Melanoma - SI

[My Flight Surgeon]

This is another in the series of condition for which the FAA grants Special Issuance certificates.

As with all other conditions, the FAA will want to review the entire medical record. Your AME or www.faaspecialissunace.com can assist you in preparing your records for submission.

The topic today is Melanoma
Melanoma is the most serious type of cancer of the skin. Each year in the United States, more than 53,600 people learn they have melanoma.
In some parts of the world, especially among Western countries, melanoma is becoming more common every year. In the United States, for example, the percentage of people who develop melanoma has more than doubled in the past 30 years.
Melanoma occurs when melanocytes (pigment cells) become malignant. Most pigment cells are in the skin; when melanoma starts in the skin, the disease is calledcutaneous melanoma. Melanoma may also occur in the eye.
Melanoma is one of the most common cancers. The chance of developing it increases with age, but this disease affects people of all ages. It can occur on any skin surface. In men, melanoma is often found on the trunk (the area between the shoulders and the hips) or the head and neck. In women, it often develops on the lower legs. Melanoma is rare in black people and others with dark skin. When it does develop in dark-skinned people, it tends to occur under the fingernails or toenails, or on the palms or soles.
When melanoma spreads, cancer cells may show up in nearby lymph nodes. Groups of lymph nodes are found throughout the body. Lymph nodes trap bacteria, cancer cells, or other harmful substances that may be in the lymphatic system. If the cancer has reached the lymph nodes, it may mean that cancer cells have spread to other parts of the body such as the liver, lungs, or brain. In such cases, the cancer cells in the new tumor are still melanoma cells, and the disease is called metastatic melanoma, not liver, lung, or brain cancer.
No one knows the exact causes of melanoma. Doctors can seldom explain why one person gets melanoma and another does not.
Risk Factors
However, research has shown that people with certain risk factors are more likely than others to develop melanoma. A risk factor is anything that increases a person’s chance of developing a disease. Still, many who do get this disease have no known risk factors.
Studies have found the following risk factors for melanoma:
·Dysplastic nevi: Dysplastic nevi are more likely than ordinary moles to become cancerous. Dysplastic nevi are common, and many people have a few of these abnormal moles. The risk of melanoma is greatest for people who have a large number of dysplastic nevi. The risk is especially high for people with a family history of both dysplastic nevi and melanoma.
·Many (more than 50) ordinary moles: Having many moles increases the risk of developing melanoma.
·Fair skin: Melanoma occurs more frequently in people who have fair skin that burns or freckles easily (these people also usually have red or blond hair and blue eyes) than in people with dark skin. White people get melanoma far more often than do black people, probably because light skin is more easily damaged by the sun.
·Personal history of melanoma or skin cancer: People who have been treated for melanoma have a high risk of a second melanoma. Some people develop more than two melanomas. People who had one or more of the common skin cancers are at increased risk of melanoma.
·Family history of melanoma: Melanoma sometimes runs in families. Having two or more close relatives who have had this disease is a risk factor. About 10 percent of all patients with melanoma have a family member with this disease. When melanoma runs in a family, all family members should be checked regularly by a doctor.
·Weakened immune system: People whose immune system is weakened by certain cancers, by drugs given following organ transplantation, or by HIV are at increased risk of developing melanoma.
·Severe, blistering sunburns: People who have had at least one severe, blistering sunburn as a child or teenager are at increased risk of melanoma. Because of this, doctors advise that parents protect children’s skin from the sun. Such protection may reduce the risk of melanoma later in life. Sunburns in adulthood are also a risk factor for melanoma.
·Ultraviolet (UV) Radiation: Experts believe that much of the worldwide increase in melanoma is related to an increase in the amount of time people spend in the sun. This disease is also more common in people who live in areas that get large amounts of UV radiation from the sun. In the United States, for example, melanoma is more common in Texas than in Minnesota, where the sun is not as strong. UV radiation from the sun causes premature aging of the skin and skin damage that can lead to melanoma. Artificial sources of UV radiation, such as sunlamps and tanning booths, also can cause skin damage and increase the risk of melanoma. Doctors encourage people to limit their exposure to natural UV radiation and to avoid artificial sources.
How to avoid risks:
·Avoid exposure to the midday sun (from 10 a.m. to 4 p.m.) whenever possible. When your shadow is shorter than you are, remember to protect yourself from the sun.
·If you must be outside, wear long sleeves, long pants, and a hat with a wide brim.
·Protect yourself from UV radiation that can penetrate light clothing, windshields, and windows.
·Protect yourself from UV radiation reflected by sand, water, snow, and ice.
·Help protect your skin by using a lotion, cream, or gel that contains sunscreen. Many doctors believe sunscreens may help prevent melanoma, especially sunscreens that reflect, absorb, and/or scatter both types of ultraviolet radiation. These sunscreen products will be labeled with “broad-spectrum coverage.” Sunscreens are rated in strength according to a sun protection factor (SPF). The higher the SPF, the more sunburn protection is provided. Sunscreens with an SPF value of 2 to 11 provide minimal protection against sunburns. Sunscreens with an SPF of 12 to 29 provide moderate protection. Those with an SPF of 30 or higher provide the most protection against sunburn.
·Wear sunglasses that have UV-absorbing lenses. The label should specify that the lenses block at least 99 percent of UVA and UVB radiation. Sunglasses can protect both the eyes and the skin around the eyes.
Often, the first sign of melanoma is a change in the size, shape, color, or feel of an existing mole. Most melanomas have a black or blue-black area. Melanoma also may appear as a new mole. It may be black, abnormal, or “ugly looking.”
If you have a question or concern about something on your skin, see your doctor. Do not use the following pictures to try to diagnose it yourself. Pictures are useful examples, but they cannot take the place of a doctor’s examination.
Thinking of “ABCD” can help you remember what to watch for:
·Assymetry—The shape of one half does not match the other.

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·Border—The edges are often ragged, notched, blurred, or irregular in outline; the pigment may spread into the surrounding skin.

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·Color—The color is uneven. Shades of black, brown, and tan may be present. Areas of white, grey, red, pink, or blue also may be seen.

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·Diameter—There is a change in size, usually an increase. Melanomas are usually larger than the eraser of a pencil (1/4 inch or 5 millimeters).

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Melanomas can vary greatly in how they look. Many show all of the ABCD features. However, some may show changes or abnormalities in only one or two of the ABCD features.

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If the doctor suspects that a spot on the skin is melanoma, the patient will need to have a biopsy. A biopsy is the only way to make a definite diagnosis. In this procedure, the doctor tries to remove all of the suspicious-looking growth. This is an excisional biopsy. If the growth is too large to be removed entirely, the doctor removes a sample of the tissue. The doctor will never "shave off" or cauterize a growth that might be melanoma.
If the diagnosis is melanoma, the doctor needs to learn the extent, or stage, of the disease before planning treatment. Staging is a careful attempt to learn how thick the tumor is, how deeply the melanoma has invaded the skin, and whether melanoma cells have spread to nearby lymph nodes or other parts of the body. The doctor may remove nearby lymph nodes to check for cancer cells. The doctor also does a careful physical exam and, if the tumor is thick, may order chest x-rays, blood tests, and scans of the liver, bones, and brain.
Treatment
The doctor can describe treatment choices and discuss the results expected with each treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient’s needs. Treatment for melanoma depends on the extent of the disease, the patient’s age and general health, and other factors. People with melanoma may have surgery, chemotherapy, biological therapy, or radiation therapy. Patients may have a combination of treatments.
FAA Special Issuance
AME Assisted Special Issuance (AASI) is a process that provides Examiners the ability to re-issue an airman medical certificate under the provisions of an Authorization for Special Issuance of a Medical Certificate (Authorization) to an applicant who has a medical condition that is disqualifying under Title 14 of the Code of Federal Regulations
(14 CFR) part 67.

An FAA physician provides the initial certification decision and grants the Authorization in accordance with 14 CFR 67.401. The Authorization letter is accompanied by attachments that specify the information that treating physician(s) must provide for the re-issuance determination. If this is a first time issuance of an Authorization for the above disease/condition, and the applicant has all of the requisite medical information necessary for a determination, the Examiner must defer and submit all of the documentation to the AMCD or Regional Flight Surgeon for the initial determination.

Examiners may re-issue an airman medical certificate under the provisions of an Authorization, if the applicant provides the following:

• An Authorization granted by the FAA; and
• A current status report performed within 90 days that must include all the required followup items and studies as listed in the Authorization letter and that confirms absence of recurrent disease.

Note:

• A Special Issuance or AASI is required for any metastatic melanoma regardless of Breslow level
• A Special Issuance or AASI is required for any melanoma which exhibits Breslow Level > .75 mm with or without metastasis
• A melanoma that exhibits a Breslow Level < .75 mm which has no evidence of metastasis may be regular issued.