Diagnosis

All patients should have a complete skin check.

Most diagnoses occur in the primary care setting.

Specialist management may include complete excision (in rare instances where a punch, shave or incisional biopsy was performed pre-referral) or re-excision with recommended margins, and imaging.

Staging

Sentinel lymph node biopsy should be considered for patients with a melanoma greater than 1 mm in thickness and for patients with a melanoma greater than 0.75 mm and other high-risk features such as ulceration; this will provide optimal staging and prognostic information. If metastatic melanoma is detected, discuss how to manage the regional lymph nodes region. The options are observation with clinical and ultrasound review or completion lymph node dissection (CLND). CLND does not offer any survival benefit over close observation. A subset of patients who have metastatic melanoma detected in the sentinel nodes are likely to be referred to a medical oncologist to discuss the role of adjuvant systemic therapy.

Genetic testing

Patients that may be appropriate for referral include:

• people with more than one first-degree relative with melanoma – they should be referred to a dermatologist for a clinical risk assessment
• people with three or more relatives with melanoma and/or pancreatic cancer – they should be referred to a family cancer service for a genetic risk assessment.

Treatment planning

The multidisciplinary team should meet to discuss patients with unusual pathology, any patient where treatment may be unclear and all patients with stage III and IV disease, within 4 weeks of the initial diagnosis.

Research and clinical trials

Consider enrolment where available and appropriate. Search for a trial.

Communication

The lead clinician’s (1) responsibilities include:

• discussing a timeframe for diagnosis and treatment options with the patient and/or carer
• explaining the role of the multidisciplinary team in treatment planning and ongoing care
• encouraging discussion about the diagnosis, prognosis, advance care planning and palliative care while clarifying the patient’s wishes, needs, beliefs and expectations, and their ability to comprehend the communication
• providing appropriate information and referral to support services as required
• communicating with the patient’s GP about the diagnosis, treatment plan and recommendations from multidisciplinary meetings (MDMs).

Checklist

Timeframe

Staging investigations should be completed within 2 weeks of the specialist’s assessment.