Background

Australia has the second highest melanoma rates in the world (after New Zealand),1,2 and melanoma represents a huge burden to the Australian health system with treatment costs alone surpassing $200 million annually3 and expected to grow substantially with the expansion of new therapies for later-stage disease.4,5 Melanoma is the third most common cancer in both Australian men and women, accounting for 10% of all new invasive cases (about 14,000) and almost 5% of cancer deaths (over 1,800) in 2017. These incidence figures don’t take into account in situ melanomas, which are diagnosed in even greater numbers than invasive melanoma.3

They also don’t take into account multiple primary melanomas for the same person. A paper from the QSkin Sun and Health Study showed that 11% of people diagnosed with melanoma developed at least 1 more primary melanoma within a 3-year period.6 Patients with stage I melanomas have a 10-year survival of 95%, compared to <70% for stage III or IV melanomas.7 Melanoma disproportionally affects young people, as it is the most commonly diagnosed cancer among persons aged 25-34, and in men aged 35-49.1 Invasive melanoma incidence rates have been stable or slightly declining in Australia over the past 10 years, but this is not consistent across age groups, with over 60s, particularly men, continuing to experience increasing incidence rates.2,8

Skin cancer is the most expensive cancer for the Australian health system, by virtue of the number of people it affects. In NSW alone, the lifetime cost of the 150,000 incident cases of skin cancer diagnosed in 2010 was estimated at $536 million, of which one third was due to melanoma alone.9 The incidence of the more common keratinocyte cancers is higher than that of all other cancers combined, with two thirds of Australians diagnosed in their lifetime.10

Prevention and early detection remain the foundations of melanoma control, and while systemic treatments for metastatic disease have recently begun to extend survival, timely and appropriate surgical and radiation treatments remain critically important at all stages of disease.

The landscape of melanoma care is vibrant, rapidly evolving, and challenging, with:

  • a lack of a systematic, sustainable model of follow-up of high-risk individuals;
  • high potential of biomarkers of risk assessment, diagnosis, staging and treatment selection;
  • rapid evolution of targeted and immune-modulatory therapies to drive upward the proportion with long term control of metastatic disease;
  • and heightened complexity for patients, with gains in survival and quality of life previously unseen in melanoma, greater jeopardy from new toxicities and the challenges of longer survivorship.

Finally, there are great risks to the net costs of melanoma care for the Australian and other Governments if these impacts are not managed well.

This CRE is harnessing major opportunities for the health system and the community to achieve greater value for money and better health outcomes through more effective and efficient melanoma prevention, control and care.

It is achieving this in three core areas:

  1. Identifying and managing people at high risk of developing melanoma
  2. Optimising management of people with curable, early-stage melanoma; and
  3. Psychosocial care, survivorship and the patient experience

Our multi-disciplinary team combines leading clinical expertise in melanoma diagnosis and treatment with methodological expertise in epidemiology, bioinformatics, economics, qualitative research and implementation science to influence healthcare practice and policy.

In health services and medical research contexts, implementation science advocates effective and evidence-based interventions, in targeted settings, that improve the health and wellbeing of specific populations 11. Embedding a 'test and implement' element to the work of the three CRE Cores will enable the Melanoma CRE to examine how interventions from the Core work: improve drug uptake, impact on patient's earlier assessment, diagnosis, testing and treatment, and how therapies control the disease more effectively, over the longer-term. However, interventions and new knowledge in this area will also indicate how more targeted healthcare practices can make a difference to patients' lives, and how improvements to team performance impact not only routine clinical care but also on patient quality of life.

Implementation science is concerned with knowledge translation, and the long-term sustainability of new knowledge as it becomes embedded in clinical practice, including its translational effect12. As a result, implementing strategies aligned to each Core will support not only knowledge distribution and evidence translation, but also knowledge uptake and acquisition (fidelity, spread and assessment). By throwing its net widely, this will ensure healthcare professionals are resilient in the face of rapidly changing healthcare systems, are working professionally, and can practice empathically, for the benefit of patients in their care13.

The model of implementation, indicated below, which covers five key phases of an implementation approach, ensures preparations made, interventions are assessed, and necessary resources are leveraged, so that change to clinical practice becomes embedded early on and for the long-term. This will have a positive effect on care provision and patient health and wellbeing for the betterment of society in general.

References

  1. Australian Institute of Health and Welfare. Cancer in Australia 2017. Cancer series no. 101. Cat. no. CAN 100. Canberra 2017
  2. Whiteman DC, et al. J Invest Dermatol, 2016;136(6):1161-71
  3. Elliott TM, et al. Appl Health Econ Health Policy, 2017;15(6):805-16
  4. Long GV, et al. N Engl J Med, 2017;377(19):1813-23
  5. Weber J, et al. N Engl J Med, 2017;377(19):1824-35
  6. Gordon LG, et al. Aust N Z J Public Health, 2018;42(1):86-91
  7. Gershenwald JE, et al. CA Cancer J Clin, 2017;67(6):472-92
  8. Aitken JF, et al. Int J Cancer, 2018;142(8):1528-35
  9. Doran CM, et al. BMC Public Health, 2015;15:952
  10. AIHW, et al. Non-melanoma skin cancer: general practice consultations, hospitalisation and mortality. Canberra 2008
  11. Lobb R, et al. Annu Rev Public Health. 2013;34:235-251 & Rapport F, et al. J Eval Clin Pract. 2018;24:117–126
  12. Braithwaite J, et al. Inter J Qual Health Care 2014;26(3):321-9
  13. Braithwaite Jet al. Health care as a complex adaptive system. In Resilient Health Care. Farnham, Surrey, England: Ashgate Publishing. 2013. p. 57-73