What specialties should a person with melanoma see, dermatology or oncology?

Melanoma Management: Specialty Referral

Patients with melanoma require care from a multidisciplinary team that includes both dermatology and oncology specialists, with the specific composition depending on disease stage and complexity. 1

Initial Diagnosis and Early-Stage Disease

Dermatologists serve as the primary specialists for initial diagnosis, surgical management, and follow-up of early-stage melanoma (stage I-IIA). 1, 2

• Patients with suspicious pigmented lesions should be referred urgently to a dermatologist or surgeon/plastic surgeon with expertise in pigmented lesions, ideally within 2 weeks of referral 1
• Dermatologists are optimally trained to perform full skin examinations, recognize melanoma at earliest stages, and obtain appropriate full-thickness excisional biopsies 2
• For stage IA melanoma (Breslow thickness <1mm without ulceration), dermatologists can perform definitive wide local excision with 1 cm margins under local anesthesia in outpatient settings 1, 2
• Stage IA patients require only 2-4 follow-up visits over 12 months, then discharge, which can be managed entirely by dermatology 1

Intermediate and Advanced Disease: Multidisciplinary Team Required

All patients with stage IB or higher melanoma must be referred to a Specialist Skin Cancer Multidisciplinary Team that includes dermatologists, surgical oncologists, medical oncologists, pathologists, radiologists, and specialized nurses. 1

Specific referral criteria to multidisciplinary oncology teams include: 1

• Stage IB or higher when sentinel lymph node biopsy is available
• Stage IIB or higher in absence of sentinel lymph node biopsy capability
• Any patient with metastatic melanoma at presentation or follow-up
• Patients eligible for clinical trials
• Multiple primary melanomas
• Children younger than 19 years with melanoma
• Melanomas at special sites (mucosal, head and neck, gynecological)

Role Distribution by Disease Stage

Stage I-IIA (Early Disease):

• Primary specialty: Dermatology 2
• Dermatologists perform excisional biopsy, wide local excision, and follow-up
• No routine imaging or oncology referral needed 1

Stage IIB-III (Intermediate/High Risk):

• Both dermatology and oncology required 1
• Surgical oncology for sentinel lymph node biopsy and lymph node dissection
• Medical oncology for consideration of adjuvant therapy and clinical trial enrollment
• Patients should be referred to Cancer Centre multidisciplinary team within 8 weeks of surgery 1
• Dermatology continues skin surveillance for new primaries

Stage IV (Metastatic Disease):

• Primary specialty: Medical oncology with dermatology involvement 1
• Medical oncology manages systemic therapy (immunotherapy, targeted therapy, chemotherapy)
• Surgical oncology for oligometastatic disease resection
• Dermatology for skin surveillance and management of cutaneous metastases
• All decisions made through Specialist Skin Cancer Multidisciplinary Team 1

Practical Implementation

The optimal model involves shared care between specialists based on risk stratification: 3

• Low-risk patients (stage IA): Dermatology alone or alternating with general practitioner
• Intermediate-risk (stage IB-IIA): Dermatology with periodic oncology consultation
• High-risk (stage IIB-IV): Co-management by dermatology and oncology through multidisciplinary team 1

Critical Pitfalls to Avoid

• Do not delay referral to multidisciplinary team for stage IB or higher disease—sentinel lymph node biopsy and adjuvant therapy decisions are time-sensitive 1
• Do not assume dermatology alone is sufficient for any melanoma beyond stage IA—mortality and morbidity outcomes improve with multidisciplinary care 1
• Do not perform routine imaging for stage I-IIA disease—false positive rates are high and true positive rates are low 1
• Do not discharge patients with stage IB or higher from specialist follow-up prematurely—these patients require 3-5 years of regular surveillance 1

In summary: The answer is "both," with dermatology leading care for early-stage disease and oncology becoming increasingly central as stage advances, always within a multidisciplinary framework for stage IB and beyond. 1, 4