Melanoma: assessment and management

Resource impact summary report

The guideline covers the assessment and management of melanoma (a type of skin cancer) in children, young people and adults. It aims to reduce variation in practice and improve survival. It updates the previous version published in July 2015.

The number of people who develop melanoma each year is estimated to be around 26 per 100,000 population (National Cancer Registration and Analysis Service data from 2018).

For melanoma, and other types of cancer, more targeted treatments are being made available and people are living longer and needing more follow up scans. In addition, melanoma has the fastest growing number of cases of all types of cancer. In the last 10 years, statistics for the UK show the incidence of melanoma has increased by 32% and is continuing to rise (Cancer Research UK - melanoma incidence).

Experts on the committee identified that in general, there are demand pressures in radiology and ultrasound services. This applies to scanning for all cancers, and non-cancer indications.

Most of the recommendations in the updated guideline reinforce best practice and do not need any additional resources to implement. However, some of the guideline areas and recommendations may represent a change to current local practice. Where a change is required to current practice, this may require additional resources to implement, which may be significant at a local level. Benefits derived from the change in practice may help mitigate any additional costs.

Due to a lack of robust data on current practice and the variation across organisations and services, the size of the resource impact will need to be determined at a local level. A local resource impact template has been produced to assist organisations.

Depending on current local practice, recommendations/areas which may require additional resources and result in additional costs include:

• Consider staging with body and brain contrast-enhanced (CE)-CT for people with stage IIB melanoma (recommendation 1.4.6). This was not previously recommended in the 2015 guidance.
• Staging with CE-CT of the body and brain to people with stage IIC to IV melanoma (recommendation 1.4.7). The guidance has not changed except services are now recommended to offer staging that includes the brain for stages IIC to IIID.
• Psychosocial support (recommendation 1.9.2). Experts suggest this is currently undertaken by the cancer nurse specialists (CNS) who are trained to provide this support. The demands on the CNS are likely to increase with the recommendation to offer all patients this support. This may require additional CNS hours/additional staff and additional patient visits.
• Planning routine follow up (recommendation 1.9.15). Experts suggest the recommendations on follow up at each stage of melanoma may have resource implications. Resource constraints identified were trained radiologists, radiographers, and scanners. The guideline recommends services to consider using ultrasound scans as part of surveillance during follow up from stages 1B to stage 3. Clinical experts suggest this is likely to have resource implications due to the capacity of ultrasound services.

Implementing the guideline may lead to the following benefits:

• enable treatment to be started sooner by recommending V600E BRAF analysis to be considered earlier at stage IIA or IIB melanoma. There will be some extra resource needed within pathology departments to prepare the samples. (recommendation 1.3.9)
• reduce sentinel lymph node biopsy in people with melanoma and a Breslow thickness of 0.8 mm to 1.0 mm by targeting it specifically to those with risk factors for a positive sentinel lymph node biopsy (recommendation 1.4.3)
• reduce variation in the use of imaging during staging, with an increase in the use of CE-CT and reducing the use of PET-CT scans (recommendations 1.9.13 and 1.9.15)
• reduce the number of clinic visits for people with stages 2B to IIC melanoma (reduced from 4 visits to 2 visits in year 3; recommendation 1.9.15)
• reduce the use of less cost-effective imaging at stage 3 melanoma to allow timely identification of recurrences (recommendations 1.9.5 and 1.9.15)
• lead to better health outcomes and care experience.

These benefits may also provide some savings to offset some of the potential costs identified above.

Melanoma services are commissioned by NHS England (people who have invasive skin cancer and cutaneous skin lymphomas) and integrated care systems/clinical commissioning groups. Providers are NHS hospital trusts.