Q & A: Dr Derek Power on melanoma treatments
Last month, Dr Derek Power, Consultant Medical Oncologist at Cork University Hospital and The Mercy University Hospital, took part in a live Q & A session over on our Facebook page to discuss melanoma treatments. Dr Power took part in "Áine Lawlor: Facing Cancer", a two-part documentary which screened on RTÉ 1 on 7th and 14th November.
Below is an edited transcript of the Facebook Q & A.
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Question: Is there family screening available for melanoma other than mole mapping? I have had it and two of my cousins I would like to know if I am carrying a melanoma gene and if it's been passed on to my children so we can be more proactive.
Dr Power’s Answer: There is mole mapping with a good dermatologist. This is not screening as such as you say, but is a good way to watch moles that are suspicious.
The issue of genetic testing is a good question. There are some familial syndromes that can cause melanomas. The family history would need to be analysed by a genetics counsellor and then a decision made on formal genetics testing. Your dermatologist could refer you to The National Centre for Medical Genetic in Crumlin who run this service. As a word of caution these genetic syndromes are very rare. Also if the genetic test is positive then how to screen can be a problem.
Hope this is helpful...
Question: I had melanoma nine years ago, I had follow-up for five years now, yearly mole mapping. I have also brought my children to have various moles checked out. When I have asked about us being put under care of dermatologist I have been told no need just come to CUH or south infirmary for to be checked out at clinic. I am a public medical card patient, this worries me endlessly given very strong family history shouldn't me and my kids be checked or at least be under care of a specific dermatologist? Should I try and pay for it privately or is coming to the clinic when I have a concern enough for all of us?
Dr Power’s Answer: I think it all depends on your family history. I think the public and private system is the same and please do not think that care is any different – if you are with good Drs then that is the most important thing. If the family history is very positive then you should be referred to The National Centre for Medical Genetics. A good dermatologist can refer you. Also a dermatologist should examine you regularly if you have multiple moles.
Question: What are your views on isolated limb infusion?
Dr Power’s Answer: I do have experience of isolated limb perfusion. This is very specialised treatment but there is good evidence to support it in my view – in very specific situations. You need to see someone who has experience – this is available in Ireland.
Question: What are your views on Interferon either as a month high dose cycle followed by maintenance 3 times a week, or no month high cycle just increasing dose to 9 miu's 5 times a week for 12 months from highest dose managed? Do side effects not outweigh what appears to be a tiny success rate and is it worth it?
Dr Power’s Answer: The role of interferon is very controversial and opinions widely differ all over the world. I personally do not prescribe this as routine after surgery on the primary melanoma. I do think toxicity is a major problem and the benefit overall is low. In disease that is ulcerated and has positive lymph nodes and can be removed surgically there may be a benefit, however, but this is a very specific group of patients and each case is different.
Hope this is helpful.
Question: Dear Dr Power brilliant programme last night! So glad I watched it! I have malignant melanoma stage 3c. Contained in my groin lymph nodes. I had surgery to remove them and ones in my stomach. Of the 10 removed 4 in groin were positive but 6 from stomach were negative. I am now technically cancer free! My question is what are the chances of it spreading to other parts of my body? And if I'm not accepted onto the brim trial what other treatment is there for me now? Thank you in advance.
Dr Power’s Answer: Thanks for the email. This would depend on the BRAF status. If negative then I would favour watching with scans. Some Drs would consider Interferon but this is very controversial. There is a clinical trial comparing Interferon with Ipi in this situation – this is not open in Ireland yet but will be in a month or two. Also the BRAF trial in this setting is an option if the disease has the mutation. This is open in Cork, Galway and Dublin but there is a placebo arm for 50% of patients. If the disease was removed over 70 days ago then the BRAF trial is not an option. Hope this is helpful. It is great you had surgery as this is the best treatment.
Question: I was diagnosed with a stage 2 Clarks Level 2.8 melanoma four years ago and now my partner has just been diagnosed with a stage two melanoma from a halo mole. We have a seven-year-old son and I am extremely concerned about the genetic implications for him from familial melanoma. Do his chances of contracting it now greatly increase or should he be ok once I monitor his skin closely? He does have a few moles and I have brought him to my GP this week who gave him the once over, I would love him to see the dermatologist in Waterford regional hospital but have been told that wouldn't be an option at his age even if I went privately. Just wondering is there anything more I should be doing other than checking him regularly and obviously being extremely vigilant in the sun as we all are?
Dr Power’s Answer: Hi, Thanks for the email. If there is no further family history in your blood relatives or your partner’s blood relatives then I think normal sun protection measures as advised by your GP are appropriate. Familial melanoma is very rare. Your partner and you are not blood related so it is unlikely that there is an increased risk of melanoma in your family. Please look into your family history in more detail and if you find more melanoma in siblings or first/second degree relatives then this is more concerning. But as of now the risk in your family is the same as the population risk.
Question: This is a message of thanks, and of learning and hope. Firstly I personally want to thank all of you involved in tackling and overcoming the many cancers and forms of cancer out there. It must be like trying to see a 3D picture of an image hidden in the midst and even that keeps changing! Those of us who have dealt with it and continue to deal with it in differing ways would literally be lost without you. Secondly, I want to thank all my wonderful family, my strong and loving friends, workmates etc but most of all my amazing husband for the support, love and help he has given me. His positive attitude after I was diagnosed with breast cancer was to gently let me know that while there was the operation, chemo, radiotherapy and medication for 5 years to face, we could do it together and create a healing, unstressed, loving and safe environment around us and an attitude of taking control wherever we could and believe in the power and strength supplied by those around us who wanted nothing but health and happiness for us. For me, and I know this is me only, I now count my experience and any to come as a blessing which while frightening, sickening etc was also a journey and I thank everyone who walked it with me. My question: Do you think we can be of help to ourselves by being positive and accepting?
Dr Power’s Answer: Thanks for the message and well done on everything you have got through. The least you and everyone deserve is excellent state of the art care and I firmly believe this is available in Ireland. Being positive and accepting can be very difficult but it does help in my view.
Question: Hi Dr Power I have just had a 1.2mm MM removed from my inner forearm. Thankfully margins clear. I have had Hodgkin’s Lymphoma twice before and I am in remission 8 years from it. Do you know of any link between MM and Hodgkin’s? Many thanks
Dr Derek Power’s Answer: Thanks for the message and well done on what you have come through. The connection here is not clear. There is a risk of developing melanoma after radiotherapy if you have a family history of melanoma with a known genetic mutation. However this is by no means scientific fact. Lymphoma affects your immune system and there can be an increased risk of melanoma as a result. This has been shown in some large population studies but the exact reasons why are not well understood. A regular skin check with a dermatologist or your GP is a good idea.
Hope this is helpful.
Question: I started Ipi this week after being on dacarbazine for 18 months. I have had no side-effects at all to the Ipi. I know everyone reacts differently but if I am to get side-effects would they normally happen on the second or third dose?
Dr Power’s Answer: There is no good evidence that the side-effects of Ipi correlate with response so please be reassured. Also side-effects can appear at any time even many months after the Ipi is finished. During the treatment they can also appear and are very treatable – they usually tend to appear after 3-4 doses but this is variable.
As long as you are being monitored closely and you inform your Drs of anything unusual then everything should be fine.
Hope this is helpful.
Question: Why as a melanoma patient are you not offered scans, or get regular blood testing as other cancer patients ? Surly the goal is to ensure it has not metastasised to the organs As a MM patient I have had a lot of expense getting these done regularly.
Dr Power’s Answer: I know this is very frustrating and Drs who treat melanoma are struggling with this issue all around the world. There is no good evidence that regular scans and blood tests can pick up recurrent melanoma earlier. I know this is difficult to understand but melanoma is not like other cancers in this regard. The goal is exactly as you say but the evidence supporting regular scans and bloods is just not there yet. However I would recommend a regular skin check with a dermatologist or GP along with routine bloods which can also be helpful for other health reasons. Scans should only really be done if the primary melanoma that was removed is at very high risk of recurrence. Sometimes regular ultrasound of lymph nodes close to the primary tumour is a good idea.
Hope this is helpful.
Question: My darling husband died in October of Melanona. It started in his eye three years ago and we had eye removed. It was a large tumour. Last November metastasised to liver, bones and lungs. What is bothering me if he has gone sooner about his eye would we have had longer, or do the seeds go around the body when the tumour is starting? Thank you and God bless all of you. Your manner to your patients is so good. Mary
Dr Power’s Answer: Thanks for the email Mary and the kind words.
I am sorry to hear of your husband. It is very hard to know what would have happened if he had gone sooner about his eye. However given that it took three years to develop more disease it is unlikely the ‘seeds’ of cancer were there at the start. I hope this is helpful and my condolences once again.
The Irish Cancer Society would like to thank Dr Derek Power for providing his time and expertise so generously for this valuable Question & Answer session. We aim to carry more live Q & A's with experts in different areas of cancer in 2014. Keep an eye on our Facebook page for more details.
Click here for extended interview footage from Part 1 of "Áine Lawlor: Facing Cancer"
