These are the advances that will ensure that no one dies of melanoma

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No one should die from melanoma, stated the American physician

, one of the most influential in modern dermatology.

The reflection continues in the face of a tumor that grows slowly, to the naked eye, and whose removal can be curative.

However, there is still the paradox that among people at low risk of having melanoma, it is diagnosed at a more advanced stage, even metastatic.

In these cases, early detection may have failed due to a matter of

.

As explained by the dermatologist

, of the International Dermatological Clinic, in Madrid, sometimes people without risk factors for melanoma "do not have the feeling that it could happen to them, and they do not see the appearance of a mole and its growth as a problem; they are not attentive. At least in my experience, some of these patients

and can kill. It is a shock for them," says Pizarro, who has dedicated his entire professional life to making his Ackerman's premise.

"Early detection of melanoma is extremely effective in saving lives."

How to favor this early identification?

Simply, with the

of the signs of suspicion of melanoma and with self-monitoring.

"It is enough to look at the skin two or three times a year; we can photograph the areas that we do not see; the key is

" emphasizes Pizarro (paraphrasing the director of the WHO when he recalled the importance of testing in the pandemic).

"Don't be scared if you see a new mole, because most of the time it won't be a melanoma, or a problem, but in case that spot or mole is growing or changing, you should see your doctor."

It is one of the messages released by this melanoma expert during the conference

, held at the Ramón Areces Foundation in Madrid, under the coordination of dermatologists Ricardo Ruiz and Ignacio Sánchez-Carpintero, both from the International Dermatological Clinic of Madrid and Pedro Rodríguez, from the Hospital Ruber Internacional.

With a disseminating vocation and with a kaleidoscopic approach (prevention, detection, surgery, systemic treatment, vision of the dermatologist, the pathologist and the patient), the meeting reviewed the current management of skin cancer of various types, the most frequent affecting the human species.

This is how the medical director of Dermatology at the International Dermatological Clinic and the Ruber International Hospital,

, recalls it, who comments that "half of the cancers diagnosed in the world are skin cancers. Some types of skin cancer are rare. aggressive, such as basal cell epitheliomas, but others are more dangerous such as

or

. Squamous cell carcinoma is the skin cancer that causes

, since it is much more frequent than melanoma".

Today, an early diagnosis and surgery constitute the best curative opportunity for skin cancer.

Hence the emphasis placed by specialists on self-

and early consultation with the doctor in case of suspicion.

But, to what extent should be reviewed?

"The ideal thing is

, adapt it to the risk profile of each patient and leave the most sophisticated techniques for those with the highest risk, without forgetting to insist on the photos - even if you go to a periodic review, it is good that you

- and keep in mind that the Abcde rule in low-risk people with few moles

," says Pizarro.

At high risk: full mapping

If the person is considered very high risk and very difficult to monitor, "there is no other option, in my opinion, than to resort to a

of all their moles with digital dermatoscopy. Of course, this consumes a lot of resources, fundamentally, the time, but it is the

that any patient who really has many moles, in atypical areas and with some risk factor for melanoma should have access to".

That mapping can be done

.

"My experience is that for most patients, an annual check-up is sufficient, provided that in some way the patient has the facility to make a quick consultation, if in the time until his next check-up, he notices something that worry".

Will the machines diagnose us?

In these digital dermatoscopy systems to map moles, "we are applying

" says Ricardo Ruiz.

"It automatically detects lesions that may be suspicious for malignancy due to the characteristics of the edges or pigmentation," explains Ricardo Ruiz.

"On the other hand, there are studies that show that the algorithms designed, for example, by

are more effective in diagnosing melanoma than the dermatologists themselves. However,

, but rather that they are going to be of great help to us."

help to make a more accurate and faster early diagnosis of melanoma.

Ángel Pizarro agrees on this, who sees in the current applications of artificial intelligence (AI) a way to help the doctor, rather than an automated diagnosis.

"There are already certain apps that have diagnostic accuracy better than that of a primary care physician or general dermatologist, or equal to, and even in some contexts better than, that of an expert dermatologist. But we also know that these apps have failures, just like the expert dermatologist has. They do not offer

one hundred percent

and

in what type of patient and in what type of lesions is it easier for the doctor to get it wrong or right, and in which ones will the machine do it better, and for this

are essential ", where the two methods are compared. That is This is quite a challenge in the case of melanoma, since due to its incidence (6,000 or 7,000 melanomas per year in Spain), tens of thousands of people monitored for years would be necessary to be able to draw statistically relevant conclusions.

Consequently, "we are going to work with a very powerful technology, but with relatively weak evidence on its effectiveness under normal clinical practice conditions. That said, I am certain that AI will gradually be incorporated into our consultations, which will help, but neither the doctor nor the patient should take for granted that artificial intelligence is better than

There will be situations where you will have reasons to trust it, and perhaps there will be others in which the doctor's

will weigh more , and factors like other clinical data of the patient. I believe that the future lies in the collaboration between man and machine".

Moh's surgery

Once skin cancer has been detected, "Mohs surgery achieves the best oncological results, since it eliminates the entire tumor, and aesthetic results, since it only eliminates the tumor," says Ricardo Ruiz, a pioneer in the introduction of this surgical technique in Spain.

"This microscopically controlled surgery

in speed and precision since it is being combined with techniques such as augmented reality, artificial intelligence or devices such as confocal microscopy or OCT [optical coherence tomography].

This technique is increasingly used in Spain, mainly performed by dermatologists.

But not all epithelioma-type skin cancers should be treated with Mohs surgery: only those that are located in areas at risk (nose, perioral or periocular region) and have infiltrative epithelioma histology."

As if that argument were not enough to endorse Mohs surgery in cases where it is indicated as the best option, one can use some of the reasons that

, dermatologist at Hospital Ruber Internacional , has outlined in his speech.

, and among which a

out (three times lower with this technique);

(and therefore less disfigurement) ;

applicable in

(dermatofibrosarcoma protuberans and pleomorphic sarcoma);

, in the medium and long term, by avoiding recurrences and the consequent treatments, and the one that achieves the

of the patient.

Squamous cell carcinoma

The different surgical techniques achieve a very good prognosis, with complete responses in the vast majority of cases of squamous cell or cutaneous squamous cell carcinoma.

However, as pointed out by

cutaneous squamous cell carcinoma

, with a higher probability of developing metastasis."

If the metastasis is lymph node, a five-year survival is estimated at 50-83%, and if it is distant metastasis, it is established at 40%.

An important part of the research is now focused on determining

with high risk and for this, Sanmartin has indicated, certain biomarkers are being explored (elevated expression of podoplanin or PD-1), as well as certain genetic and epigenetic traits of the patients.

And where surgery does not come, there is the resource of

, which in recent years has made great strides with targeted therapies and, more recently, with immunotherapy.

Ricardo Ruiz brings up the new protocols for disseminated skin cancer, especially

, provided at the last meeting of the European Society for Medical Oncology (ESMO), which was held last week.

"For these more advanced melanomas that have spread, we have drugs that do not directly attack the tumor, but rather

so that it is our own body that fights against the malignant cells (nivolumab, pembrolizumab, cemiplimab and avelumab, which are the drugs called anti PD1).

In this congress, studies were presented where the efficacy of the combination of these new drugs and their influence on the

of these patients were demonstrated". In his talk,

, head of the Dermatology Service of the Virgen Macarena University Hospital, in Seville , has pointed out about these pharmacological treatments that block immune control points (

inhibitors ) that, in effect, their

, as well as

(before surgery).

The specialist has also elaborated on the potential immune-mediated

of these treatments, something that must be controlled by different specialists.

However, he is convinced that

, "it is now in its infancy", in such a way that it will further reduce mortality from advanced skin cancer.

Photoprotection, networks and inspiring patients

For several years now in Spain, dermatologists have been embarking on a crusade so that the fact that photoprotection is a preventive habit against cancer, just like not smoking, takes hold.

, president of the Spanish Academy of Dermatology and Venereology (AEDV), and head of the Dermatology Service at the Miguel Servet Hospital in Zaragoza, alludes to the fact that it has demonstrated its usefulness in countries with a high incidence, such as Australia.

It is to be hoped that as it spreads, it will also

.

Gilaberte mentioned at the conference a recent international study presented at the last European congress, where the good position of Spain in measuring this preventive habit is confirmed;

"Probably because of the culture of the sun and the awareness campaigns, the population is becoming more and more aware."

The president of the Academy has addressed some controversies around photoprotection, such as the impact of certain compounds of these products on the environment -something, as she has mentioned, more and more is being tried to control in new formulations- and if it is necessary in

or

.

"The blue spectrum [a part of visible light] does have biological effects on the skin, specifically hyperpigmentation and aging, but it is not associated with skin cancer," she explained.

On the other hand, she does not consider the use of photoprotection indoors necessary.

Counter wrong messages

A formula to deliver these preventive messages is social networks.

This is well known to

, who combines her work as a dermatologist at the Jiménez Díaz Foundation Hospital in Madrid with scientific dissemination on various platforms, including a successful

account .

Molina is in favor of making a

based on the

offered by the networks and that is raised by professionals, so that they can counteract actions as viral as

or the challenge of the

sun tattoos.

Initiatives such as that of the patient

, founder of the NGO Spot the Dot (literally, "Find the dot").

Eight years have passed since Kruis was diagnosed with melanoma IIB.

She could well be one of those patients Ángel Pizarro was talking about, who at the time of diagnosis are ignorant of everything about skin cancer.

With her illness, Kruis said, "I began my journey to fight misunderstandings about melanoma in the general population: misconceptions that skin cancer is not fatal, that it doesn't happen to young people, or that it's just a disease. for light-skinned people.

For this reason, Kruis believes that the focus should be on detection (although she also emphasizes prevention), since "literally, the earlier you detect it, the better chance you have of treatment.

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