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An Interview with Tana Frumento, PA-C, co-author of “Real-world performance and utility of a noninvasive gene expression assay to evaluate melanoma risk in pigmented lesions”, Melanoma Research, July 2018.

October 1, 2018

Tana Frumento received her Master’s Degree in Physician Assistant Studies (MPAS) and Arts in Bioethics from Midwestern University in Glendale, AZ. She is a member of the Arizona Dermatology Physician Assistant Society, Society of Dermatology Physician Assistants, and the American Academy of Physician Assistants. An Arizona native, Tana has a keen interest in the diagnosis and treatment of skin cancer along with educating sun safety and reducing skin cancer risk.

Why did you choose to participate in this clinical study?
I chose to participate in this study because I believe that the PLA test is a tool that can increase the likelihood that melanomas are not missed. It is the test’s objectivity that draws me to using it on every suspicious pigmented lesion I encounter.

Do you regularly treat melanoma (or skin cancer) or dysplastic nevi patients?
Yes, I advise all my patients to have a full body skin cancer screening annually. A patient who has been diagnosed with melanoma is given a recommendation to have screening exams every 3 months for the first year, then every 6 months for the second year. If the exams do not turn up any atypical findings, then I am comfortable with the patient coming in annually after that. During each skin cancer screening, I review with patients what makes a lesion seem suspicious by going through the ABCDs of Melanoma. I encourage my patients to conduct their own skin self-exams. There was a study last year that found 70% of melanomas arise in new moles. I try to drive the point home to my patients to not only watch for changes in their existing moles, but to make note of new moles that develop.

What are some of the challenges you face as a clinician when seeing these patients and assessing their lesions?
Patients come to dermatology practices to have us evaluate their skin, give them peace of mind and to provide them with certainty that there are no suspicious or potentially harmful spots. We use our primary tool of visual inspection to identify those lesions that we deem atypical. Once I am faced with a lesion that I am concerned with, I explain to the patient that there are features I see on their skin that make me want to evaluate that spot further. As soon as I mention that there is a spot of concern, I can sense a change in their body language, likely driven by a fear of the unknown or fear of being poked by a needle and carved on like they have been previously. Needless to say, patients are very receptive to hearing about a noninvasive tool like the PLA test.

Has your dermatopathologist also seen value in using the PLA to assist with the management of these patients?
Indeed, how could they not? When I get a positive PLA test, I bring the patient back in and perform a biopsy. I write it on the requisition to the dermatopathologist that this lesion has tested positive for a genetic marker for melanoma. When I first started utilizing this test, I recognized that due to the fact not all dermpaths have been taught what these findings mean, it was important that I take the time to explain the meaning of this additional information. I told them, just as I do every patient that I perform this test on, that a positive genetic marker does not mean that it is histologically melanoma. I explain that it does have the potential written in the blueprints to become melanoma. Being given this information supplies the dermpath a heads up to look especially close at the specimen. Each of the dermpaths have expressed gratitude for sharing this information. After all, we are all working together with the common goal to catch more melanomas.

How has the Pigmented Lesion Assay altered your management of pigmented lesions?
It has changed my approach entirely! Before having the PLA test, if I encountered a pigmented lesion that I clinically felt was suspicious, but didn’t yet warrant a biopsy I would photograph the lesion. Depending on my level of concern, I would have them return in 3-6 months to evaluate for any changes. I would educate the patient on what I am seeing in that lesion and what changes to watch for. With having the PLA test available in our practice, those lesions that I felt seemed suspicious but not worrisome enough to biopsy, I no longer take the wait and see approach. I am now able to give them and myself peace of mind with the quick and easy application of an adhesive patch. I still photograph the lesion, explaining to the patient that if the test is negative this photograph will give me a reference at their next annual skin exam. If it is positive, the next step I take is to biopsy the lesion. In cases where I examine a lesion that I feel is without a doubt a melanoma, I still perform the PLA. However, I also perform a biopsy on it during the same visit. My explanation to patients is that, although our dermatopathologists and their team are some of the best in the country, the reality is that they are human and errors can occur. The PLA test has less than a 1% chance of missing a melanoma, whereas dermatopathologists on average have a 17% chance of missing an early stage melanoma. Until this test became available a surgical biopsy was the best tool that we had, but now I feel that by using the PLA I am giving my patients a greater chance that a melanoma will not go undetected.

What do you feel are the biggest benefits to including this test in your practice?
I love seeing the smiles on the faces of my patients when I explain to them that I can do a non-invasive, objective, more accurate test on their suspicious pigmented lesions. However, that is not the biggest benefit to our practice. It is the fact that my patients take the knowledge of this PLA test and share it with their loved ones, their neighbors, their coworkers, etc. Countless times I have seen patients come into the office saying so and so told them that they came in for an exam and didn’t have to get cut on like they had at previous dermatology appointments. This test has opened my eyes to how many individuals were fearful to come in and have their skin evaluated. If this test can make patients more at ease with coming in for routine skin exams, that is the greatest benefit.

Were you surprised that nearly 100% of the time providers followed the PLA test results?
I was not surprised at all. The test is very straight forward with what information is gained from the results. The results are black and white and easily guide next steps.