Bigger melanoma cut to save lives

By MARTIN JOHNSTON

Some melanoma patients may have died because doctors cut out too little flesh for vanity reasons.

Researchers in Auckland, the region with the world's highest rate of the disease, found the risk of a recurrence was often higher if the original cut was too small.

In the interests of patient safety, they have called for the removal of more flesh around melanomas.

"There's a tendency to under-treat because of concern about the cosmetic appearance of it," one of the researchers, Auckland Hospital surgeon Wayne Jones, said yesterday.

Melanoma kills about 250 people in New Zealand a year, although it is readily cured if treated early.

The researchers reviewed the cases of 1155 people treated for melanoma in Auckland between 1976 and 1996.

Eighty-four (7 per cent) had suffered a "local recurrence" - a flare-up within 5cm of the original lesion. Nearly 40 per cent of them had died, compared with 8.4 per cent of those without a local recurrence.

Another of the researchers, Professor James Shaw, said that 30 years ago melanoma removals were generally performed with a 5cm margin around the lesion and a skin graft.

Treatment had become less aggressive and some studies now promoted margins of less than 1cm. Consequently, skin grafts were needed in only a minority of cases.

But the Auckland study showed that margins of at least 1cm were needed for all melanomas except those detected at the earliest stage, he said.

Mr Jones said GPs usually handled patients with suspected melanomas correctly by cutting them out with a margin of 1mm to 2mm of tissue around the lesion and sending this biopsy to a laboratory for analysis.

About 90 per cent were negative, but the remaining positive patients should be sent to a specialist for further tissue removal and tests.

"Possibly some of those cases haven't been appropriately referred for excision.

"The difficulty is, I think, that there has been a perception that thin lesions can have a narrow excision because we don't want to leave people with big wounds so people may have been erring on the conservative side of things rather than treating the melanoma."

That had resulted in deaths, he said.

Surgeons now also check many melanoma patients for spread of the disease to lymph nodes using coloured and radioisotope dyes, a technique thought to improve survival chances.

Regular melanoma training sessions have been run for GPs and Mr Jones said he had noticed both a rising number of referrals to Auckland Hospital and a declining rate of melanoma recurrence.

College of GPs chairwoman Dr Helen Rodenburg said the referral problems highlighted by the research had been solved. Auckland GPs in particular had received a lot of training in the past decade in diagnosis and minor surgery for melanoma.

It was standard practice, she said, depending on the nature and location of the lesion, to refer patients to a specialist following laboratory-confirmed diagnosis.

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