The aim of the S3-guideline melanoma contains recommendations on diagnosis, therapy and follow-up of cutaneous melanoma in its primary, limited locoregional and metastatic stages. Mucosal and uveal melanomas are not considered. Questions on early recognition have been considered in the S3-guideline on prevention of skin cancer. Objectives and formulation of questionsThe aim of the S3-guideline melanoma is to provide physicians in office and clinical practice in the field of oncology an accepted, evidence-based decision-making aid for the selection and performance of suitable measures for diagnostics, therapy and follow-up of cutaneous melanoma. The systematic presentation of study results with respect to benefits and risks are intended to support physicians as well as patients in their decision-making.The basis of the recommendations is a review of available evidence according to the criteria of evidence-based medicine, the adaptation of available evidence-based international guidelines as well as in the event of lack of evidence on the basis of good clinical practice. All recommendations were evaluated by interdisciplinary representatives and consented.The guideline should set quality standards and thus in the long term improve care of melanoma patients. Addressees and duration of validityThe S3-guideline melanoma is directed at dermatologists, family physicians, internists, general practitioners, gynecologists, surgeons, oncologists, radiologists and radiation therapists in inpatient and outpatient settings and other medical specialties involved in the diagnosis and treatment of patients with cutaneous melanoma. The guideline is also directed at affected patients and their family members. Further, it should serve as orientation for health insurance providers and political decision makers.The maximum duration of validity stipulated by the AWMF is five years. A modular update in yearly intervals is planned.In 2015 an update of the entire guideline is planned with a designation of new mandate holders.The recommendations were developed on the basis of key questions that were agreed upon at the start in a kick-off meeting by the mandate holders. Evidence-based recommendations: Statement of evidence level (quality level of evidence) as well as grade of recommendation (inclusion of the clinical evaluation) and strength of consensus.Basis: adaptation of source guidelines or systematic search of the literature de-novo. Non-evidence-based recommendations: A smaller share of recommendations was not evidence-based but based on GCP (Good Clinical Practice), strength of consensus, no level of evidence, no grade of recommendation.

The description of a faster and greater relief of episodic breathlessness by transmucosal fentanyl versus morphine justifies further evaluation by a full-powered trial.

This first German evidence-based guideline for cutaneous melanoma was developed under the auspices of the German Dermatological Society (DDG) and the Dermatologic Cooperative Oncology Group (DeCOG) and funded by the German Guideline Program in Oncology. The recommendations are based on a systematic literature search, and on the consensus of 32 medical societies, working groups and patient representatives. This guideline contains recommendations concerning diagnosis, therapy and follow-up of melanoma. The diagnosis of primary melanoma based on clinical features and dermoscopic criteria. It is confirmed by histopathologic examination after complete excision with a small margin. For the staging of melanoma, the AJCC classification of 2009 is used. The definitive excision margins are 0.5 cm for in situ melanomas, 1 cm for melanomas with up to 2 mm tumor thickness and 2 cm for thicker melanomas, they are reached in a secondary excision. From 1 mm tumor thickness, sentinel lymph node biopsy is recommended. For stages II and III, adjuvant therapy with interferon-alpha should be considered after careful analysis of the benefits and possible risks. In the stage of locoregional metastasis surgical treatment with complete lymphadenectomy is the treatment of choice. In the presence of distant metastasis mutational screening should be performed for BRAF mutation, and eventually for CKIT and NRAS mutations. In the presence of mutations in case of inoperable metastases targeted therapies should be applied. Furthermore, in addition to standard chemotherapies, new immunotherapies such as the CTLA-4 antibody ipilimumab are available. Regular follow-up examinations are recommended for a period of 10 years, with an intensified schedule for the first three years.

Background: By definition, palliative care (PC) is applicable already in early stages of incurable and life-threatening diseases, in conjunction with therapies that are intended to prolong life, such as for example chemo- or radiotherapy. Many patients suffer from distressing symptoms or problems in early phases of such illness. Therefore, it is not a question of “if” PC should be integrated early into oncology, but “how.” General PC is defined as an approach that should be delivered by healthcare professionals regardless of their discipline. This is often referred to as “general” or “primary” PC. For this, routine symptom assessment, expertise concerning basic symptom management, and communication skills are basic requirements. Communication skills include the willingness to engage in discussions concerning patients' fears, worries and end-of-life issues without the fear of destroying hope. Specialist PC is provided by specialist teams regardless of the patients' disease, be it cancer or non-cancer. Such teams should be integrated in the care of PC patients depending on the availability of these services and the patients' needs. Key messages: “Early PC” must not be used synonymously with “early specialist PC” because much of the PC is delivered as basic oncology PC. For the integration of specialist PC, the identification of triggers is warranted in different institutions to facilitate a meaningful and effective cooperation. Such cooperations should be based on patients' needs, but must also account for questions of availability and resources.

Although important information gaps were identified, the data draw attention to critical public health interventions required in poor health districts, and to motivate for pro-equity policies.

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Ein herausfordernder GoldstandardBut I must go and meet with danger there, Or it will seek me in another place, And find me worse provided. W. Shakespeare, Henry IVPatienten mit inkurablen und fortschreitenden Grunderkrankungen, insbesondere malignen Tumoren, leiden unter einer Vielzahl an Symptomen und psychosozialen Belastungen -dies nicht nur in weit fortgeschrittenen oder sterbenahen Situationen, sondern bereits im frühen Erkrankungsverlauf. Insbesondere in frühen, inkurablen Erkrankungssituationen treten tumortherapiebedingte Belastungen zu den erkrankungsbedingten Belastungen hinzu.Die Belastungen von Patienten mit inkurablen und fortschreitenden Grunderkrankungen zu lindern, stellt eine der Kernaufgaben in der Behandlung von Krebspatienten dar. In aller Regel wird diese Aufgabe der "Allgemeinen Palliativversorgung" (APV) dem Onkologen in Zusammenarbeit mit dem Hausarzt zufallen, da er die Patienten durch ihren Erkrankungsverlauf hindurch betreut und im Rahmen der regelmäßigen Kontakte am ehesten in der Position ist, physische und psychosoziale Belastungen der Patienten zu erkennen, zu behandeln und weitere Unterstützung zu koordinieren. Bei einigen inkurabel erkrankten Patienten stellen sich besonders komplexe Belastungssituationen dar, die mit den Ressourcen und auch der Expertise der onkologischen und hausärztlichen Alltagsroutine nicht aufzulösen sind. Diese komplexen Belastungssituationen stellen eine Domä-ne der sog. "Spezialisierten Palliativversorgung" (SPV) dar, die durch einen breiten, multiprofessionellen und interdisziplinären, sowohl akut-interventionellen als auch dauerhaften Unterstützungsan-satz -zusätzlich zu den Strukturen der Regelversorgung -gekennzeichnet ist.Dieser Beitrag stellt die Grundzüge des interdisziplinären palliativmedizinischen Behandlungsansatzes dar, diskutiert gängige Definitionen, beschreibt die in Deutschland etablierten stationären, konsiliarischen, ambulanten und häus-lichen spezialisierten palliativmedizinischen Versorgungsstrukturen und fasst die wissenschaftliche Evidenz sowie die Empfehlungen der onkologische Fachgesellschaften für einen frühzeitigen Einbezug spezialisierter palliativmedizinischer Handlungsansätze in die Behandlung von Krebspatienten zusammen.

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