinner lesions is higher than one might think. In this study, over half (51.1%) of the patients with metastases had T1 or T2 disease (ie, lesions no thicker than 2 mm). We give every patient with an invasive melanoma the list of ROS questions, regardless of thickness.