Mapping Melanoma

Cartography is the mapping of uncharted territories.

Melanography is the mapping of uncharted moles.

In a unique effort to detect early stage melanoma, nurses are being trained as melanographers.

Melanographers are relatively new in the U.S., said Maddie Pallamary, RN, nurse manager at MoleSafe in Millburn, NJ.

“The position was coined by Adrian Bowling from the company MoleMap in New Zealand to identify this nurse with very specialized expertise,” she said. “It has been around for 13 years in New Zealand and Australia because these countries sit underneath a sizeable hole in the ozone, resulting in a higher incidence of melanoma.”

MoleSafe, a melanoma screening clinic, provides training to registered nurses looking to specialize in melanography.

“The melanography training requires 2 weeks of on-site instruction. The first part consists of textbook training in dermatological principles. Then, we worked on the clinical aspect of actually performing patient screenings and prevention education,” said Dana Coleman, RN, oncology nurse navigator at St. Joseph’s/Candler Hospital in Savannah, GA.

Melanographers like Pallamary and Coleman utilize both general nursing skills and highly specialized skills; one example of a specialized melanography skill is the usage of dermatological imaging technology.

“Doing hands-on work with the actual digital imaging equipment is a crucial component of the melanographer training,” Coleman said.


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From Nurse to Melanographer

As with many nursing specialties, melanographers draw heavily from their prior nursing experience before they worked in a specialization.

“I had worked for many years in oncology until I found out about MoleSafe. For me, early detection was a huge draw. Working as an oncology nurse, I did not often get to see people getting better. Using technology like this to save lives is very exciting,” Pallamary said.

The frustration of late intervention is not uncommon among oncology nurses; just like Pallamary, Coleman found the early detection of melanoma screening to be highly attractive.

“Most of my nursing career had been practiced in the field of oncology. Over the years, I began to notice that the patients I was treating were becoming younger and younger,” Coleman said.

Over time, caring for increasingly younger patients affected Coleman deeply; eventually, she decided something had to be changed.

“I had a 16-year-old melanoma patient. When you are treating someone that young, it takes a huge hit on you as a nurse; it completely changes the way you think about cancer prevention and screening,” Coleman said.

Though skin cancer is often construed as a less aggressive form of cancer, melanoma should not be lumped in with the others; melanoma accounts for only 4 percent of new skin cancer cases, but it makes up 77 percent of all skin cancer deaths (UCSF Department of Dermatology, May 4, 2007).

“Melanoma is a completely different animal compared to basal cell carcinoma or squamous cell carcinoma. Melanoma does not necessarily have to come from a pre-existing mole; it can be a new growth on the skin,” Coleman said. “Also, there can be a hereditary factor to developing melanoma.”

Screening Process

Patients come to a melanoma screening clinic for many different reasons: familial history of melanoma, previously biopsied lesions or a primary care physician’s referral.

“We tend to have individuals who were referred to us by their physician because of certain risk factors. However, we also have people who simply found us on their own,” Pallamary said.

Sometimes a mole that just does not look right prompts someone to have it checked out by a melanographer.

“Being here in Savannah near a military base, it is not uncommon for a serviceman to request a screening because his wife noticed a mole that just did not look right,” Coleman said.

Nurses work closely with patients, guiding them from start to finish through the entire screening process.

“The Molesafe appointment is with a nurse who has been trained as a melanographer. The appointment consists of three portions: risk assessment, total body photography and total body dermoscopy,” Pallamary said.

The risk assessment portion of the appointment comes first.

A nurse ascertains patient information that is specific to melanoma risk factors. Some unexpected risk factors exist; for instance, organ transplant recipients have a high risk for melanoma.

“The melanographer will go through a risk assessment that covers the patient’s personal history, skin type and any previous biopsies,” Coleman said.

Total Body Imaging

Total body imaging is the second portion of the screening process. A nurse trained in melanography also performs this portion of the patient’s visit.

“Next, moles are carefully charted, with particular attention being given to those that are 6 mm or larger. All the moles are plotted onto a computer with our specially designed software,” Pallamary said.

As the melanographer catalogues the moles, she keeps in mind the acronym ABCDE: Asymmetry, Border, Color, Diameter and Evolution (changes over time). Following the mole cataloguing, the melanographer creates multiple images of the patient’s moles.


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“We then document any questionable moles with specialized cameras,” Coleman said.

“Two different high-resolution cameras are used: one at a clinical level, macroscopic, and the other at a dermoscopic level, microscopic,” she explained. “With these, we are looking at the mole for different nuances such as its true color, shape, and whether the edges are typical, abnormal or jagged.”

These carefully produced images serve two purposes: Diagnosing present concerns and monitoring moles longitudinally.

“The images are encrypted in an electronic medical record for the purpose of patient privacy,” Pallamary said.

“The images are then diagnosed by a dermoscopist using a tele-dermatology platform and a report is rendered and sent to the patient and their physician. The images are also utilized for later follow-up.”

Using high-resolution images to track subtle changes in a patient’s moles takes the guesswork out diagnosing melanoma.

“The beauty of our program is the ability to do sequential monitoring,” Pallamary said. “Change is the one universal truth for melanoma prevention. And, generally speaking, by the time a doctor can see melanoma visually, it is probably too late. That is why early detection is vital.”

Following the total body imaging portion of the screening, a dermatologist will review all information collected by the melanographer and make a treatment determination. Throughout the entire process, nurses seek to intersperse elements of patient education.

“As we do each melanoma assessment, we also teach the patient about proper skin protection; this gives them some preventative measures to go forward with,” Coleman said.

Treatment & Patient Education

“The documentation that we do can range from just a few moles to more than 100. As a result, the time for each screening session can range from less than an hour to an hour and a half,” Coleman said.


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Yet, that is an hour well spent if it leads to early detection of melanoma; as with most cancer, early detection is key for a positive outcome.

“Melanoma tends to be malignant and, if not fully removed, can become metastatic. If detected early, surgery is the first line of treatment,” Coleman said. “As with other types of cancer, chemotherapy is the main treatment option for metastatic disease.”

As a result of their broad medical knowledge, nurses are uniquely qualified to be melanographers.

Although additional training is required, nursing fundamentals are heavily drawn upon in screening for melanoma.

“Melanographers need a nursing background because of nurse’s assessment skills,” Pallamary said. “The right questions need to be asked in that portion of the examination. Also, like nurses, melanographers need to have the ability to make patients feel comfortable.”

An increasing number of nurses are being trained as melanographers. Yet, even if a nurse does not receive specialized melanoma training, it is essential nurses be aware of melanographers.

“Nurses need to be aware of technology that is available for melanoma detection. Many are involved in patient education and this is a resource that must be shared,” Pallamary said.

A. Trevor Sutton

is a frequent contributor to ADVANCE.

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