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This guide provides a step-by-step approach to explaining a diagnosis of melanoma. You should also read our overview of how to effectively communicate information to patients.
Structuring your explanation
Explaining a diagnosis requires structure and adequate background knowledge of the disease. Whether the information being shared is about a procedure, a new drug or a disease, the BUCES structure (shown below) can be used.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
BUCES can be used to remember how to structure a consultation in which providing information is the primary focus. Before explaining the various aspects of a disease, it is fundamental to have a common starting point with your patient. This helps to establish rapport and creates an open environment in which the patient can raise concerns, ask questions and gain a better understanding of their problem. After introducing yourself, it is important to take a brief history (this is the first part of the BUCES structure):
- What has brought the patient in to see you today?
- What are their symptoms?
- Are there any risk factors that can be identified? (e.g. sun exposure/family history)
For example, a patient with melanoma may describe a symptomatic pigmented lesion.
Tip: Practice taking concise histories to get the timing right. In OSCE stations, timing is crucial and you do not want to spend all your time taking a history when you are meant to be explaining a diagnosis! A rough guide would be to keep the introduction and brief history between 1-2 minutes maximum.
What does the patient understand?
Following a brief history, it is important to establish the patient’s knowledge of their condition, as you may encounter patients with differing levels of knowledge about melanoma. Establishing a baseline understanding of their condition will allow you to better tailor your explanation at an appropriate level.
Due to these reasons, it is important to start with open questioning. Good examples include:
- “What do you think is causing your symptoms?”
- “What has been explained to you so far?”
Consultations that are set to inform a patient about a melanoma diagnosis are usually not the first consultation and are preceded by a biopsy to establish the histological diagnosis. Therefore, follow-up questions according to the patient’s response may include:
- “Do you know why the biopsy was done?”
- “Have you been told what the result of the biopsy has shown?”
Open questioning should help you to determine what the patient currently understands, allowing you to tailor your explanation at an appropriate level.
At this stage, primarily focus on listening to the patient. It may also be helpful to give positive feedback as the patient talks (e.g. should a patient demonstrate some understanding, reinforce this knowledge with encouraging words and nonverbal communication, such as nodding).
Checking the patient’s understanding should not be solely confined to this point of the consultation but should be done throughout by repeatedly ‘chunking and checking’.
Tip: Try using phrases such as, “Just to check that I am explaining melanoma clearly, can you repeat back to me what you understand so far?” This is far better than only saying, “What do you understand so far?” as the onus is placed upon the quality of your explanation rather than an issue with the patient’s ability to understand.
What are the patient’s concerns?
The patient’s concerns should never be overlooked. Asking the patient if they have any concerns before beginning your explanation allows you to specifically tailor what is most relevant to them, placing them at the centre of the explanation. The ICE (ideas, concerns and expectations) format can provide a useful structure for exploring this area further.
ICE
Ideas
- What does the patient think is causing their symptoms?
- What is their understanding of the diagnosis?
Concerns
- What are the patient’s concerns regarding their symptoms and diagnosis?
Expectations
- What is the patient hoping to get out of the consultation today?
Explanation
After determining the patient’s current level of understanding and concerns, you should be able to explain their condition clearly.
You should begin by signposting what you are going to explain to give the patient an idea of what to expect.
“I’m going to begin by talking about the normal function of the skin and then move on to discuss what your diagnosis is, what causes it and how we can manage it together.”
Tip: Use the mnemonic “Normally We Can Probably Manage” to help you remember the structure of explaining a disease.
Normal anatomy/physiology
“The skin contains three main layers called the epidermis, dermis, and hypodermis. The epidermis is divided into different layers, one of which is called the basal layer. This layer contains a type of cell called a melanocyte. Melanocytes are skin pigment cells that contain a pigment called melanin. This gives us the colour of our skin.”
What is a melanoma?
Breaking bad news
Delivering the news of a malignant melanoma diagnosis requires sensitivity and clarity. Here are some tips to help you do this:
- Provide a warning shot: “The biopsy results have shown something worrying” or “The biopsy results are not what we would have wanted.”
- Be direct, and use simple language without medical jargon: “The biopsy shows that you have malignant melanoma, which is a type of skin cancer.”
- Pause: give the patient time to absorb this information and allow the patient to process the diagnosis
- Be compassionate, offer support and reassurance: acknowledge the emotional weight of the diagnosis of a malignant condition, “I know this may be difficult to hear, but I’m here to answer any questions and guide you through the next steps.”
- Explain the implications: “melanoma can be serious because it can spread to other parts of the body. The stage and depth of the melanoma help us decide on the best treatment.”
For further information, read the Geeky Medics guide to breaking bad news.
Melanoma is a malignant tumour derived from melanocytes. There are four main subtypes: spreading, nodular, acral lentiginous, and lentigo maligna. It usually presents as a new lesion (i.e. de novo) or a change in the size, shape, or color of a pre-existing mole. Occasionally, it may present as a lesion without pigment, known as amelanotic melanoma. Melanoma spreads locally, regionally, and distantly, including to the liver and lungs.1
“Melanoma is a type of skin cancer that develops when the normal skin pigment cells (melanocytes) become cancerous and multiply in an uncontrolled way.”
“There are several types of melanomas, some more aggressive than others, however, all of them are considered to be serious.”
“Melanoma may spread from the skin to other parts in the body, such as the liver, lungs and lymph nodes, in a process known as metastasis.”
“Melanoma may present as a change in size, shape or colour of an existing mole or freckle, or begin as a new lesion. Occasionally, they may have no pigment. Most melanomas do not usually give any symptoms.”
What are the causes of melanoma?
Several factors increase the risk of developing melanoma, including:
- UV and sun exposure: the most significant modifiable risk factor. Those with a history of sunburn are at higher risk.
- Fitzpatrick type 1-2: those with light skin, hair, and eyes and those who burn easily
- Moles: a large number of benign moles or the presence of atypical moles
- Family history: a history of melanoma in close relatives
- Personal history of skin cancer: patients with previous melanoma or other skin cancers
- Genetic syndromes such as xeroderma pigmentosum
- Immunosuppression (squamous cell carcinoma is more common)
“Risk factors for melanoma include sun and UV exposure, and previous sunburn increases the risk further. Those with light, pale skin, a history of other moles or a family history of melanoma are also more at risk.”
Problems/complications of melanoma
With a diagnosis of a malignancy, patients are often concerned about the associated prognosis.
Early-stage melanomas have a very good prognosis, with high cure rates following surgical excision. However, more advanced melanomas may cause significant morbidity, require aggressive treatment, and may be fatal despite treatment. Therefore, it is important to tailor your prognosis explanation according to the stage of the melanoma.
The prognosis for melanoma depends on several factors, mainly:
- Breslow thickness: the thickness of the tumour measured from the surface of the skin to the deepest point of cancer
- Ulceration: ulcerated melanomas have a worse prognosis
- Lymph node involvement: melanoma that has spread to nearby lymph nodes typically has a poorer prognosis
- Distant metastasis: the presence of cancer in distant organs indicates advanced disease and worsens the prognosis
You may relay this information to your patient using the following examples to explain the seriousness of the diagnosis whilst maintaining hope and encouragement.
Early stage
“Although the diagnosis of a cancer such as melanoma is a serious one, we have fortunately identified it at an early stage. We use the thickness of the melanoma to identify the stage of the cancer, with thinner melanomas having better outcomes.”
“In your case, the thickness means it is at an early stage. Although you will require further treatment, such as a wider removal of the skin around the melanoma, these melanomas are associated with a very good prognosis, with very high cure rates.”
Later stage
“The diagnosis of a cancer such as melanoma is a serious one. We use the thickness of the melanoma as well as whether the melanoma has spread to your lymph nodes or organs to identify how far the cancer has progressed.”
“In your case, the thickness means it is at a later stage. Melanomas of this type require more investigations to check for the spread of cancer and choose the most ideal treatment to ensure the best possible prognosis.”
Management
Often, patients feel that a diagnosis of a malignancy is life-changing, and thus will enquire about the spread of cancer and whether they will require further scans, surgery or oncological treatment.
The management depends on the histological staging of the tumour size, based on the Breslow thickness and the presence of ulceration, and metastatic spread.
Multidisciplinary team
Most cases are discussed with the multidisciplinary team (MDT), which may include a dermatologist, oncologist, plastic surgeon, nurse specialist, radiologist and pathologist. Some patients also wish for a second opinion, and informing them of this discussion will aid in reassuring them that they are receiving the most appropriate treatment and that the opinions of multiple professionals have been sought.
“We will be discussing your case at the multidisciplinary team discussion. This meeting is held between doctors and other specialists from multiple areas who may be involved in managing your case. This will enable us to get the opinion of different specialists and discuss which investigations are needed in your case and which treatment will be most suitable.”
Wide local excision
Histologically confirmed melanoma will require a follow-up excision around the scar of the site of the previous melanoma, known as a wide local excision. The peripheral margins (how big the excision needs to be) are based on the Breslow thickness of the lesion and vary from 0.5 cm to 2 cm.2
Reconstructive options may need to be discussed if the wide local excision is not amenable to primary closure.
“Once the diagnosis of melanoma is confirmed by taking a sample of the lesion, we would need to proceed with a wide local excision, which involves removing any residual cancer and/or extra skin around it. The size of the excision depends on how deep the melanoma is. This is done to increase the chances of complete clearance of the cancer. Usually, the incision can be closed using sutures, however, if the area is too big to close, we might need to discuss reconstructive surgery, such as a skin graft.”
Sentinel lymph node biopsy
A sentinel lymph node biopsy (SLNB) is indicated in melanoma ≥ pT2a or ≥ pT1b with high-risk features.3
If the SLNB shows spread of the melanoma, the patient may require further surgery, e.g. complete lymph node dissension or adjuvant therapy. It is important to explain the potential complications of an SLNB, including, although rare, lymphoedema.4
“Given the thickness of your melanoma, a lymph node biopsy is required. This is a procedure to test for the spread of the cancer. This test has a role in the staging of melanoma, and, therefore, will help guide further treatment and outcomes.”
“If a melanoma spreads, it tends to first spread from the skin to the nearest lymph node. This test will identify and remove this lymph node and send it to the lab to identify any spread of the cancer. The biopsy may be in different parts of the body, such as the knee, groin and armpit, depending on where the melanoma is. This is done under general anaesthetic and is usually done during the same operation as the wide local excision.”
“The position of this lymph node is identified by injecting a small amount of dye into the melanoma and performing a scan to identify the movement of the dye.”
‘‘Rarely, a complication of the surgery is lymphoedema. This means that the limb where the lymph nodes are removed from experiences a build-up of tissue fluid, causing swelling of the limb. This can happen from days to months after the surgery, and although it is temporary in some cases, it may be permanent in others.”
Imaging
A whole-body PET scan and dedicated brain imaging, such as a contrast-enhanced CT or MRI brain scan, may be indicated to identify metastatic spread to complete staging.
“You may need a whole-body or specific brain scan to check if the melanoma has spread to other parts of your body. These scans help us to assess the spread and stage of the melanoma and plan the most effective treatment.”
Oncological adjuvant therapy
Advanced-stage melanoma (i.e. stages 3 or above) may require further treatment after surgery.
This may include targeted therapy and immunotherapy under the guidance of an oncologist. The route, duration and side effect profile will depend on the drug of choice.
”If the melanoma is advanced, further treatment such as targeted therapy or immunotherapy may be recommended. These treatments aim to stop the cancer from growing or spreading and are guided by an oncologist, a doctor specialised in cancer care.”
Patient support
Despite a serious diagnosis of a malignancy, it is important to offer hope by discussing the high cure rates and good prognosis, especially in early-stage melanoma.
Offer details of support groups, counselling services, or patient advocacy groups that can help patients cope emotionally and practically.
You may offer the patient information leaflets with a reliable source of information they can refer to at home, such as the British Association of Dermatologists website.5
Lifestyle and prevention advice
Provide the patient with lifestyle advice to prevent further sun damage and potential skin malignancies, such as:
- Sun protection: with broad-spectrum sunscreen with SPF 30 or higher, wearing protective clothing and avoiding tanning beds
- Skin surveillance: advise the patient to check their skin regularly for new moles or changes in existing ones
Closing the consultation
Summarise the key points back to the patients by outlining the next steps in the patient’s management according to the stage of the melanoma.
Direct the patient to further information about the condition using websites and leaflets.
“Today, we have discussed the results of your biopsy, which has shown that the lesion is a melanoma, and the next steps we will need to take to manage this. I realise that I have given you a lot of information and that it is a lot to take in. Therefore, I’d like to provide you with a leaflet which has the vital information that we’ve spoken about, for you to be able to refer to when you go home. The next step will be [next procedure/appointment], which will be on [provide procedure or appointment date or information about how they will be contacted regarding this date].”
Ask the patient if they have any questions or concerns that have not been addressed.
“Is there anything I have explained that you’d like me to go over again?”
“Do you have any other questions before we finish?”
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Reviewer
Mr. Kurt Lee Chircop M.D. (Melit.) MRCSI MSc
Plastic and Reconstructive Surgery Registrar
Editor
Dr Jamie Scriven
References
- Heistein JB, Acharya U, Mukkamalla SKR. Malignant Melanoma. StatPearls. 2024. Available from: [LINK].
- NICE NG14. Melanoma: assessment and management. 2022. Available from: [LINK].
- Peach H, Board R, Cook M, et al. Current role of sentinel lymph node biopsy in the management of cutaneous melanoma: A UK consensus statement. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2020. Available from: [LINK].
- British Association of Dermatologists. Melanoma stage 2. 2019. Available from: [LINK].
- British Association of Dermatologists. Patient Information Leaflets. Available from: [LINK].
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