May 20, 2013
by Tim Dean
Each May, media reports remind us about the dangers of too much sun exposure and the rising incidence of skin cancer—especially melanoma, the most invasive and malignant form of skin cancer.
As it turns out, living in Northern New England doesn't make us any more immune—about 400 new cases of melanoma are diagnosed in NH every year. Learn more about fighting sun exposure risk.
On the Rise
"The incidence of melanoma has increased in all age-gender groups nationally in recent decades, and our rate of increase has generally been on par with the rest of the country," explains John Colby, Jr., PhD, an environmental epidemiologist with the NH Environmental Public Health Tracking Program.
"Part of that increase is due to reporting and diagnostic improvements, which have led to better survival rates overall in recent years," he says. "And part is due to a real increase in disease from greater UV exposure."
Two groups in particular have been at higher risk, says Colby, both in NH and nationally. "We saw a dramatic increase in the 1990s to early 2000s in melanoma diagnoses in young women (age 15 to 39), and we think one of the major culprits is tanning facility use," he says.
"Then, in older men (age 65+), we've seen very high rates in both incidence and mortality," he adds. "We attribute that to long-term exposure, including occupational exposure, as well as perhaps a tendency to ignore signs and symptoms until it's too late."
One Patient's Story
That certainly wasn't the case with Nancy Calder. About five years ago, after noticing a black welt on her waist that wouldn't go away, she went to her doctor in Concord. "I had a biopsy done and it came back metastatic melanoma," she recalls. "I had no other symptoms; it just came out of the blue."
In her late 30s, Calder had had some small basal cell carcinomas removed from her forehead—a usually benign and slow growing type of skin cancer that is the most common cancer in the U.S. Then in 2006, she had an ‘in situ' melanoma on her nose that was successfully treated by dermatologist Shane Chapman, MD, at Dartmouth-Hitchcock (D-H).
"'In situ' refers to when a melanoma is confined to the outermost layer of skin," explains Chapman. "If caught early when they're thin, melanomas can often be surgically removed, if you have a wide enough margin to work with and the borders of the cancer are well-defined. In Nancy's case, they weren't, so we used imiquimod cream, a topical treatment that causes an immune response to kill the cancer cells. She responded well, and that took care of it."
But now, two years later, Calder had a different form of melanoma, one that had already metastasized or spread throughout her body and that only 6 percent of patients survive. "I was devastated and scared," she recalls. "I called Dr. Chapman, and God love him, he called me back on a Sunday night. He answered all my questions, recommended I see Dr. Marc Ernstoff at D-H, and helped me get an appointment right away."
A noted oncologist and researcher, Ernstoff has focused much of his 30-year career on finding more effective treatments for melanoma. "It's a complex disease that is probably, cell for cell, more aggressive than other cancers," explains Ernstoff, Associate Director of Clinical Research and Director of the Melanoma Program at Dartmouth-Hitchcock Norris Cotton Cancer Center. "But here at Norris Cotton Cancer Center, we have access to the latest new agents to treat melanoma (as well as other cancers), and we have an active research program that allows us to do that."
Taking the Offensive
Calder chose interleukin 2 (IL 2), a targeted therapy which works to boost the immune system. "I had a lot of confidence in Dr. Ernstoff," she says. "I couldn't just pretend it wasn't there. I chose to fight it head-on, and I wanted the most aggressive treatment possible."
That treatment involved a grueling two-week cycle of intense IV therapy in the hospital, with a six-week break. When the first cycle dramatically shrunk her tumors, Ernstoff scheduled a second, which also had very good results. The IL 2 treatments were followed by two surgeries by cardiothoracic surgeon William Nugent, MD, to remove two small tumors that remained in her lungs.
Remarkably, Calder, who just turned 70, has been in complete remission since 2008. "The treatments were difficult to endure and it probably took me a year to get all of my energy back," she says. "But I feel great. I'm so grateful for the unbelievable support I received from my family and friends, and the superb care I received at D-H. Dr. Ernstoff is my hero."
"She's the real hero," says Ernstoff. "Nancy was willing to take a high-risk medication and to go through a therapy that is pretty toxic to patients. But she's done remarkably well, and she's a great case study for helping us understand how we can improve treatments for metastatic melanoma patients in the future."
New Resource for Patients
With greater numbers of people at risk for developing melanomas and other skin cancers, Drs. Chapman and Ernstoff are starting a new interdisciplinary clinic this month at Dartmouth-Hitchcock Heater Road for patients diagnosed with melanoma.
"We'll be focused on seeing people who are at higher risk, who have complicated melanomas, or who've had the disease and need to be monitored very closely for recurrences," explains Chapman. "By combining our specialties and seeing patients and families at the same time in this clinic, we hope to provide better, more responsive care while making the care experience more convenient and less stressful for them."
Like Calder, patients participating in the clinic will have access to new therapies under investigation as part of a clinical trial. Learn more about our clinical trials at cancer.dartmouth.edu/clinicaltrials.