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Scott Webb (Host): One-On-One with Regional One Health as your inside look at how we're building healthier tomorrows for our patients in our community. Join us for expert insight that empowers you to achieve a lifetime of better health. Today, Dr. Martin Fleming, who specializes in the treatment of melanoma is with us to give patients information they can use to protect against skin cancer.

I'm Scott Webb. Thanks for joining me. Dr. Fleming, thanks so much for your time. I know you specialize in the treatment of melanoma. So, how preventable is melanoma and what can patients do to protect themselves?

Martin Fleming, MD, FACS (Guest): Melanoma, it's definitely preventable, but the problem is the causal effect that leads to the melanoma often happens very early on in life; 95% of melanomas we feel, are related to sun exposure. They are most often in fair complected people, often blue eyed. Red hair is very common, lots of freckling and moles.

Now it's not exclusively those people, but those are the most common people because of their skin and the effect of sun on their skin. There's historically a large population of Scotch, Irish and Nordic people that came to the United States and settled in the Southeast, forming what we now call the Melanoma Belt because the warm sun of the Southeast of the United States often being populated by farmers out in the fields a lot over the last hundred years has led to a large number of people with a lot of sun exposure. The skin was not designed for it. So, that being said, you know, if somebody is fair complected and they grow up in a sunny climate of Florida, the Southeastern United States, a very large population in the world is in Australia because of all the British folks that settled in Australia, it leads to accumulation of sun exposure that leads to a higher risk of melanoma. So, the sun you get when you're a child and a teenager or a young adult, is what often leads to melanoma, when you're in your forties, fifties, and 60. So in that sense, it is preventable.

Minimizing sun exposure as you grow up, certainly not adding to it as you age, with sunscreens, and productive clothing and things like that in sunny environments, definitely will help prevent melanoma from ever happening, and certainly will minimize the risks going forward for folks that have had a lot of sun exposure.

Host: That's interesting. I'd never heard that before, the Melanoma Belt, that's kind of a humorous in a way, if it wasn't such a serious topic. So, the Melanoma Belt and a lot of what you're describing, kind of describes me and my family history, a Scotch Irish, and so on. So I know that you said, you know, 95% is from sun exposure. Is that other 5% genetics and family history?

Dr. Fleming: It's not real clear. Certainly genetics seemed to play into it though there's no one specific gene that we test people for to put some at very high risk for melanoma. But melanoma is the term for cancer from the cells of the body that have melanin and melanin is pigment. So it's what's on your skin that helps you tan when you're out in the summertime, that's the melanin, but melanin is also in cells in other parts of the body and people can get primary melanomas of the GI track or other areas of the body where the sun is not an issue at all. And so it clearly, it's not all sun related. We also see a melanoma, fairly regularly, but in much smaller percentages in folks with a lot of skin pigment, Latino population, African-American population, all can get melanoma and we see melanoma in those people, but it's just far less common than in fair complected folks with a lot of sun exposure.

Host: Yeah. And you mentioned the blues eyes as well again, describing me. So thanks doc.

Dr. Fleming: Yeah.

Host: Yeah. So what should we watch out for in terms of signs of melanoma so that we can catch it early? Let's just say we grew up in an era like I did in the seventies when we didn't really have, or use sunscreen. And so we find ourselves in our forties and fifties, what can we look out for and how can we catch it early?

Dr. Fleming: I'd say a couple of things. One, you can continue to participate in prevention. So using sunscreens in the highest SPF or sun protective factor you can get on your sunscreen, the better. There's a little bit of controversy. A SPF of a hundred is not necessarily twice as much as SPF of 50, as far as protection.

That's not a linear progression, but it's still better. And so use sunscreens and minimize sun exposure going forward. Then as far as surveillance now, we know that if we find melanoma very early, it becomes more of a nuisance than a real life-threatening problem. It might require a simple outpatient day surgery to take care of it, with a 99% cure rate.

The way we look for it in surveillances, it's just skin exams, both dermatology and surgical oncologists that deal with melanoma a lot, do surveillance exams on a regular basis. For some folks that's very difficult. They have hundreds of moles and freckles and to know which one might be a melanoma can be tricky, but there are some basics we teach patients about. We call them the ABCs of melanoma.

So A is for asymmetry. Meaning if a little brown freckle is irregular in shape. It's not round or ovoid like a more typical mole or freckle would be, that's a hint. B as for border irregularity. If the edges of a pigmented lesion kind of feather out into the normal skin tone, rather than stopping abruptly like a normal mole or freckle would, C is for color variation. If you have a pigmented lesion that is not just light brown, but might be brown or blue or pink, or even red kind of mixed in, those can be a hint of a melanoma. D is for diameter. We usually say a diameter more than five millimeters. And just for a kind of a thumbnail, I tell people if it's about the size of a pencil eraser or smaller, then it's probably okay.

But anything that gets bigger than that probably needs to be evaluated. And then E we use the term evolution, meaning it's changing. So a mole, if it's very small and it's growing rapidly, or if it starts bleeding or itching or doing something strange, then that needs to be evaluated. And all of those are imperfect.

You know, you can have all of those and still not have a melanoma, but those are all hints of a skin lesion that probably needs to be evaluated, possibly biopsied or taken off in the office just to make sure it's okay.

Host: And as a surgical oncologist, how do you treat melanoma? What should patients expect from the treatment in terms of outcomes, recovery, scarring and so on?

Dr. Fleming: And just backing up just for one minute for the surveillance, a good tool that's free from the American Cancer Society, is a, they have a little card that has small pictures that go along with each one of those descriptors. If somebody wants that they can certainly call the American Cancer Society and they give those out free all the time.

Just a plug for the American Cancer Society would be it's one 1-800-ACS-2345 is the number. And it's a one 800 call number from the American Cancer Society where you can get any number of free information and stuff mailed to your home. So if people are interested or they're concerned, they can certainly get one of those. And they used to make glossy version of it. You can hang in the shower so that when you're actually not dressed, you can look around and look at moles and freckles.

So surgical intervention. So the way you treat melanoma is primarily with surgery, for thinner melanomas, because the depth of the melanoma is what determines the risk. And we actually, when someone has a biopsy and if it's melanoma on the pathology report, they will give us an actually numerical depth. They take a ruler underneath a microscope and measure how far from the surface down the melanoma extends and the deeper it goes, the higher the risk. So for thin melanomas, all it is an outpatient day surgery procedure just to remove the melanoma.

Now when I say remove the melanoma, it's much bigger than just simply taking out the spot. There's some prescribed distances that are considered safe, that you have to go around the melanoma and patients pretty universally surprised by how far around the melanoma you have to go. But in the grand scheme of things is a simple outpatient day surgery procedure. For thicker melanomas, it also involves checking for any evidence of spread. So, after our physical exam, if we don't see or feel any lumps or bumps or evidence of spread for thicker melanomas in the operating room, after we take out the melanoma with the wide excision, we do what's called a sentinel lymph node mapping and biopsy as a technique where we can identify a lymph node in the body that is at risk for maybe having cancer cells in it.

We go find it using a radioactive isotope technique. Make a small incision. Take out the lymph node and send that off to pathology for them to check. And I tell patients the fact that we found the lymph node isn't bad. That does not mean there's cancer in the lymph node that just tells us of all the lymph nodes in your body, and there's hundreds of those, which lymph node is the one at highest risk for maybe having cancer cells in it. And we send that off to pathology and let them look for microscopic evidence of spread. So, for the thicker melanomas, that surgery has two components. For the thinner melanomas. It's just the wide excision.

The next step people always go home and say, well, what if the melanoma's in the lymph node? What happens next? And there's only three ways to treat cancer, surgery, chemotherapy, or medical treatments and radiation. Those are the three arms of any cancer treatment, and hopefully we don't need all three.

And for simple melanomas, that early surgery is all you need. But for the deeper melanomas, especially if there's evidence of lymph node spread, there are great medicines. Now, a whole family of medicines called immunotherapy that are available to treat spread from melanoma that, actually have a very high cure rate and, and a much lower rate of causing problems and complications from the treatment. Chemotherapies can be kind of harsh in certain cancer treatments, hard on patients to go through. Immunotherapies are not perfect, but they are much lower at causing complications and side effects. So I would really encourage folks that immunotherapy is out there if they need it.

Radiation is used less often for melanoma, but still in some instances for more advanced disease, we use it. So there are other arms in addition to surgery that can be used. But the earlier we find it, the simpler the treatment and the higher the cure rate.

Host: This has been really educational today. What are your takeaways when it comes to melanoma? How we can do proper surveillance and what you and the folks at Regional One Health can do to help people.

Dr. Fleming: Yeah, I would say a couple of things. One, early is always better for almost any cancer and certainly for melanoma. So, if anyone has something that they're concerned about or they feel is changing in any way, don't be shy about going to see somebody, if they don't have a dermatologist or primary care doctor, they can come see us directly.

And we just take it off from the office, send it off to lab. And it's a, 10 minute little procedure that they can walk in and walk out and be sure that it's nothing to worry about. But certainly don't put it off. If you know, there's a problem, have somebody assess it and evaluate you for a possible melanoma.

And if you have a diagnosis of melanoma, we would certainly be happy to see you and bring to bear all those kind of newer, sophisticated treatment options and make sure we do everything possible to get rid of it and minimize its impact on your life.

Host: Yeah, well, that's great. And I really appreciate your time and your expertise today, Doctor. And you stay well.

Dr. Fleming: Thank you so much.

Host: And to learn more, go to regionalonehealth.org/oncology-Maine-campus, or call 901-515-9595. And thanks for making One-On-One with Regional One Health part of your journey to better health. Join us next time as we cover another topic to keep you on the path to a healthier tomorrow. I'm Scott Webb. Stay well.