Spotting Melanoma: Risks, Treatments & Research

Memorial Sloan Kettering Cancer Center Patient Information Session
Spotting Melanoma: Risks, Treatments & Research
November 2, 2022

Corporate Speakers

• Michael A. Postow, MD; Memorial Sloan Kettering Cancer Center; Chief of the Melanoma Service.
• Charlotte E. Ariyan, MD, PhD; Memorial Sloan Kettering Cancer Center; Carol Bassok Lowenstein Chair.
• Erica H. Lee, MD; Memorial Sloan Kettering Cancer Center; Associate Director of Mohs Micrographic and Dermatologic Surgery.
• Tierra R. Hurd, MPAS, PA-C; Memorial Sloan Kettering Cancer Center; Lead Advanced Practice Provider, Dermatology Service.
• Charlene Hochreiter; Memorial Sloan Kettering Cancer Center; Clinical Trials Nurse.

Presentation

Michael Postow: Hello, everybody, and welcome to our special session this afternoon on spotting melanoma. This is an educational session on melanoma treatment and diagnosis —what to do if you've had a diagnosis of melanoma; what to do if you're worried about a diagnosis of melanoma; what to do if you're under treatment for melanoma or thinking about treatment or taking care of a loved one or a family member or close friend. We’re really glad that everybody is able to join us today.

My name is Dr. Michael Postow, and I'm the Chief of the Melanoma Service here at Memorial Sloan Kettering Cancer Center. I'm joined by four fantastic panelists who will be helping lead this conversation about melanoma and this particular skin cancer. The four panelists that we have that joining us today are Dr. Charlotte Ariyan, who is one of our melanoma surgeons, and she'll be talking about a lot of the surgical applications and treatment for patients with melanoma that has been diagnosed. Charlene Hochreiter, who is one of our clinical trials nurses, and she and I work very closely in treating patients with more advanced melanoma with drugs that go through the whole body. She'll be talking a lot about what life is like in a clinical trial and some of the research that we're working on now to advance the treatment of patients with advanced melanoma particularly. We have Tierra Hurd, who is our Lead Advanced Practice Provider on the Dermatology Service, and she'll be talking to us about how we monitor our skin, how we take protective sun behavior to heart, and all the great things going on in the dermatology world related to taking care of patients who have been diagnosed with melanoma or who are worried about melanoma. We also have Dr. Erica Lee, who is one of our Mohs micrographic and dermatologic surgeons, to talk about melanoma diagnoses and how some early-stage melanomas are treated, particularly some of the surgical applications of melanoma treatment.

We’re very much honored that so many people have joined us today. This is a great conversation that we’ll kick off today, and we hope some of the questions in the interest that that you all have as participants in our panel can be carried forward in conversations with us in the clinic, and if you haven't yet connected with us at MSK around a melanoma diagnosis, we welcome you to our program so that we can help try to find what kind of treatments might be best for your particular situation.

So, Dr. Erica Lee, I'm going to start with you, because I think in the dermatology world, most patients are first confronted with the diagnosis of melanoma, and that's a discussion they have with their dermatologists. Could you tell us a little bit about what melanoma is? Why does it happen, and what should somebody do if they're told that they have a diagnosis of melanoma?

Erica Lee, MD: It’s great to be here. Those are great questions, and I just want to start with a with an overview about melanoma. Melanoma is the third most common skin cancer diagnosed in the United States every year; we probably have well over about 100,000 cases diagnosed per year.

When you look in the skin, we have a lot of different cells that make up the skin, and one of the cells that we have is called the melanocyte, and the melanocyte is where we are making all the pigment in our skin. So basically, the melanoma is derived from that cell, and there are lots of different risk factors for why people will get a melanoma, and that will include sun exposures, a slight genetic predisposition — it's a very multi-factorial sort of profile of why a person will get melanoma.

But if you are diagnosed with melanoma — and that's often done in the dermatologist's office — there's a lot of information that we get from the pathology report. I kind of like to think of melanomas falling into four big buckets, or as we call them, subtypes. So, when you look at the most common subtype — we call that the superficial, spreading melanoma — and as the name implies, it really likes to live at the top layer of the skin for some time before it delves into the second layer of the skin. Then we have a different subtype called the nodular subtype, and that grows a little bit less on the top layer, but it likes to go into the second layer a little bit quicker. And then we have another more common subtype that we see in dermatology, and that's called the lentigo maligna subtype, and we’ll usually see that in patients who have had a lot of sun exposure. These patients were almost always in an area that had a lot of sun. So the face, the head and neck, the scalp, those are the most common areas. The last major subtype is called acral melanoma, and these are the ones that we know the sun doesn't go there, so the sun doesn't have to contribute to the development, but they typically will develop on the palms and soles of individuals.

Once we get a diagnosis of melanoma, it really depends on the pathology report. The report will tell us where the melanoma is. It’s going to tell us if the melanoma is closer to the surface of the skin, and then, if it is, it can be treated probably just with the procedure, and you're done. If it goes a little bit deeper in the skin, then we measure how deep it goes, and that gives us a lot of information that will kind of decide if this is going to be treated by a dermatologic surgeon —a surgeon like Dr. Ariyan— or a head and neck surgeon. There's a lot of overlap when it comes to what can be treated by who, and there are lots of cases that can be treated by all of us. But you know, if a melanoma does go a little bit deeper in the skin that we're not happy with, then we do, call Dr. Ariyan or someone else to kind of take over.

Charlotte Ariyan, MD, PhD: I think that's an important point Dr. Lee, because I get asked that a lot in the clinic. We always measure the size as one of the most prognostic things, and so if it's a superficial spreading two- or three-millimeter melanoma, for example, is that better than a two- or three-millimeter nodular melanoma? But in reality, they're going to be treated in a similar way, right? So even though there are these different classifications, which may point to a little bit of how they evolved or how they came to be, once they get to be what we call an invasive melanoma, the treatment is going to be similar. Would you agree with that?

Erica Lee, MD: Yeah. The most important part for melanoma is you want to get it out, right? So, we want to remove it, and then we always want to remove it with the margins, so we'll be a little bit more generous if it's an invasive melanoma, and if it's what we call an in situ, where it's only limited to the top layer of the skin, we can be a little bit more conservative in how much we end up taking. But you know, what's really important about melanomas is when you have a melanoma diagnosis, you understand where it is in the skin, and I think that will help you understand the stage of the melanoma and what the next step is in terms of whether you just need removal, or if need to do anything else besides that.

Michael Postow, MD: Dr. Lee, a lot of people hear about Mohs surgery. Can you tell us what Mohs surgery is, and then also how you think about the use of Mohs surgery?

Erica Lee, MD: So, Mohs surgery, or Mohs micrographic surgery, is a surgical technique that we do in the outpatient settings. So, the patients are awake, and they come on in, and we basically will remove the skin cancer, and we're going to look at this issue in real time, so we're able to process it while the patient is in the office. And we're only really looking at the margins, and we're able to assess at that point right away if the margins are clear or if they’re not clear. So what we predominantly do Mohs for is what we call for the non-melanoma skin cancers. If the audience has heard basal cell —which is actually the most common skin cancer— and squamous cell, is what we predominantly use Mohs surgery for. It is also used for some pieces of melanomas, and that's really an institutional decision. Some institutions like to do Mohs for melanomas, others institutions don’t do Mohs for melanomas, and I think it really depends on your view of what information that you want. Mohs for melanoma is a great option. The most important thing is you get it out and you have clear margins. But there are some limitations, in how you actually look at the tissue for Mohs surgery, because we're doing it really quickly, so sometimes, some of the melanoma cells can be kind of distorted the way that we see it under frozen sections. So, some can argue that they that might not be the best approach when you're doing melanomas.

Charlotte Ariyan, MD, PhD: Yeah. I think just to be clear, because I get this question a lot too, some of the stains to look specifically for melanoma cells —which can be tricky to see on an initial look— require overnight incubation with tissue or can't be done in a what we call a frozen section very accurately. And so that's one of the limitations that you're having if you have Mohs surgery, would you agree with that?

Erica Lee, MD: Yeah. So, when you look at the melanocytes underneath the microscope, sometimes, if you have a cluster of them, they're really easy to read. But when you get to the edges of a melanoma, sometimes they can skip around a little bit, and they're kind of hard to see just with the standard stain, so you typically need additional stains, and that is time intensive. You can do it the same day, but you definitely need a lab that’s really good at doing it, and you need to have really good training to read it. So, I think it's really straightforward to kind of read it underneath the microscope when you see a cluster of them, but when it gets to an area where you just see a sprinkling, you definitely need additional slides, and you need an expert to read them.

Charlotte Ariyan, MD, PhD: And that's been a lot of the pull against Mohs for it being done for melanoma. It's not universally accepted.

Erica Lee, MD: It’s not, and I think if it is going to be done, then it should be done in a place that has a really well-respected lab and by someone who has a lot of experience reading the tissue. There is definitely sort of a transition to doing more of it for the early-stage melanomas, it's really reserved for the most early-stage melanomas, and I do think there can be a good role for it, but I think it's a work in progress. We're getting better at the stains, we’re getting better at the reading, and I think as we get better, we can show data on it. Then it might become more mainstream, and I think for some places it might be. But I think the most important thing is making sure you have the margins assessed very well.

Michael Postow, MD: Thank you. There’s a lot of subtleties and granularity there that are important on a patient-by-patient basis. Dr. Lee, you mentioned a few other skin cancers like, basal cell skin cancer and squamous cell skin cancer, which are more common than melanoma, and I’d like to move to Tierra Hurd, who is our Lead Advanced Practice Provider on the Dermatology Service. Tierra, my question for you is what makes melanoma potentially more serious than these other types of skin cancers, and how do you approach a patient with melanoma similarly or potentially differently than patients with other skin cancers?

Tierra Hurd, MPAS, PA-C: Sorry, I needed to unmute there. Yeah, that's a great question Dr. Postow. As Dr. Lee already mentioned, melanoma is the third most common, so when potentially screening someone for melanoma, we are looking at patients that may have a mole that has changed over time or evolved. We're looking at patients that may have all of a sudden developed a new mole that doesn't look like any of their other moles. It’s kind of what we nickname that ugly duckling or outlier. Melanoma can be more serious, because if it's not caught early, then it has the potential to spread or what we call metastasize to other parts of the body. Now, we have different tools and screening where we can kind of catch melanoma early if we're screening patients properly and regularly, so can catch it, and it's early in situ, as Dr. Lee mentioned, before it becomes invasive.

Michael Postow, MD: What are the tools that you guys use in the dermatology clinic to catch these melanomas early? What kind of technologies? How do you advise patients to look at their skin on their own education? How would you interact with a patient that's coming to see you and is worried about melanoma? Maybe they had a diagnosis of an early-stage melanoma that was surgically removed in the past.

Tierra Hurd, MPAS, PA-C: There are a couple of tools that I definitely use for every single person that comes in the door and gets undressed to be screened. Number one is I have my handy dandy dermatoscope, which uses a polarized and non-polarized light and also a magnifier. To the naked eye, some moles can look okay. They can look, you know, pretty friendly, as I say. But then when you start to look a little bit closer under the magnification, they can have certain features that we've been trained to look at, or certain vessels or certain colors that help us determine what's a benign or non-cancerous mole versus what’s possibly a malignant lesion.

Secondly, some of us that you might see who a little bit older also have a regular magnifier that just helps us to look at the skin overall in general, because again, sometimes different skin tones or different skin in different light can look a bit at different or have different textures. And then the third thing that we've really been revamping here and are fortunate enough to have at MSK is our 3D imaging technology, and that allows us to scan our patients as a whole and to compare their photos that were previously taken to their in-person exam. And that allows us to easily detect if there's been any new moles that we may have missed, especially for patients who are coming in with hundreds of moles that we have to go one by one to check on. It allows us to screen for any of the slightest changes. And again, sometimes you can't see that with the naked eye; it’s not until you use that tool that really magnifies, and it says, ‘Oh, you know, that feature wasn't there six months ago, let’s potentially do another picture,’ or ‘maybe we need to have you come back in shorter time, three months to re-check it,’ or maybe ‘we even need to go ahead and proceed with a biopsy.’

Michael Postow, MD: That's great. It's really, really cool for us to learn about how these new technologies are helping aid your diagnostic interpretations of this, to try to biopsy the lesions that are most concerning of course, and avoid biopsying everybody, because that would be hundreds of moles, and not all those can be done.

Erica Lee, MD: And one of the best things about photography, or just even doing a skin exam on yourself, is that we're looking to see if there's evolution or change in a mole. I think that's one of the biggest factors that might determine whether or not a biopsy is done. We're always looking with the photography if we're able to notice if there's a big change, because biologically, that might mean that something is going on. And I think Tierra, you're also educating patients to kind of look at their own skin and then just do a monthly quick check to see if they notice anything that's really different or changing, because a lot of the times that patients come in, they’re the ones who notice that something is actually different.

Tierra Hurd, MPAS, PA-C: Absolutely, and like Dr. Lee said, you want to be checking once a month. And sometimes I even tell patients, either take a picture of the mole yourself or have a family member or friend take a picture, especially in those tricky areas like your back, the back of the legs, or in the scalp where you can't necessarily monitor it. But again, most of the patients do pick up on their own skin cancers or potentials skin cancers, or family members say, ‘hey, what's that mole that changed?’ or ‘it looks a little funky.’ So, yeah, absolutely checking yourself routinely, checking for new pigment under the nail polish. I tell women who get manicures or pedicures to check for any um new spots before they repolish. Whatever stylist cuts your hair, make sure they're also looking in the scalp for any new moles or bumps that weren't there before.

Michael Postow, MD: That’s really important. Once you and your team make a diagnosis of melanoma in the clinic, then you may say, ‘this patient needs to be seen by a melanoma surgeon,’ and it moves from dermatology to the surgical world, those patients would see someone like Dr. Ariyan. I guess I would then turn to Dr. Ariyan. Let's say you see a patient with a relatively intermediate or thicker melanoma in the clinic that's been biopsied by a dermatologist. How would you talk to that patient about what they would expect next regarding the appropriate surgical intervention for the melanoma, and what are some new ways to handle melanoma surgically, and how do you think about different surgical approaches on different parts of the body?

Charlotte Ariyan, MD, PhD: So, I think when a patient comes in to see me, as Dr. Lee mentioned, the most important thing is the pathology report. The most prognostic piece of information we can get from that report is the thickness of the tumor. We call it the Breslow thickness, because that lets us know if it's really early-stage, or if it’s something that's more intermediate or advanced. When we're examining the patient, we're trying to see if that biopsy represents what we're seeing clinically, and if it does, and if it falls into what you are just saying like the intermediate-risk melanomas, then we're trying to remove the melanoma with clean margins. That's an ultimate principle in all cancer care. But the second part is to try to stage the patient, and if melanoma is going to travel the first most likely place it tends to travel as the lymph nodes. And so over time, our most sensitive test to see that is something called a sentinel lymph node biopsy, which is actually a misnomer, it’s a sentinel lymph node excision. And what we do is an injection to see which lymph node is the filter for that area of the melanoma, and we remove that node and give it to pathology, and they look very carefully to see if there's any evidence of melanoma present within the lymph node. We that's a very prognostic test. The risk of recurrence is higher if it’s travelled to the lymph nodes, and then obviously, it's a referral to you [Dr. Postow] and other people about what the risk and benefit is of other treatment, or whether surgery itself was curative. So, I think that's where we're trying to frame people, and moving forward, you know surgery and care for melanoma has become much more interdisciplinary, so we're trying to figure out ways to be just as effective without necessarily having to be so morbid and surgery and everything else. And so there's certainly new things on the horizon, newer imaging newer prediction models that everyone's working on to try to see if we could estimate some of those risks, and will it be as sensitive as taking out a sentinel node, and would you, as a medical oncologist, be willing to treat, based upon those risks assessment, some of which were are less-invasive, it could just be a blood test or a test on the tumor itself. We have ongoing trials right now looking at just whether we can reduce the margins of melanoma. For many years, surgery was really one of the only effective treatments for melanoma, and so people were very, very aggressive, and now we know that can,

overtreat many people. There's a worldwide trial going on right now called the MelmarT trial, which we are participating in, and it’s looking at whether you could just do a centimeter around any melanoma. And we know, as you were mentioning, in certain sites, we accept less of a margin, especially on the face or other areas, as is Dr. Lee probably going to comment on, and we know that's been safe as well.

Erica Lee, MD: Just kind of going on exactly what Dr. Ariyan said. We typically want to take a wide margin for melanoma. We want to clear it. We want to give it enough margin around and underneath it, but obviously in areas such as the face, if you end up taking a one centimeter or even more from the get-go, it could be really tough, aesthetically, after you want to try to close a big wound like that. So just to give you an idea of what our approach is in dermatologic surgery, if we have a melanoma on the face, what we like to do is, you know we mentioned Mohs before, but we actually do a different approach. It's called the stage excision, and with that approach, a patient would come in — it’s all done in the outpatient setting— and then we’ll mark our margins around it and we'll remove it. But we're not going to close the wound until we get negative margins, because, you know, like I mentioned before, one of the more common subtypes on the face is called the lentigo maligna subtype, and sometimes those are really tricky when you look at them, and they don't have a very clear beginning and end. So, even though you want to take your margin, you might not want to close that, because if you get a positive margin and you close it, it just muddies the water and makes the re-excision a lot more complicated. So, you know, we'll remove it, and then we have a great system, for example, at MSK where the turnaround time is really fast. We get an answer in 24 hours on the margin status, and if the margins are clear, great. The patient will come in, and then we'll close them up and put stitches in the area of the face. But if the margin is actually positive, we'll just go back to the quadrant that's positive or the area that has positivity, we’ll take a little bit more, and we’ll send the patient back home. It's all outpatient, and then we'll get another answer in 24 hours.

With this approach, what's really nice is that we will make sure the margins are clear. It is a few day commitment, but we have the pathologist read it if they have to do additional stains, and then we can give patients the best aesthetic closure that we can, and we can reassure them that the margins are clear, and we don't have to go back and do it again.

Michael Postow, MD: That that's great, Dr. Lee. And now let's say you've done all the surgery you want to do, or maybe Dr. Ariyan’s done all the surgery she wishes to do, and the melanoma has hopefully been cured. Tierra, I know that melanoma still can come back unfortunately, so could you talk a little bit how you follow these patients moving forward, and what the risks of potential recurrence are that you discuss in the dermatology clinic?

Tierra Hurd, MPAS, PA-C: Sure, so typically again depending on the stage, or how invasive, or if it was an invasive melanoma, most patients on average in the beginning, probably within the first three to five years after treatment or surgery, are typically followed every three months or every six months. And then once they've gotten to that five-year mark, then, I’ll say they'll either graduate to just every six months or once a year. Sometimes melanoma, if it does recur, is more likely to recur within the first few years, so we like to have a close eye on you, and we're just looking for specifically in that previous melanoma site, are there any new lumps, bumps, any re-pigmentation? We're also looking for any other kind of what we call satellite lesions around other moles that might look a little bit atypical or different than the normal mole pattern. We just want to monitor, and I also want to empower my patients to be vigilant and monitor those sites, and check and make sure that they’re keeping up with their sun protection, and if they notice any change, to take a picture of it. A lot of them will send us a picture on the portal, or give us a call, and we'll bring them back in and look at it, do photographs again. So usually on average it’s about quarterly, and then every six months, and then you graduate to a year as long as you’ve not developed anything new within that time.

Michael Postow, MD: That's great. It's important that you follow your patients so well so that they maintain good relationships there. And I think it's great to stay on top of all this, and I think one of the issues that came up, and I'm going to bring Charlene into this conversation from a clinical trials perspective, but one of the concerning things about melanoma, unlike some of the other types of skin cancers, is that melanoma has a higher risk of spreading to the lymph nodes, as Dr. Ariyan mentioned, and that's the reason we do sentinel lymph node biopsy, but melanoma can also spread to other places in in the body, both to other places under the skin or other lymph nodes, or even inside the body, into the internal organs. And when that happens, we in medical oncology need to get involved.

One of the participants wrote in, “who's a candidate for immunotherapy?” and I’ll answer that rather generally. Most patients are candidates for immunotherapy when their melanoma is a certain risk profile. If it’s a higher risk melanoma that’s been surgically removed, we like to talk about the pros and the cons of using immunotherapy as a preventative type strategy after all the surgery is completed. It's not for everybody, and then there's definitely some nuances, so it's important to talk that out with your doctor and treatment team. If melanoma has established itself in a distant place, meaning it's spread from the skin inside the body, then immunotherapy really is indicated in most of those situations, and the reality about immunotherapy in that context is that it can really dramatically help patients with their current melanoma, and these patients can continue to live really long, great, productive lives when the treatments work well. I think it's a testament to all the science and the advances that we've done for our patients with more advanced melanoma in those situations, and it's great when all the treatments work, and one of the areas that our group is really focused on is trying to come up with new treatments and pushing the envelope and making sure this treatment works for everybody, because, despite our best efforts, the standard treatments that we have still don't work for everybody, and one of the areas that we're developing these new treatments is in a group of studies called clinical trials. Clinical trials are where we’re testing new drugs or new combinations, and Charlene is one of our clinical trials research nurses. So, Charlene, could you talk to us a little bit about what it's like when you're talking to a patient about whether a clinical trial is right for them. How do you help them figure out if this is an appropriate treatment along their junction, and how you work in conjunction with all of us medical oncology. Tell us your perspective on this and how you got into it.

Charlene Hochreiter, RN: So, first of all, hi everyone, my name's Charlene Hochreiter, I’m the clinical trials nurse for the Melanoma Service. In terms of what brought me in, I really enjoyed the bigger picture of treatment, and in terms of MSK and the Melanoma Service with clinical trials, we have a wide array. We have plenty of trials directed to patients who've never had treatment before, otherwise known as treatment-naïve. We have patients who have had surgical resection and they need or are thinking about adjuvant treatment, we have trials for them, too. We also have trials for patients who have received multiple lines of treatment or patients who are unable to have a current standard of care treatment, and as you know, in these situations, treatment options are very limited. And we have trials that address a specific mutation, like BRAF or NRAS. And sometimes, we have trials that are specific to even just their type of melanoma, like uveal, which is very rare. We have trials directed to trying to push the envelope on treatments for uveal, mucosal, and cutaneous melanomas, and then all these trials that we have currently involve a treatment, whether it’s an IV infusion, oral pills, self-injections, or almost all the above. And some of them involve something that's already a standard of care, and potentially improving it, or taking an investigational drug that has promising results preclinically or promising results with other cancers that may one day become the latest novel approach in the treatment for your melanoma.

Michael Postow, MD: Thank you, Charlene. A lot of people, I think, have a reasonable fear of clinical trials when they think about clinical trials. A lot of people equate that to, ‘well, I don't want to get a placebo or a sugar pill.’ Could you tell us what that is and how that is or is not appropriate in the clinical trials that we're doing?

Charlene Hochreiter, RN: Yeah, and like we said, the trials that we are involved in always involve a treatment, or patients have had a treatment, and we're following up with every patient with a cancer diagnosis. Our priority is controlling melanoma. We would never give you a placebo, and if we do, it's involved with an already standard-of-care treatment. For example, we have nivo-cabo [nivolumab-cabozantinib], so people have nivolumab, which is a standard, and then potentially a pill. That may or may not be a placebo, but at least you're getting a treatment to hopefully show us or give us information on does adding this drug actually improve outcomes better than the standard that we already give other patients with melanoma. But you're right, participating in a clinical trial is rigorous and even undergoing screening to be eligible for a trial alone can be time-consuming. Trials require multiple visits, sometimes additional biopsies prior to even starting treatment, and some trials involve long-duration clinic days, you're there to monitor blood work or observation for hours. Sometimes it's frequent visits in the first several weeks, that can space out eventually over time.

Though they may seem demanding, the entire team, including not even just your MDs, but also the research team, the office coordinators, the care coordinators, the other clinical trial nurses are here to help guide you every step of the way. And the expectations of being on a clinical trial can be very different from receiving standard of care. For example, we ask you to disclose your medications, everything that you're taking, everything that you're doing, every side effect that you have, and to reach out to us when symptoms do arise, whether you believe they’re related or not. As clinical trial nurses, we're here to educate you on what to anticipate as soon as it's evident that you might be eligible. We're here to help oversee your care for as long as you're a part of this trial to make sure you're safe that you're taken care of, and that we can better us understand what undergoing these treatments can be like. Whether you started or completed a trial, we'll be here for you for the long-term.

Erica Lee, MD: What's the average duration of a trial like, how long are people typically on one on average?

Charlene Hochreiter, RN: So, depending on the trial, the treatment duration could be maybe one to two years, and then some treatments, as long as they're showing a benefit to you, could be indefinite. And the indefinite ones luckily are typically oral pills, if they seem to prove benefit to you. And for the ones that require follow-up, it could be minimum of a few years to a lifetime for follow-up, which includes just phone calls every three to six months.

Erica Lee, MD: What's nice about when we see patients who are on clinical trials, you know, the side effect profile is so different, and it's so much improved from the traditional chemotherapy. So, we see patients all the time, and they come in for other things like other skin cancers they might be getting, and they're on a clinical trial, but they're doing so well, they're functioning so well, the lab work looks great, it's very different than a decade ago when patients were on chemotherapy. If their blood counts weren’t good, you’d have to pause chemotherapy, but immunotherapy, I feel like despite the clinical trials being so rigorous on the patient, it sounds like the patients are doing well, and they're able to function a lot better and carry on with their normal day-to-day activities.

Michael Postow, MD: That's really important for us, Dr. Lee, as you mentioned. Quality of life is critical, and that's really the goal for all of our treatments, to ensure that quality of life is maintained as much as possible on any kind of treatment. There's always the risk of side effects, and that can happen. And I think one of the areas at Sloan Kettering that I take great pride in our institution is we have an entire institution that's dedicated to the treatment of the patient that might have been diagnosed with melanoma or other cancers, and that all of the supportive care services here at Sloan Kettering, Cardiology, Pulmonology, Infectious Disease, all these other specialties in medicine are really geared around the question, ‘how do we best support the patient with cancer that's undergoing some type of a treatment or needs some surgery?’ I think we have world experts in —at least in this specific example of immunotherapy— side effect management, and when you give some of the treatments for advanced melanoma, there can be side effects from that treatment, and by bringing the experience that we have and handling those side effects with the world experts in each of the specific organs that might be involved, I think that helps improve the patient's quality of life as best as possible. And I will acknowledge that there are certainly problems with side effects, and that's natural when we're giving these types of treatments, but I think that our experiences speak to getting through the treatments as best as possible, and part of that is —in addition to the scientific expertise and experience— because I think our group is a really warm and welcoming group, and that goes a long way. And I hope that that's being conveyed in the enthusiasm we have with interacting with the panelists today. We work well together, we enjoy seeing our patients and talking about things that are not related to treatment or melanoma — grandkids, family events, things going on in our lives, so it's a real relationship that we build, and I think that's really important for long-term outcomes.

Dr. Ariyan, I saw that you unmuted yourself, so if you had something to add to that, that would be great.

Charlotte Ariyan, MD, PhD: Well, I just want to say that yes, I agree with all those statements. But you know, a lot of people think that clinical trials are a scary concept, or they’re only for people who are at the end of their rope, but really, clinical trials can often be used even in earlier-stage disease. We just had some success looking at trying new agents in what we call a neoadjuvant setting, so that's right before surgery. We're trying novel agents and getting kind of a personalized response. Dr. Postow and I and others have recently showed that these new drugs can be just as efficacious, maybe have less side effects, so there's really important things that we can learn that may have a benefit to for you individually. Clinical trials offer hope and new opportunities for treatments in later stages of disease, but we're even using them more and more in early-stage disease.

Michael Postow, MD: Yeah, that’s a really important issue to highlight. And I think alongside that because of immunotherapy and other treatments moving earlier in the spectrum, and in situations where traditionally, maybe surgery alone would have been pursued, but now immunotherapy is showing some benefits and reducing recurrences and helping facilitate surgeries and things, I think the other part of the group where it's important is this intersection of all the different players involved: surgery, medical oncology, dermatology. Dr. Ariyan, could you elaborate a little bit on how we make group decisions when multiple disciplines are involved in a patient's case? And then I’ll turn it to Tierra and Dr. Lee about their discussions in Dermatology as well.

Charlotte Ariyan, MD, PhD: Well, I think we all interface, from the early stage with Dr. Lee and from the later stage with you [Dr. Postow]. One of the few things that's actually been shown to improve outcomes is to have more than one person thinking about you and your disease, and that's been shown worldwide, that's a really important thing. And so we do have that, we have a melanoma group that gets together once a week, and we have the radiologists and all the oncologists, dermatologists, and other people in the room, and we go through the cases, go through the new cases, and it's a great way to think about it. You may be thinking of something very routine, and someone might say, ‘Oh, did you think about this or that?’ So it's really an opportunity to make sure that all every stone is being unturned to get the best individual individualized treatment for you. So that happens, and one portion is more focused on more advanced disease and then one portion is more focused on earlier-stage disease, so again, more focused on the surgical reception and coordination with our plastic surgeons, and Dr. Lee can comment more on that.

Erica Lee, MD: We have so many conferences, and I think it's really for the benefit of the patient and for our own education. We're always learning. And we've been here for over a decade, for example, and so in Dermatology, I’m just going to backtrack for example, every week, we have a conference with the pathologist and the entire Dermatology Service, and this is really important, because you can look at a report, but it's also very different when you look at the slides and you actually look and see what it looks like underneath the microscope with the pathologist. And if there are questions or concerns, or you know, interpretation of what we're seeing, I think having that dialogue and having those weekly meetings really makes a huge impact on patient management. So, we're able to do that every week, and in addition to the Melanoma Disease Management Team that meets every Friday, we have another skin cancer tumor board that meets twice a month, and there, we also are able to talk about all types of skin cancers, but we talk about these early-stage melanomas and the approach to them. You know, should we do something different? Because in some scenarios, while surgery is the standard of care of what we do, there are some scenarios where we consider and we use, for example, a cream to a treat very, very early-stage melanoma. These are decisions that we make together, and I think you know, when you have this sort of group conversation, and we go back with the patient, it's like having opinions with an additional like five to ten people, and I think that has a lot of value. And I think you know, for patients, it's hard because you're seeing one physician, but in fact, the group is discussing the cases, and we're coming back to them with a group opinion. So, I think, from that perspective, we're able to give patients really good, sound advice.

Michael Postow, MD: Absolutely. I think that's the one of the real fun parts about being here and getting everybody's ideas. I'd like to take a couple of the comments and questions that people submitted ahead of time and Tierra, the first one is coming your way. We’ll just take two of these questions that people submitted, and then we'll kind of move on to some final thoughts subsequently, but for Tierra, one of the viewers had written in previously: “I'm a patient. I have dark skin, Hispanic background. How do I look for melanoma on my skin?”

And then, if you could address this specific question, but then any more general questions about unique concerns about melanoma in patients of color. How do you approach that?

Tierra Hurd, MPAS, PA-C:  Yes, very important. So, in skin of color, particularly darker skin of color, moles can automatically appear darker, which can be trickier to diagnose for an untrained eye. So, I tell patients, again, ‘you know your body the best.’ So, if most moles that you have are typically kind of the same size, shape, color, it’s that ugly duckling or outlier mole that looks a little different, it has multiple colors, it easily bleeds, it's traumatized, it doesn't heal months later after you may have nicked it shaving, or after a bug bite or something. You want to look for those little things that can be telltale signs, like a new lump that's not going away where your lymph nodes would be. Even though melanoma in skin of color, again, is not as common, when melanoma does appear, a lot of the times, it will appear in areas where there's not pigment, such as the nails or the palms of the hands or the soles of the feet. So it's very important, even with sunscreen protection or prevention, to help cover those areas and keep them protected, but also just looking in those areas, your nails and the bottom of the feet and the hands for any of those changes or dyspigmentation or changing moles and things like that.

Sometimes I think there's been myths that skin of color doesn't need some protection, but in fact, it does. It may not burn as well, but over time, that constant UVB and UVA exposure can damage those melanocytes, as Dr. Lee mentioned earlier. So again, from a small age on up, we want to make sure that we're protecting that skin. We want to make sure we're reapplying that sunscreen protection, wearing a hat, especially a wide rim hat, and men, where we can also protect the ears, reapplying the sunscreen if you're in the water or doing sports or boating or golfing, whatever outdoor activity. I think those are the takeaways for people with skin of color. Bob Marley, a famous Reggae musician, unfortunately passed away from melanoma that was of the foot, so I think even though we have a lower risk of getting melanoma when it is hot, sometimes it's a little bit more in the advanced stage, because it's often not diagnosed early enough, or it's sometimes misdiagnosed. So those are the things you want to stay vigilant about, just making sure you're monitoring those areas that may not have that pigment, such as again your palms, soles of feet, your nails, and then looking for moles that may that look different than your normal moles that you were born with, or that you've developed over the years through adulthood.

Erica Lee, MD: And we're always telling patients, when you think about sun protection and sunscreen, you really should look for one that's broad spectrum. You want the coverage to be SPF 30 or higher because if you are not getting broad spectrum, then you're not getting the UVA rays, which also contributes to skin cancer development. So all year round, sunscreen is necessary for all skin types, so it’s important for everyone to be wearing it.

Michael Postow, MD: And that's a great reminder. A lot of the times, one of the questions that comes up when someone's been diagnosed with melanoma, in addition to sun protection as we've been talking about, people always want to know, ‘how do I protect family members?’ and this will be a question for you, Dr. Ariyan. What do we know about genetics of melanoma risk for other family members when one family member has been diagnosed? There are certainly genes that do run in families, although those are usually pretty rare, but sometimes, multiple people in certain families will have had melanoma. How would you counsel a patient that has been diagnosed with melanoma about recommendations for other family members, just in a general sense, perhaps?

Charlotte Ariyan, MD, PhD: The risk of melanoma to your other family members is important to consider for a variety of reasons. We know that there's a sun-induced form of melanoma that comes from sun exposure, and that tends to run in families. If you were in the sun, you may have been in the sun with your children, other types of things like that. And if you’re fair-skinned, your children may be fair-skinned like you, so that's a risk factor, even without even having genetic screening, right? If you’re fair skin with light eyes, that's a well-known risk factor. There are genetic mutations that predispose you to melanoma and we're probably learning more about that every day. We don't know all of them, but some of them, often it's very obvious. You have multiple family members who've had melanoma and so some of the ones I think about are p16 or—

Erica Lee, MD: CDKN2, but we get a lot of questions about who should actually be screened for melanomas. What I usually tell patients is that it's really your risk factors, right? Obviously, if you have a personal history of skin cancer, you should get screened on a regular basis, and if you have a family member who's…usually we say a first-degree relative in your family has had melanoma, that’s a risk factor. Other risk factors are lots of moles, and that's usually genetic, so a family member can have tons of moles on their bodies, and that alone is a risk factor. And again, exactly what Dr. Ariyan mentioned: If you've had a lot of sun exposure, and if you are fairer-skinned and have a predisposition to burn easily, then those are risk factors. So, I think depending on your risk factor profile, you should be screened for melanomas. And what's nice about screening is screening is available in the community. You know, you have a board-certified dermatologist that’s trained to do screenings. We have advanced practice providers, such as Tierra, PAs [physician assistants] who work closely with dermatologists, but you know, there are a lot of avenues to get screened, but it's usually when you look at your risk profile and you can say, ‘I have these,’ if you can check off some of these risks, then that’s a flag to say, ‘Okay, you know what, I should get screen for melanoma.’

Michael Postow, MD: There's a lot of opportunity to be mindful of your own skin, the health of your family members, and thinking about the genetics, and it was great that we had a little bit of discussion about patients with different kinds of racial and ethnic backgrounds, and melanoma can affect everybody, despite differences in risk and types of melanomas. So, we're coming up close on the hour, and one of the exciting things we could talk about all day and all into the evening, but I wanted to go through each of the panelists, and I'll start with you Charlene. I think a diagnosis of melanoma, really any skin cancer or any cancer in general always invokes a lot of fear, but we've had such advances in all of our treatment. Patients with diagnosed melanoma are now living longer and better than they ever have before, and a lot of that is due to the work that we've done in clinical trials from years ago, and now continue to do. But I’ll go through each of the panel, so I just want everyone to kind of talk about what they're most excited about for the future with this disease and with the work going on at Sloan Kettering, so we'll each take a turn on that answer and then I think we'll try to wrap up subsequently. Charlene.

Charlene Hochreiter, RN: Yeah, sure. Speaking as someone working directly and primarily on clinical trials, seeing what advances are made, and what molecules, what proteins, what blockades are being discovered to combat what makes melanoma alive, that’s what brings me hope on the future. There are so many trials that keep coming, that keep begging to be part of MSK and to see that we can see point A and the long-term can be, one of these drugs is going to be what everyone with melanoma is going to have potentially one day, and they're going to look to this day and think, ‘Wow! Remember when it was a trial, and we had to go through all these visits and we felt terrible, or we felt fine. And now it's like my grandchildren's treatment, and I was one of the first people who tried this.’ Seeing how people are responding, how people aren't progressing, how people are living and living longer because of something that is now available to them, like this is what this role is for, and I’m so excited.

Michael Postow, MD: And we're glad to have you. To date myself, I remember one of the first trials I got involved with Sloan Kettering was the phase one trial of pembrolizumab, and the brand name for that is Keytruda, and that was the first time it was being given to patients at all. That not only got FDA-approved in melanoma because it dramatically helps so many patients, but it’s FDA-approved in so many different types of cancers now, and so I think you never know, with some of these trials what the next big wins are going to be, so there’s a lot of hope and excitement for some of our new drugs in development. Dr. Ariyan, could you tell us about what makes you hopeful for the future and the surgical treatment of melanoma?

Charlotte Ariyan, MD, PhD: Well, as I mentioned, I think you know, we're being smarter than we were in the past, and not trying to just operate on everyone, and we’re trying to give some drugs beforehand. This allows for a more personalized approach to cancer and understanding whether this drug is the right drug for you individually. And so I think that's so exciting, because in the past, we just lumped people together in big lumps, and now we understand so much more individually based upon genomics and other things. So that's what I’m excited about: defining tomorrow's treatments today, I’d say, and I think there's so much hope in melanoma that we've seen. We've made great strides, and we're really just pushing as hard as we can to still have that to continue to move forward.

Michael Postow, MD: Great! We'll go Dr. Lee and then with you, Tierra!

Erica Lee, MD: So, I’m really fortunate because I get to treat patients with early-stage disease, and you know they come in, everyone's extremely worried, they have a lot of anxiety, and I think just the first thing is understanding the disease and knowing there are so many options at every stage of the disease. I think it's really promising, and I am just so excited about what is in store for how we can treat patients quicker, faster, and do things even better. And I think about quality of life that you mentioned before, I am really into quality of life. I think you know, the most important thing is, you want to treat the patients, but you really want to preserve every aspect of their quality of life as much as possible, because once you get past this disease and you are treated, then you're going to realize that you're just going to go on and continue. You just make all the changes you have to with your sun protection and skin exams and follow-ups for your routine. So, I’m just excited by the whole world of melanoma. I think we're getting really close to understanding, just like Dr. Ariyan said, about personalizing it, and we can make decisions based on the patients and exactly the qualities of their melanoma. With all that, and we have such a dynamic team, it's just really fun to be a part of everything.

Michael Postow, MD: That’s great, thank you, Dr. Lee.

Tierra Hurd, MPAS, PA-C: Just to echo what’s already been beautifully said by our panel, I’m excited by the future for our patients, because again, we’re seeing people that were stage III, stage IV, who have completed immunotherapy and are doing well, and from a first glance, you’d never know that they even had a cancer, but are coming in for their routine skin exams and living life fully. I'm excited that after this treatment, and with the treatments that are forthcoming, that we can use advanced imaging and technology to continue to monitor them. And then also, my hope is that I’m just excited that patients are increasing their education and knowledge on melanoma, and even becoming little detectives on how to pick up on moles and slight changes, and I just I hope that that continues.

Michael Postow, MD: That's great. Well, thank you all for really inspiring comments and personal connections with this disease and our patient population, and I really wish we could address all the questions that came in during the session, but we tried to come up with as many as we could. I'd really like to thank everybody who made the time to join the call today and share their questions in advance, and I hope you found this informative and helpful. Thank you to the four panelists to join me for this discussion with everybody. And if you're not a patient at Sloan Kettering, there will be some information that we hope to extend to you about ways that you could connect with us depending on the situation. We always want to make sure that you're in touch with your doctors and care teams. We know that there are a lot of different individual situations, and many of those are discussed best with the people that are taking care of you, so I encourage you to do so, and we look forward to connecting with you further as a melanoma program at Sloan Kettering. Thanks, everybody, and have a great evening.