The official start of summer is almost upon us, and I suspect many of you are now busy planning your upcoming beach vacations. To prevent melanoma and other skin cancers, you will want to take plenty of sunscreen and follow U.S. Centers for Disease Control and Prevention recommendations for avoiding the sun’s harmful rays.
We at Hillman believe that second best to melanoma prevention is early melanoma detection, which can identify skin lesions that are pre-malignant or at the earliest stages of malignancy, when a full cure is much more likely. Surprisingly, there are currently no national guidelines for skin cancer screening. This is because few studies have been completed to demonstrate whether screening is truly effective at lowering the risk of death from melanoma.
Hillman faculty Drs. Laura Korb Ferris, Yan Lin, Jian-Min Yuan, and John Kirkwood, and their University of Pittsburgh collaborators—investigators who combine expertise in dermatology, biostatistics and informatics, epidemiology, and treatment of melanoma—have been conducting a large-scale study within the UPMC health care network to determine whether full body skin cancer screening by primary care physicians (PCPs) during routine annual physical exams is both feasible and beneficial. Perhaps some of you are already familiar with their efforts, based on a skin screening exam that you may have received from your own UPMC doctor.
The first step of this landmark study was to provide access to an online training module to instruct PCPs in how to respectfully request permission to conduct a whole body skin exam and, when consent is received, how to actually perform the exam. During the first year that it was made available, 155 UPMC physicians completed the specialized training and over 53,000 patients underwent screening. The study relied on UPMC’s comprehensive electronic health record, which prompted the trained physicians to screen eligible patients, collected the results of the screenings that were performed, and provided the study’s data analysts with key information pertaining to patient demographics and any medical follow-up that took place. The results, which were published in JAMA Oncology last summer, showed that patients who underwent full body skin screening were more likely to be diagnosed with an in situ or invasive melanoma than the approximately 280,500 unscreened patients with whom they were compared. As predicted, however, the melanomas that were detected in the patients who were screened tended to have lower “Breslow thickness,” which is associated with a better cure rate and less extensive surgical scarring. What remains to be seen over time, however, is whether this approach will actually reduce the number of people who succumb from a new or recurring melanoma.
Unfortunately, melanoma remains a large problem in Hillman’s 29-county western Pennsylvania catchment area, with the number of new invasive melanoma cases in 2015 (the most recent year for which data are available) being nearly 4.4 times higher than that in 1990. The good news is that, starting in 1996, immunotherapy strategies became available for treating melanoma, starting with the clinical testing and subsequent FDA approval of alpha-interferon, which was spearheaded by Dr. Kirkwood who co-leads Hillman’s Melanoma Program. New immunotherapies have improved the three-year overall survival rate for advanced melanoma (i.e., a melanoma that has metastasized to other body sites) from a dismal 9% at the time prior to introduction of alpha-interferon, to somewhere around 40-60% today, when two different immunotherapy agents are combined.
Because we at Hillman do not consider 40-60% survival good enough, the members of our Melanoma Program are collaborating together and with investigators from other Hillman programs and throughout the University to test innovative new strategies for melanoma treatment. In this regard, Melanoma Program co-leader Dr. Hassane Zarour, with Hillman colleagues Drs. Diwakar Davar and Panayiotis (Takis) Benos, was recently awarded a grant by the National Cancer Institute to determine whether patients who do not originally benefit from immunotherapy can be converted to being responsive after receiving a fecal microbiome transplant from a melanoma patient who has shown a particularly good and long-lasting response to immunotherapy. This exciting work is based on their preliminary data showing that there are measurable differences in gut flora species when immunotherapy responders are compared to non-responders. In another project that was recently funded by the Department of Defense Peer Reviewed Cancer Research Program, Drs. Yana Najjar from our Melanoma Program and Greg Delgoffe from our Cancer Immunology Program are conducting a clinical trial to determine whether the commonly prescribed anti-diabetes drug metformin is able to improve the response to immunotherapy in advanced melanoma patients. This trial is based on Dr. Delgoffe’s published work that used a well-characterized mouse model of melanoma. When metformin was combined with a PD-1 blocking antibody, the tumors disappeared in 70% of the mice and showed significant shrinkage in another 10%.
There is no question that significant progress is being made at Hillman in research that is aimed at early detection and treatment of melanoma. Since prevention remains the most effective strategy for further reducing the death rate from this aggressive skin cancer, I hope my June Director’s Message has inspired you to take sun safety very seriously this summer.
Robert L. Ferris, MD, PhD