Clinical Review

Melanoma—Part 2: management

BMJ 2008; 337 doi: (Published 01 December 2008) Cite this as: BMJ 2008;337:a2488
  1. Christina Thirlwell, specialist registrar, medical oncology1,
  2. Paul Nathan, consultant medical oncologist2
  1. 1Royal Free Hospital, London NW3 2QG
  2. 2Mount Vernon Cancer Centre, Northwood HA6 2RN
  1. Correspondence to: P Nathan nathan.pd{at}

    Summary points

    • The seven point checklist is useful for identifying suspicious lesions

    • Suspicious pigmented lesions should be excised by specialists

    • Rapid referral for surgery and further management are imperative to improve outcomes

    • Multidisciplinary specialist teams should manage patients with high risk or advanced disease

    • Systemic treatment options have modest effectiveness, so patients should be offered entry into clinical trials of new agents

    Most melanomas that are detected and treated early are cured. However, advanced disease carries a dismal diagnosis, and timely intervention from members of the multidisciplinary skin cancer team at all stages of the disease is essential to maximise cure rates. The management of patients with incurable disease is highly specialised and requires the input of surgeons, medical and clinical oncologists, palliative care teams, and clinical nurse specialists. In the second of this two part series on melanoma we review its management from primary lesion through to metastatic disease.

    Sources and selection criteria

    We used Medline (1966-2008), Cochrane Library, and Embase (1980-2008) to identify studies and meta-analyses for this review. The search string included the terms melanoma, adjuvant and metastatic therapy, wide local excision, and sentinel lymph node biopsy. We accessed the websites of the National Institute for Health and Clinical Excellence, National Cancer Research Network, and National Cancer Research Institute for guidelines and current trials in the United Kingdom.

    How is melanoma managed in primary care?

    In the past, suspicious lesions were often removed in primary care. However, recent national guidance recommends that patients with suspicious pigmented lesions are referred to a specialist member of the hospital based skin cancer team using the two week cancer wait procedure.1 2 This has been the subject of much debate and if fully implemented will result in a change in practice for many general practitioners.

    Primary melanoma is often difficult to diagnose, even for those with a specialist training. A prospective study showed …

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