It’s time for a “change” in our approach to early detection of malignant melanoma

Abstract

The ABCD’s of Melanoma (Table 1) have been one of the most successful mnemonics in medicine and proven to be an excellent tool for professional and lay education about the clinical features of malignant melanoma.1–3 All dermatology residents and most primary care residents use this systematic approach to the physical examination of a patient’s moles. Patients are comforted to know that they can identify these simple features of melanoma and feel a part of the team as they monitor their moles on a monthly basis. It has become clear that the ABCD criteria are often insufficiently sensitive to allow for the diagnosis of early malignant melanoma (Fig. 1).4,5 A review of recent literature confirmed our suspicion that it is time for a “change” in our approach. Malignant melanoma is curable if lesions are identified early and are completely excised. The treatment is difficult, at best, once metastatic spread has occurred. Early melanoma studies have proven that a “change” in a mole is the earliest finding and can lead to the diagnosis of melanoma in the absence of the ABCD physical diagnostic criteria.6–10 In fact, change is the most important diagnostic feature reported by patients.6,11–14 Changes in shape, size, color, crusting, bleeding, and pruritus can be early clues to the diagnosis of melanoma. In the area of melanoma education, an emphasis on change is not new. The American Cancer Society’s “Seven Warning Signs of Cancer” always included, “A change in a wart or mole.”15 MacKie’s seven-point melanoma checklist, which is the standard approach in the United Kingdom, requires any one of three major criteria, or two minor criteria to prompt action in examining nevi (Table 2).16 All three major criteria reflect a recent change. In fact, the importance of change in a mole in the diagnosis of early melanoma has been emphasized by a variety of experts.2,17–23 Even dermoscopy experts who use a hand-held tool to enhance and magnify suspicious lesions have emphasized the limitations of physical diagnostic criteria and emphasized the importance of a recent change as a significant component to early detection.24–30 Finally, photography experts have suggested serial standardized photographic methods to identify changes in moles.31–33 Recent reviews that focus on the ABCDs have not always highFrom the Yale University School of Medicine, New Haven, Connecticut, and the Ohio Division, Inc., American Cancer Society, Northeastern Ohio Universities College of Medicine, Rootstown, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Address correspondence to Robert T. Brodell, MD, 2660 East Market Street, Warren, OH 44483. E-mail address: rtb@neoucom.edu. Table 2. MacKie’s Seven-Point Melanoma Checklist