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Rapid response to:

Head To Head

Should we rename low risk cancers?

BMJ 2019; 364 doi: (Published 23 January 2019) Cite this as: BMJ 2019;364:k4699

Rapid Response:

Re: Should we rename low risk cancers?

Dear Sir/Madam,
I am a Plastic Surgeon treating patients with skin cancer including Malignant Melanoma, and a core member of our Supra Regional Specialist Skin Cancer MDT.
I read your debate with great interest as the issues of “naming” and “overdiagnosis” are pertinent to skin cancer and melanoma in particular.
Daily I am troubled by the conflict between my duty to prevent the terrible consequences of metastatic disease in a small minority of my patients, and the exhortation to “primum non nocere” – a constant challenge for the surgeon.
As Birte Twisselman’s patient commentary highlighted, we still use the term Basal Cell Carcinoma for a vast number of essentially “benign” tumours excised from the skin. I, personally, try to reduce the anxiety associated with this “name” by reiterating that this is merely a name based on the microscopic appearance. I stress that it “does not go anywhere”; that “most of us” would rather not call it cancer, and that for all intents and purposes it “has been removed” and “job done”.
However, this is less useful for the increasing number of patients diagnosed with the thinnest, and lowest risk stage IA melanomas, which your debaters and responders did not cover. There has been a recent (2017) adjustment by the USA AJCC to the way these are staged in an effort to further identify the lowest risk primary tumours, which are to be ‘discharged early with education and reassurance’ [1]. Research continues to look for better prognostic indicators which can even further differentiate the true metastasising cancer from the non-cancer.
The mortality risk, essentially from metastasis, for these lowest risk lesions is accepted at being 1% at 5, and 2% at 10 years. Since we believe that these few metastasising lesions have almost certainly ‘spread’ by the time of diagnosis and complete excision, and this is a tiny minority of this sub group, most national including UK NHS NICE guidelines recommend discharge after 12 months [2,3].
However, we are currently in the process of revising for publication, work from our own unit, that suggests that the metastatic risk is even lower than the above figures, and perhaps these USA AJCC figures are larger, due to primary misdiagnosis, due to (apologies to Dr Murali, but this is said with the support of my Specialist Skin Pathologists), the human error involved with identifying key prognostic indicators [4,5].
This is relevant as there has been an increase in such “lowest risk” diagnoses globally, but without an equivalent reduction in metastatic presentation. In our unit alone, there has been a 3-fold in 6 years, and accounting for 2/3 of the nearly 500 patients now being given a “melanoma cancer” diagnosis [6]. All of these patients are currently counselled separately by both a Consultant Dermatologist, Skin Cancer Clinical Nurse specialist, and later, the Plastic surgeon performing the mandated wide local excision (WLE).
Currently many skin cancer clinicians balk at any suggestion that the recommended wider local excision surgery that is mandated for even these lowest-risk lesions, may be the ‘over treatment’ of >97% of these patients, citing minimal morbidity. This is despite the professionally published acceptance that (WLE) does not increases the melanoma specific survival of these patients nor prevent regional or distant metastasis in those very few patients whose low risk tumours, are in fact higher risk.
We have previously presented [7] and are preparing our data for formal publication that shows that approximately 30% of patients formally report complications, including 30% surgical, and 10% increased anxiety and distress. WLE does lead to patients having increased anxiety about their ‘moles’ leading to almost a third seeking removal of more “concerning” but histologically benign lesions, whilst those ‘cleared’ of such a diagnosis, returned to do so less than a quarter as often.
The problem is that even though we clinicians may appreciate that these lesions are not actually dangerous, the increasing pressures of the service do not enable time, in practice, to “reassure” all such patients adequately about their lowest risk. At least stage IA melanoma, melanoma clinicians are confident enough to discharge them at 12 months. However, they are still burdened with the label of “cancer”.
I therefore applaud the BMJ for raising this issue so publicly and allowing a debate to start about whether we should “rename” such lowest risk “cancers”.
Yours sincerely,
Sahan V. Rannan-Eliya, Consultant Plastic, Reconstructive and Hand surgeon

1. Gershenwald JE, Scolyer RA, et al. Melanoma Staging: Evidence-Based Changes in the American Joint Committee on Cancer Eighth Edition Cancer Staging Manual. Ca Cancer J Clin 2017; 67:472–492
2. Melanoma: assessment and management. National Institute for Health and Care Excellence, UK (NICE) guideline: 29 July 2015.
3. Cromwell KD, Ross MI, et al. Variability in melanoma post-treatment surveillance practices by country and physician specialty: A systematic review. Melanoma Res. 2012 October; 22(5)
4. J Henton, J Callear, A Dearden, SV Rannan-Eliya. Are cutaneous melanoma treatment guidelines keeping pace with rapidly evolving melanoma treatment options? A review of metastatic melanoma at a supra-regional service. Presented at ECCO 2017: European Cancer Congress, Amsterdam 27-30 January 2017.
5. Lorimer PD, Benham EC, et al. Reporting of mitotic rate in cutaneous melanoma: A study using the national cancer data base. J Surg Oncol. 2017 Mar;115(3):281-286.
6. Rannan-Eliya SV, Henton JH, et al. Does the proposed removal of mitotic count as a prognostic indicator in melanoma, accurately reflect the risk profile for metastasis in UK patients? J Plast Reconstr Aesthet Surg. 2018 Feb;71(2):261-262.
7. Lau TK, Bradish T, et al. “Primum Non Nocere”: How Harmless is Routine Wide Local Excision for AJCC 1A Melanoma? Presented at Regional Melanoma Focus meeting, Newcastle, UK – 19th May 2017, and Association of Surgeons in Training 2018 Conference, Edinburgh, UK – April 2018. Int J Surg 2018; July 55; Supp 1: S91.

Competing interests: No competing interests

14 February 2019
Sahan V Rannan-Eliya
Consultant Plastic, Reconstructive and Hand surgeon
Department of Burns and Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK