World’s melanoma capital needs more dermatologists

AUSTRALIA’S Olympic swimming gold medallist, Cate Campbell, recently posted a photo on her Instagram account of a large scar on her arm where a stage I melanoma had just been removed. This follows a celebrity trend of posting content regarding their respective skin cancer experiences; including Hugh Jackman, who has had five basal cell carcinomas removed from his face and AFL Hawthorn club captain, Jarryd Roughead, who has publicly shared his battle with metastatic melanoma.

Their message is simple: get your skin checked. This is the same message that we advocate for as dermatologists. Unlike breast, bowel and cervical cancers, there is currently no population-based screening program for melanoma.

Australia has the unenviable reputation of being the melanoma capital of the world, with the highest age-standardised incidence rates for invasive melanoma. The estimated number of new cases of melanoma to affect Australians in 2019 is 15 229. In fact, melanoma is the most common cancer among Australians aged 15–39 years. If caught early (stage I), the 5-year survival rate for melanoma is high (99.2%). However, this rate decreases to only 26.2% for Australians diagnosed with stage IV melanoma.

Table 1: Incidence and 5-year relative survival for people diagnosed in 2011, by cancer type and registry-derived (RD) stage. Source: AIHW
				5-year relative survival
Cancer site/type (ICD-10 codes)	RD stage	Number	% of total cases	Survival (%)	95% CI lower bound	95% CI upper bound
Melanoma of the skin (C43)	I	8730	78.0	99.2	98.5	99.9
	II	1577	14.1	73.6	70.5	76.5
	III	331	3.0	61.1	55.1	66.8
	IV	233	2.1	26.2	20.3	32.4
	Unknown	328	2.9	90.8	85.8	94.7
	Total	11 199	100.0	92.9	92.1	93.7

Early detection is the key to saving lives. In order to achieve our vision of a world without melanoma, a multipronged approach will be required.

While there is no recommendation for a population-based screening program, there is new evidence from the University of Queensland (UQ) Dermatology Research Centre showing that an impact could be made by focusing surveillance on people at highest risk. UQ researchers have discovered that Australians with a mole count of 20 or more, who also possess the “red hair” gene (MC1R), have a 25-fold increased risk of developing a melanoma in their lifetime. The interplay of knowledge of genetic risk combined with other known risk factors should allow for the development of targeted surveillance programs.

Delivery of specialist dermatology services in regional, rural and remote areas is particularly challenging.

The sheer burden of melanoma in Australia affords Australian dermatologists the opportunity to lead advances in melanoma detection worldwide. Commencing this year, the Australian Cancer Research Foundation Australian Centre of Excellence in Melanoma Imaging and Diagnosis is pursuing a world-first approach to tackling the burden of melanoma, with the aim of achieving a “World Without Melanoma”.

Led by UQ, together with the University of Sydney and Monash University, this work will implement cutting edge, three-dimensional (3D) imaging technology with a telemedicine network to improve the early detection of melanoma.

This project will see 15 3D whole-body imaging machines positioned in capital and regional centres across Queensland, New South Wales and Victoria, with the potential to expand the network Australia-wide in the future. The machines will be linked with innovative telemedicine capabilities, enabling earlier detection of melanoma with the aim of ultimately saving lives.

Using the latest imaging system, which takes a 3D whole-body image in milliseconds, will allow us to significantly improve lesion identification and tracking, in combination with greatly reduced appointment time and health care costs.

Three-dimensional total body data will be transmitted from 3D imaging systems in regional and rural Australia to centralised image storage repositories. This centralised storage repository will allow dermatologists, or suitably trained general practitioners (GPs) with subspecialty knowledge, to review the patient images independent of time, location, or population density parameters. This will provide enhanced access to specialist services for those living in rural and remote areas, and it is hoped this will improve survival rates dramatically by allowing the disease to be detected early.

Devices will change the daily practice of dermatologists. This technology will facilitate improved triage capabilities for patients who require more specialist attention and care.

Smartphone dermoscopic imaging with built-in artificial intelligence (AI) will most likely prove the most accessible method for future skin lesion analysis. These technological advances will serve as enablers for the dermatology community.

Importantly, technology is not a replacement for a dermatologist, but rather, another tool to allow us to best care for our patients.

It is estimated that each of the 15 3D imaging machines will provide 3000 examinations each year, generating approximately 45 000 images from all systems, annually. This will produce a large dataset of skin images, adding to the capacity to inform other clinical studies, including the computation of AI algorithms to support clinical decision making.

AI and its adoption in dermatology is proceeding rapidly, such as for identifying the potential characteristics of melanoma, and is being integrated into software for various types of imaging platforms.

In the meantime, however, the number of new cases of melanoma in Australia is predicted to continue to rise, placing a substantial burden on Australia’s health care system. Our profession also faces workforce shortages nationwide.

According to the Department of Health, the Australian dermatology workforce is projected to be short of at least 90 specialist dermatologists by 2030, representing a 14% deficit of the projected demand for dermatology services.

To meet the skin health needs of our Australian population, we need to rapidly expand our training programs and increase the number of specialist dermatologists available. This requires more funding for dermatology departments in public hospitals across the country. Increasingly, health services have assigned dermatology services as a low priority, which has subsequently resulted in a funding shortfall. Increased dermatology training capacity will only be achieved when public hospital dermatology services are appropriately prioritised to meet the community’s needs. State and territory support for public hospitals, complemented with federal investment to explore new models of training, is essential to address the dermatology workforce shortage.

Continued funding for outreach services nationwide is critical to meet the health service needs of all Australians. This must also be accompanied by measures to increase dermatology services in larger regional centres. Investment in new technology, such as teledermatology, will help enable the delivery of services to rural and remote communities. Specialised consulting and surgical services provided by dermatologists in the private sector removes a huge burden on the public hospital system.

One of the Australasian College of Dermatologists’ clear objectives is to ensure high quality, dermatologic care is available to meet the community’s needs. Our College is building enduring and cooperative relationships with community groups to help better understand their members, and to guide our activities. Crucially, these groups should be consulted to shape future government health policy.

However, it’s important not to forget that age old saying that “prevention is better than cure”. Skin cancer is primarily preventable. Using a combination of sun protection measures, Australians can take positive steps each day to reduce their risk of developing the disease.

Particularly, appealing to the younger generations and reinforcing the importance of caring for the skin early in life should generate better skin health outcomes in this demographic.

It’s our job as clinicians to keep reminding Australians of this crucial message.

Adjunct Associate Professor David Francis is President of the Australasian College of Dermatologists. He works at the Dermatology Specialist Centre in Brisbane, teaches dermatologic surgery at Princess Alexandra Hospital and Royal Brisbane and Women’s Hospital, and is also a Fellow of the American College of Mohs Surgery.

Professor H Peter Soyer is Director at both the University of Queensland Dermatology Research Centre and Princess Alexandra Hospital Dermatology Department in Brisbane. He also leads the Australian Cancer Research Foundation Australian Centre of Excellence in Melanoma Imaging and Diagnosis.

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.