STARTING from 2013 in Italy, the 5-year survival of patients with melanoma has significantly improved especially in men, going from 87% in 2003-2007 to 93% in 2013-2017. And the improvement, thanks to the availability of the new immunostimulating drugs, was more marked for male patients with melanomas greater than 4 millimeters and with a worse prognosis, for whom the 5-year survival went from 48% to 61%. It is the result of a joint study by AIRTUM, the Association of Italian Cancer Registers, coordinated by the Romagna Cancer Registry, supported with funding from the Italian Melanoma Intergroup (Imi) and previewed during the XXVII IMI National Congress, which is held in Turin from today to November 8.
Good news, no doubt. Nor the only one, because at the congress the positive news are different and concern many aspects of the disease, from epidemiology, to genetics, to surgery, as Ignazio Stanganelli, president of IMI, director of the Skin Cancer Unit IRCCS Istituto Romagnolo for the Study of Tumors and associate professor of the University of Parma: “Last year we already saw a decline in the incidence of melanoma in Italy in the generation of the seventies, thanks to health education campaigns. This year we present the study on survival data, which among other things earned Federica Zamagni, a young biostatistician from IRST, the Romagna Scientific Institute for the Study and Treatment of Tumors, the Elvo Tempia Special Prize 2021 for progress of science and medicine in the knowledge of cancer “.
Initial melanoma, a project on targeted therapies to prevent relapses is underway
Life gets longer in both sexes. But in men more
Survival data previewed in Turin confirmed that in both sexes the average thickness of melanomas recorded in the period 2003-2017 continued to decrease and that, in parallel, patient survival continued to improve. “However – says Emanuele Crocetti, past-president of AIRTUM, consultant of IRST and co-author of the research – 5-year survival has increased particularly for men: going from 87% between 2003 and 2007, to 93 % between 2013 and 2017, for all melanomas “.
Immunotherapy: Women have twice as many side effects as men
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A gender difference that remains unexplained
As anticipated, the improvement in survival was stronger for men, while in women with melanomas of maximum thickness the percentage is still at 52%. Therefore, with the same severity of diagnosis, women have not gained years of life in the same period of time. Because? “We do not have an answer – resumes Crocetti – we can hypothesize that at the base of this difference between men and women there is a different way of responding to immunostimulating drugs, which we began to use in 2013”. The reasons behind the increase in survival recorded in a relatively short time are two, Stanganelli underlines: the early diagnosis that reveals less thick melanomas and therefore with a better prognosis, and the new drugs, which were introduced after 2010 and which are anti-BRAF target therapies for people who have a BRAF gene mutation and anti-CTLA-4 and anti-PD-1 immunotherapies for advanced melanoma.
Gamma Knife, “Here’s how we treat brain metastases today”
Stage IV tumors are also operated on today
Not only therapies, but melanoma surgery is also changing. Indeed, it has changed. “Today – says Roberto Patuzzo, surgeon of the Melanoma and Sarcoma Department of the National Cancer Institute of Milan – in addition to operating the first, second and, above all, the third stage of the disease as always, we also intervene on the fourth stage and on metastases, because eliminating them surgically and then administering targeted therapies to the patient we make him free from the disease again ”. “In practice – adds Pietro Quaglino, associate of the Dermatological Clinic of the University of Turin – surgery is ‘designed’ on the patient and even if it is no longer the first choice, it is a fundamental piece of the multidisciplinary treatment path”.
Melanoma, early stage immunotherapy also works in the real world
Immunotherapy makes the tumor operable
Immunotherapy, in fact, gives important results in about half of the patients, reducing the size of the tumor and making it circumscribed and operable. However, all this works if the advanced stage cancer patient is taken care of in centers where there is a multidisciplinary team, where the dermatologist, the anatomopathologist, the oncologist, the radiologist, the geneticist and the surgeon are confronted by establishing the path better therapeutic. It is no coincidence that one of the key words of the XXVII IMI congress is multidisciplinarity. Better care is taken, especially in cases of advanced disease, when the sequence of the most suitable therapies for each individual patient is decided together by dermatologists, oncologists, geneticists, radiologists, surgeons, and even by artificial intelligence, which comes to the aid of early diagnostics. .
The super-experienced dermatologist and the AI
Technology also plays a leading role. Artificial intelligence, as a secondary prevention tool, could make a difference. “The goal is to establish, thanks to advanced processing parameters, whether a mole is’ not suspicious’, ‘suspect’, ‘highly suspicious’ or’ not evaluable”, underlines Luigi Naldi, president of Gised, Italian Group for Epidemiological Studies in Dermatology and Director of the complex operating unit of dermatology of the San Bortolo Hospital in Vicenza. From this point of view, “the role of the dermatologist also changes – adds Stanganelli – who, using artificial intelligence, will become a ‘super expert’ by exploiting artificial intelligence, allowing the diagnosis of this very aggressive skin cancer at an early stage”.
Melanoma, early stage immunotherapy also works in the real world
Telepathology and computational pathology
A reality, that of AI, which in Italy however still has strong regulatory and economic constraints. While both telepathology and computational pathology are already operational and with excellent results. In the case of telepathology, pathologists are allowed to compare in real time with other specialists from all over the world before making a difficult diagnosis, quickly providing high-quality consultations from a distance. In the second case, that of computational pathology, by means of automated quantification it is possible to reach more precise and standardized diagnoses, reducing the margin of error. During the pandemic, genetic teleconsultations increased by 34%. It is precisely from the teleconsultation due to Covid that the data of another study presented in preview in Turin come. The research defines which genes are to be analyzed in case of family history or multiple melanomas, how to identify the patients to be tested and the surveillance protocols to follow.
Telemedicine: after Covid, 8 out of 10 patients want to use it also in the future
by Irma D’Aria
“Starting from 2016 – says Paola Ghiorzo, Director of the Genetics Unit of Rare Tumors of the IRCCS San Martino Polyclinic Hospital and Professor of Biology and Genetics at the University of Genoa – we have analyzed, in sharing and also thanks to the IMI teleconsultation, germline mutations (ie already present at birth, ed) of a gene group that included CDKN2A, CDK4, BAP1, POT1, ACD, TERF2IP, MITF, ATM. The tests involved 879 families of patients with melanoma from 25 different Italian centers and gave us a picture of genetic mutations at a national level in relation to the increase in melanoma cases “. The conclusions? “Our data suggests avoiding genetic testing when the age of first diagnosis is over 60,” says Ghiorzo. On the contrary, under the age of 60, and especially between the ages of 40-50, the study highlighted a decline in the percentage of patients with the mutated BRAF gene and a doubling of patients who had mutated other genes that have been more recently identified.
Melanoma before and after Covid
An AIMa.Me survey, the Italian Association of Melanoma and Skin Cancer Patients, in collaboration with IMI evaluated the management of two groups of patients with melanoma diagnosed before and after the onset of the pandemic. The goal was to understand if and how much the entry of Covid into our lives and our health system had affected the management of patients already under treatment at the time of the health crisis compared to those whose diagnostic-therapeutic path was started during the crisis. “We have a direct line with the sick – says Giovanna Nievo, president of AIMa.Me. – which allowed us to deepen the state of the art of their taking charge and care “. In all, 587 men and women were interviewed via online questionnaire: 334 in Group 1 and 252 in Group 2 with an average age of 54 and 51 years respectively.
With the closures longer times for diagnosis
The reasons that led to the dermatological examination, during which melanoma was diagnosed, are the same in the two groups: in 42-44% it was a suspected lesion and in 45-42% a general control of the nevi. On the other hand, there are significant differences, as regards the waiting times to access the dermatological examination in which the diagnosis of melanoma was made: in Group 1, 88% of patients had to wait less than 3 months, and only 2 , 7% over 6 months, while in Group 2, these percentages were 84.1% and 7.9% respectively.
But patient management hasn’t changed. Maybe it got better
“In terms of ‘patient management’ – says Saverio Caini, Medical Director of the Institute for the Study, Prevention and Oncology Network (ISPRO) – the management of the two groups was no different and therefore no particular deterioration in the quality of diagnosis and treatment between before and after covid. Indeed in some aspects there was even an improvement “In particular, the waiting time for the removal of melanoma was less than 15 days more often in Group 2 (42.5%) than in Group 1 (35, 9%), and the histological report was also delivered more quickly during Covid. The percentage of patients with waiting time for delivery of the report of less than 15 days was respectively 51.6% and 46.4% in Groups 2 and 1. “The appeal we launch as IMI – concludes Stanganelli – is to increase the centers of oncological excellence in which specialists compare and follow the indications dictated at international level “.
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