Abstract
Melanoma is the most dangerous form of skin cancer. It develops in melanocytes, the cells that produce melanin which is the pigment that gives skin its color. Melanomas can also form in eyes, and rarely in internal organs, such as the intestines. These cancerous lesions occur when UV light damages DNA by forming pyrimidine dimers from thymine or cytosine bases. Dimers may be repaired by photoreactivation or nucleotide excision repair, unrepaired dimers are mutagenic. The purpose of this research was investigating how can genomic tests be more favorable at accurately predicting the stages of melanocytic lesions over the American Academy of Dermatology staging guidelines. The hypothesis of the study was genetic testing such as chromosomal microarray analysis on the melanocytic tissue to diagnose for present chromosomal abnormalities, is more likely to accurately provide the stage of the melanoma skin cancer.
The method of the research included both inclusion and exclusion criteria. Initially, the article selected for this research were published from the year 2000 to present. The exclusion criteria further eliminated articles not written in English. The journal articles had to be related to melanoma at the molecular or genetic level. On the other hand, the inclusion criteria involved journal article that provided current data (published on or after the year 2000). The article selected could include data or discussion on the extent to which the tissues have been damaged. The accepted countries are any in which the research or methods have been used and hence no specification unless it is not written in English. In total, ten articles were chosen.
Among the search terms used included Melanoma, metastatic melanoma, malignant melanoma, skin cancer, dermatology, cutaneous, mutation, genetic testing, chromosomal microarray analysis, molecular analysis, mutation, biomarker, marker, diagnosis, stage, staging.
Introduction
Despite there being evidence that mortality and incidence rates for different forms of cancer have been on the decline, the melanoma skin cancer incidence has been found to be on the rise in the United States from the year 1973 (Oliveria, Saraiya, Geller, Heneghan, & Jorgensen, 2006). Between 1992 and 2008, the incidence rate of this type of cancer increased with an average of 2.4 percent annually (Oliveria, et al. 2006). In the year 2012, it was estimated that there were 76,250 new melanoma cases where 9,180 resulted into deaths (American Cancer Society, 2012). Melanoma is considered among the significant fatal type of skin cancer which approximately accounts for 79 percent of deaths related to skin cancer. While this form of skin cancer has been considered rare among individuals aged below 20, evidence from various studies has shown that there is a rapid increase in melanoma in teenagers and children. Melanoma has been classified as the 5th most common cancer affecting males and the 6th among females in the United States (Oliveria, et al. 2006).
According to Oliveria, et al. (2006), epidemiological studies have shown that there is a strong association between sun exposure in decisive early life periods and the ensuing melanoma risk that might occur during adulthood. Melanoma occurs in the melanocytes which are the cells that are responsible in the production of melanin a pigment in the human body that gives the skin color. Apart from this, melanoma can also develop in the eyes and in rare situations on the body internal organs like the intestines. The cancerous lesions often arise after the UV light makes damages to the DNA after formation of the pyrimidine dimmers directly from thymine or cytosine bases. Dimers may be repaired by photo reactivation or nucleotide excision repair, unrepaired dimmers are mutagenic. Melanomas has the possibility of spreading and one of the methods that doctors have been using a standard method called “staging” to determine how cancer can spread for purposes of understanding the chances of the patient’s metastasis. Among the tools that are used in confirmation of the melanoma cancer stage include blood work, x-rays, nearby lymph node biopsy, and CT scans.
While the effects of sun exposure in the early life are considered to be significant, there is controversy concerning the age period when most of the exposure happens in a person. While some studies have depicted that much of the exposure during childhood and adolescence, others have varied. Compared to adults, children have the ability of receiving almost three times annual ultraviolet‐B rays often because they spend approximately 3 hours outdoors daily. Conversely, some previous studies depict that adults and children receive equal ultraviolent doses because recent technologies have influenced children to hang about indoors during daytime. However, in either case, the health habits and behaviors that children pick when growing up which includes sun exposure that is unprotected might be sustained when they become adults. Over the years, skin cancer education programmes for adolescents and children have continued to increase and hence, the need for an epidemiological background for these programmes is critical for planning further evaluation. Importantly to note is that skin cancer including melanoma is among the types of cancers regarded to be preventable. Therefore, it is critical to improve adherence to prevention of melanoma as well as early detection behaviors. According to the American Cancer Society, some of the acceptable prevention practices include wearing sunglasses, seeking shade or wearing sunscreen with a broad-spectrum. Apart from this, other early detection practices are having medical professionals conduct annual skin examinations or conducing self-skin examinations. These kinds of practices have the capability of saving lives because of the exceptional good results for melanomas that are thin. It is estimated that between 5 percent and 10 percent of melanomas are hereditary in nature while 40 percent can explained through mutations (Glanz, et al. 2013). However, for effective use of the prevention practices, it is decisive to be aware of the skin cancer stage. Consequently, conducting this study was critical because of the need to create awareness on a type of skin cancer that can be prevented if appropriate steps are taken during childhood.
Methods
Exclusion criteria
Initially, the article selected for this research were published from the year 2000 to present. Thus, any article bearing relevant information but published before 2000 was disregarded. The search strategy included searching for full journal articles rather than those with abstracts or peer reviewed articles. The exclusion criteria further eliminated articles not written in English. The journal articles had to be related to melanoma at the molecular or genetic level. No journal articles focused on the types of treatment for melanoma were used. For example, if the article was about type of excisions on melanocytic tissue rather than about its molecular activity, then it was excluded. Importantly, articles that were not published as journals were disregarded as the authenticity of the data was considered questionable.
Inclusion criteria
On the other hand, in relation to the inclusion criteria, the journal article had to be related to melanoma staging at genetic level. Some journal articles also discuss about the molecular activity within the melanocytic tissues. The journal article ought to provide current data (published on or after the year 2000). The article selected could include data or discussion on the extent to which the tissues have been damaged. The accepted countries are any in which the research or methods have been used and hence no specification unless it is not written in English.
Search Terms
Among the search terms used included Melanoma, metastatic melanoma, malignant melanoma, skin cancer, dermatology, cutaneous, mutation, genetic testing, chromosomal microarray analysis, molecular analysis, mutation, biomarker, marker, diagnosis, stage, staging.
The evidence table was created after searching for the relevant articles that had been identified to meet the inclusion criteria. The evidence table has been attached in the appendices. The major headings used in data synthesis in the evidence table included name of author, date of publication, study design, level of evidence, study population, therapy or exposure, and the results or outcome.
Results
In general, the number of articles sampled to represent the overall findings was ten journals. These articles have both similarities and differences. First, as shown in the table below, the journal articles with the same research design were numerous. Three articles that were sampled used experimental study design. Secondly, only one sampled article adopted a cohort study design. Majority, six, of the articles utilized in the present research used case control as the preferred study design.
Study Design # of Studies
Experimental study 3
Case control 6
Cohort study 1
Table 1 Study Design Summary
Source: Author (2018)
The description of the articles sampled can also be done dependent on the type of study population adopted by the researchers. Among the sampled articles, some of the population used were similar in terms of the location. Four of the studies sourced their population from the United States while the rest from different countries such as Australia, Japan, and Germany among others. Nevertheless, majority of the articles used patients who were suffering from melanoma skin cancer or those who were at risk of the disease due to the family history factors or the like. In addition to this, in terms of the studies that used a certain type of outcome assessment, the articles sampled used a variety of these depending on the type of methods used in data collection.
In providing the results of the study, they have been explained in proximity based on the four levels of clinical treatment evidence that are in particular level 0, 1, 2, 3, and 4. Level 0 consists of the preclinical studies, level one randomized control trails, level 3 non-randomized control trial, level 3 observational studies that have controls and finally level 4 observational studies without controls.
In their study Oldenburg, Liu, & Kolodney, (2008) hypothesized that detecting mutated genomic DNA from cancer cells that circulate in the blood has the capacity of improving staging of tumor in addition to selection of the patients that could be targeted for therapy. Oldenburg et al. (2008) use a novel approach in detecting the cells that circulates which consequently habour a common point of mutation within the BRAF kinase. The research found out that there were 10 melanoma cells after 20 amplification cycles. On the other hand, it took at least 73 cycles in amplifying the unspiked blood’s epithelial-enriched fraction. The researchers had subdivided the PCR procedure into two for purpose of maximizing selectivity of the PBAS-PCR. The human blood that was used in the study was drawn from volunteers who were healthy and informed consent had been obtained. For each of the experiment, fresh blood was obtained and used. Oldenburg et al. (2008) failed to provide any statistical comparisons. In a similar study that however utilized secondary data rather than primary, Martin-Algarra et al. (2014) provides a diagnostic and treatment recommendations for managing individuals with metastatic or advanced melanoma using the available evidence on the use of biomarker. Apart from this, Martin-Algarra et al.(2014) addressed quality controls that are significant in having a successful testing of the biomarkers. The researchers relied on available data accessible to them in presenting their results and hence no specific methodological approach can be explained as they provided none. The researchers report that approximately half of all melanoma cases have an activating mutation in BRAF. At the same time, between 10 and 18 percent of melanomas usually have a hereditary background. The study depicted that there are numerous ways for testing for the BRAF mutations among them sequencing methods and polymerase chain reaction (PCR). The methods for sequencing include direct sequencing through the Sanger method that involves direct analyzing of DNA sequence that had previously been amplified by PCR. The authors state that this is significant and high sensitive method, which has the capability of detecting any form of mutations. This assertion can be proven by the fact that Oldenburg et al. (2008) utilized the method in their study. Martin-Algarra et al. (2014) noted that external quality controls applied by laboratories conducting tests for the molecular biomarkers for patients with melanoma have to ensure that the technologies used are validated in relation to sensitivity, specificity, and predictive value. Moreover, setting and adopting external control programs would be significant in achieving the desired outcomes. Majorly, the study by Martin-Algarra et al. (2014) relied on data from past studies in presenting their outcomes. Thus, there lacked substantive statistical comparisons.
In another similar study, Gaiser et al. (2013) used previous studies to examine the relationship of molecular pathogenetic in malignant diseases. Through previous articles, the researchers investigated the transition of melanoma in terms of its treatment. The results of the study revealed that there has been a continuous increase in the incident rates of melanoma. For example, in 2008, there were 18,000 new melanoma cases in Germany. In explaining their results, the researchers used the below table to present the various procedures which can be adopted in detection of mutations. These procedures are similar to those that Martin-Algarra et al. (2014) identified in their study.

Figure 1 Procedures for the detection of mutations
Source: Gaiser et al. (2013)
The figure above shows the method for detecting mutations and its description in terms of ability to identify the presence of melanoma in addition to the ease of the process and the total costs incurred. The researchers determined that when a sample has more tumour cells, the more accurate the results would be. For there to be a detection that can be considered reasonable, there should be not less than 25 percent of the DNA tumour. According to the outcomes of this particular study, while numerous mutations in melanoma have been researched, it is only the cKIT and BRAF gene mutations which are considered to having therapeutic consequences. Further, Gaiser et al. (2013) concluded that almost half of all melanoma patients having V600E mutations respond positively to treatments that are associated to certain BRAF inhibitors. To demonstrate the molecular diagnostics that are used in normal clinical practice the researchers compiled the figure below.

Figure 2 Molecular diagnostics methods
Source: Gaiser et al. (2013)
As shown in this figure 2, there is only a small percentage of melanoma mutations that are pertinent for dermatologists in regular clinical practice. The most employed methods for detecting mutations stage often vary depending on the experience and expertise that a centre has nevertheless, the most commonly used include BRAFV600E, pyrosequencing, and Sanger sequencing. Despite the lack of statistical comparison and any form of controls, the results reviewed from previous studies were in agreement with the findings by Martin-Algarra et al. (2014) on ways to identify the melanoma skin cancer stage.
On their part, Arenberger, Arenbergerova, Vohradnikova, & Kremen, (2008) conducted a study where they sought to examine early detection of melanoma progression. The study was similar to the one conducted by Oldenburg et al. (2008). Arenberger, et al (2008) recruited 65 patients where 39 were men compared to 26 who were women within the age bracket of 20 to 75 years with an average age of 55 years. The patients who were enrolled were those with a history of resected melanoma. The American Joint Committee on Cancer Guidelines were used in assessment of the stage cancer level. As negative control, the study recruited 23 donors who provided their blood samples. Analysis of the data was done statistically through SPSS software version 10 where a comparison was done between the housekeeping gene copies and the amplified marker RNA copies. The study employed a follow-up of 18 months where 18 of the 65 participants developed tumor progression. The results also revealed that 27 percent of the subjects involved in the study relapsed. Moreover, the researchers determined that before the disease progression, there was statistical significance tumor marker elevation in all the patients who had suffered a clinical relapse. The figure 1 below shows the determined tumor markers in the individuals who had melanoma progression.

Figure 3 Tumor Markers
Source: Arenberger, et al (2008)
From the figure 3 above, MAGE-3 was the marker which was most frequent and positive in this particular group which was followed by MIA while Melan-A failed to show any critical elevation as compared to the cutoff in patients with melanoma progression. From the outcome, the researchers agreed that RT-PCR was an effective real-time multi-maker that can be utilized in predicting melanoma skin cancer progression.
In a more unique research, Rocca, Ambrosio, Ginori, &Disanto, (2014) sought to examine the genetic link that has been found to exist between thyroid cancer and cutaneous melanoma. The background of conducting the study according to the researchers was the assertion that having a high percentage of these melanoma skin cancers often leads to the development of a recurrent mutation also known as the BRAFV600E which is found in the BRAF oncogene. The researchers adopted a case report methodology to present their results where they used a 65 year old man having cutaneous malignant melanoma metastatic and PTC. The study performed molecular biology analysis and cytological diagnosis on the fine-needle aspiration cytology (FNAC). Rocca et al. (2014) mentioned in their study that they considered FNAC as the most commonly and reliable thyroid nodules diagnostic test which includes the detection of mutations. The results showed that the level of the patients thyroid stimulating hormone (TSH) had increased a suggestion of hypothyroidism. The use of colour Doppler images depicted that there was an increase in the central blood flow in the same nodule. Apart from this, in the patient’s masseter muscle there was a nodule that was 0.5 cm long in diameter. The application of FNAC showed a high presence of papillary cell clusters in addition to there being the presence of green to brown melanin pigment. Through direct sequencing and PCR, the researchers found BRAF mutation. The study by Rocca et al. (2014) lack statistical comparison as the researchers did not utilize any form of control measure as they relied on a single case.
According to Tanioka, Masaki, Ono, Nagano, Otoshi-Honda, Matsumura, &Nishigori, (2007) Xeroderma pigmentosum (XP) is a form of disease which is inherited and associated to being highly sensitive to sunlight. In Japan, the researchers say that it occurs at a higher frequency compared to the United States. In this study, the researchers recruited or used the cell strains of 16 subjects who had been diagnosed with XPV who were averagely aged 57.1 years. The researchers conducted a mutation analysis in addition to an IP analysis. For the PCR products, the researchers conducted direct sequencing and RT-PCR. The results of the study depicted that the levels of UV-induced and UV sensitivity DNA analysis that was unscheduled on XPV cells were either slightly normal or normal. In identification of the POLH protein that cells contained, the researchers utilised immunoprecipitation (IP) analysis. The outcome of the IP analysis revealed that from the 16 patients who had been involved in the research as having XPV from cytological and clinical view point, 14 patients failed to have any POLH protein or contained only a minimal percentage. Additionally, the sequence analysis done subsequently showed that cells which lacked 83 kDa band and those that were weak had developed certain alterations within the POLH gene. Correlation analysis revealed that the absence of 83-kDa band from the IP analysis had good correlation with the POLH gene mutation that was present. One of the challenges established by the researchers was because diagnosis of XPV in its earliest stage is difficult considering that patients lack severe symptoms that can without doubt ascertain this disease. Out of the 15 strains, 14 had a higher UV sensitivity when caffeine was present. The results of the study also depicted that in each of the experiments conducted, normal control failed in showing the cell enhanced despite the presence of caffeine. The researchers also detected 7 germline mutations related to the POLH gene of the XPV patients having a Japanese origin that also included 3 novel mutations compared to 4 which had been reported in 3 XPV Japanese patients.
In another study, Gonzalez, et al. (2017) were engaged in measuring histopathologic features accuracy in melanocytic tumors that are challenging to diagnose in addition to determining those features interobserver agreement. For this particular study, 100 melanocytic tumors that are difficult to diagnose were examined by independently by 5 dermatopathologists. After the researchers had obtained the required permission from the Kansas University, they proceeded to creating a research set of 100 melanocytic neoplasm. The neoplasms that were selected for inclusion in the study were those that after lesion coded were either nevus or melanoma. On the other hand, the exclusion criteria involved neoplasm that had an uncertain behavior. The cases for the study were the neoplasms that had coding of melanoma while the controls were those that had been coded nevi. In the study, from each of the case a single hematoxylin-eosin slide was taken for purposes of developing the set of the study. The 10 features that the researchers selected for conducting analysis included the diameter of the broad surface, asymmetry, solar elastosis and pagetoid melanocytosis among others. The authors used a criterion that observers were provided with to document the existence of a feature or not. Data sheets that were standardised and identical set slides were given to five dermatopathologists who were certified and from different institutions. These observers apart from documenting the absence or presence of melanoma features they were supposed to indicate if the diagnosis was malignant or benign. Later data was collated using Microsoft Excel. The results of the study depicted that there was 78 percent agreement in the expert and observer final diagnosis. The disagreement between the observer and expert diagnosis was between 15 percent and 35 percent which gave a median of 23 percent. Regression was used by the researchers in an effort to identify the critical HFM available in diagnosis of a lesion being a melanoma.
In another study, Chwiro et al. (2001) examined if in situ fluorescence detection of human cutaneous melanoma based on digital imaging of spectrally resolved autoflouorescence could be utilised as a technique for selection of patients that were at a higher risk. As noted by Gonzalez, et al. (2017) in their study that diagnosis of melanoma could be challenging, Chwiro et al. (2010) noted that there are many cases of melanoma misdiagnosis in particular during the normal clinical examination compared to experts who happen to achieve high sensitivity. The method that Chwiro et al. (2010) applied in the present study was borrowed from previous publications. In brief, the fluorescence method consisted of a digital imaging in addition to a UVA light having minimal intensity. The trail was done with volunteering patients who permitted the researchers to undertake fluorescence examinations. In the three locations that the patients were recruited, approximately 10,000 subjects were recruited. The fluorescence examinations were conducted on 4079 patients while autofluorescence images received for the pigmented skin lesions that were 7228 in total. As shown in the figure 5 below, the parameter values R represent the measurement of the lesions histologically which are then classified into nevus, melanoma or other lesions that are pigmented.

Figure 4 Histogram for parameter values, R
Source: Chwiro et al. (2001)
Through the pair of results that are shown in the figure 4 above, the researchers made an assessment of the of sensitivity towards melanoma in addition to positive predictive value which seeks to detect melanoma. The sensitivity that the researchers obtained was 82.7 percent a figure that was similar to 82.5 percent obtained during the feasibility study. In terms of the specificity of the lesions, the results obtained showed they were 59.9 percent but lower than what had been reported previously. The researchers concluded that one of the reasons that they obtained lower values in the present study was because of the challenges the cases presented in relation to clinical diagnosis.
Dwyer et al. (2004) investigated whether adding information on genotype improved the forecast of melanoma risk as well as the non-melanoma skin cancer further than what is got from the skin phenotype. The study was case controlled and the subjects that were considered eligible were aged between 20-59 years from Australia. In Tasmania where the study occurred, it is legal mandatory to notify cancer cases and hence was easier to sample the diagnosis that had been confirmed. The researchers also employed controls for purposes of comparison. Genomic DNA was obtained from buccal mucosa swab through isolation kits referred to as Puregene DNA. The study used logistic regression for purposes of estimating the odds ratio of the skin cancer risk having association with MC1R variants in addition to categorising cutaneous melanin density. The results of the study depicted that presence of 5 variants of MCIR gene was in 757 of the research respondents. Compared to the controls, there was greater cases proportions had phenotypes which previous conducted studies had predicted the skin cancer risk. Further, the results showed that Asp84Glu, Arg151Cys, Arg160Trp, and Asp294His variants were responsible for increasing risk of squamous cell carcinoma and basal cell carcinoma. Similar to results from past studies, the research by Dwyer et al. (2004) determined that there was a possibility that the darkest patients were at higher risk of CCM. Specifically, the current study results showed that there subjects who were lighter skinned with less than 2% melanin.
Finally, Glanz et al. (2013) conducted a randomised controlled trial seeking to make a comparison of the impact of a strategy where test results and CDKN2A counselling are offered and not offering any on the perceived melanoma risk, attitude, behaviours of self examination on people with a hereditary history as well as sun avoidance. Glanz et al. (2013) employed a block randomized trail design where the participants recruited were adults who were considered to have high melanoma risk due to family or personal history. Four months later the researchers conducted a survey to follow-up. The participants were required to provide blood samples for MCIR and CDKN2A genotype. The counselling sessions were done in the presence of family members an activity that was optional. A genetic counsellor was responsible for the sessions. Some of the data that was collected included family and personal history related to skin cancer, risk factors for skin cancer, demographic features, genetic testing, habits on sun protection as well as history on self-examination. The statistical analysis that was used was descriptive. The comparison between the intervention and control groups was done via bivariate statistics. The researchers presented the results using the figure five below which showed aspects such as demographics, health, behaviour, and attitudes of both the control and intervention groups.

Figure 5 . Baseline characteristics
Source: Glanz et al. (2013)
All the participants were white where more than half were women. Approximately 90% of the participants had a high risk of obtaining skin cancer as shown in the above figure, BRAT score. About two-thirds had reported being previously diagnosed with melanoma. The study results depicted that was significant differences between the control and intervention groups was found on body mass index, gender and family history and no critical differences on education, age, and % at high risk.

Discussion
The research question that was being investigated was how genomic tests can be more favorable at accurately predicting the stages of melanocytic lesions over the American Academy of Dermatology staging guidelines. On the other hand, the hypothesis guiding the study was genetic testing such as chromosomal microarray analysis on the melanocytic tissue to diagnose for present chromosomal abnormalities, is more likely to accurately provide the stage of the melanomaskin cancer. The findings from the study partly confirm this hypothesis. The findings depicts that there exists lack of enough literature on the question investigated. Only few researchers have investigated accurate predicting of melanocytic lesions stages. Nonetheless, the outcomes from the studies reviewed depict that there many or numerous methods which can be employed by health professionals in detecting the presence of melanocytic lesions and cells associated with development of melanoma skin cancer.
The findings presented above depict that detection of melanoma cells that are circulating in peripheral blood could be significant in tracking the progression of the cancer tumor and at the same time predicting the clinical outcomes. The findings prove that further advancement of technology will be critical in advancing how people understand molecular pathogenetic while at the same time contributing to creation of new melanoma therapies that will be beneficial to the families affected. For instance, as the outcomes depicted, creating individual tumor signatures will ensure facilitation through patient stratification. Consequently, unnecessary processes that increase the costs of diagnosis and treatment will be reduced as personalised medicine becomes a priority for both the affected and health professionals. Important to note is that irrespective of the euphoria created by the above findings on melanoma treatment, prevention and stage detection, the application and establishment of the new molecular detecting techniques might increase the overall costs involved. Thus, it is of significance to have routine diagnostic measures while at the same time ensuring high sensitivity is maintained. Constant quality assurance is necessary for each of the procedures that various study results present to be working. Numerous research outcomes presented above were conducted in different countries and regions globally. Some of the researchers did the research in United States, Germany, Japan and Australia among others. Due to this, there is need for further synthesis and review for purposes of making conclusive and actionable plans that the entire world can benefit from concerning matters melanoma skin cancer.
Among the conclusions that can be made from the findings is that the clinical usage of genetic testing on melanoma largely remains controversial. For example, while evidence shows that mutations present in MC1R and CDKN2A have a high likelihood of increasing the melanoma risk, there is uncertainty on the knowledge whether MC1R and CDKN2A genotype affects the major aspect of melanoma prevention particularly when behaviors associated with sun protection are taken into consideration. As a result, the hypothesis that using genetic testing on melanocytic tissue for diagnosis of chromosomal abnormalities might provide accurate stage of the melanoma skin cancer is partially true as the reviewed studies depicted so. However, there are inconsistencies that require to be addressed before widespread adoption. Currently, the adoption of the technique should be by professionals with adequate knowledge and understanding of a tool that has probability of being near perfection.
Several limitations were identified from the various studies. One of these limitations common to a number of the studies was the use of a small sample size specifically for the individuals who had mutations. In one study, the researchers focused on one single patient while in another they relied on 3 participants. The use of a small sample size limits the conclusions which researchers can make from a certain recruited group. Another limitation almost present in all the studies explored was that fact that researchers mainly focused or recruited participant who had a high risk of developing melanoma skin cancer. The disadvantage of focusing on high-risk population is the inability to generalize results to populations which face low melanoma risk or even those who had never participated in a genetic study. Another limiting factor among the studies was the limitation of the follow-up period. What this meant is that if longer period would have been considered in some studies, other unique changes for instance in behavior could be identifiable. Apart from this, research participants could have experienced recall bias depending on when they filled in the questionnaires. An additional limitation was the withdrawal of participants before completion. In such cases, the sample size continued to reduce while the range of conclusions expected declined. For example, in one of the studies, the participants from an intervention group did not participate in a genetic counseling session. Other limitations included the fact that the genetic counseling protocol relied on standard principles set for cancer susceptibility however, effectiveness is dependent on the involved genetic counselors. In other words, if different counselors or professionals were used to conduct the same process, the effects of the intervention would not be replicable. At the same time, researchers acknowledged that while they were successful in sampling controls and cases achieving high response rate with no bias, the lack of ability to collect all the genotypic data from the participants involved is a possible contribution of bias in relations to the obtained estimates. The effect of this limitation is questioning the validity of the findings. Other limitations that were common in the reviewed studies included restricted outcome assessment and selection bias. Moreover, as mentioned, limiting some of the studies to expert consultation opinions means that outcomes cannot be generalized to all available types of melanocytic lesions.
Researchers from the reviewed studies recommend the need to conduct further studies affecting a number of issues. First, future studies should be done to address the questions related to whether genetic testing influences reductions in the melanoma burden in particular among carriers of mutations and if found beneficial who should be tested. In addition to this, further studies should be conducted with larger sample sizes for purposes of ensuring that the obtained data gives an opportunity for making wide range informed conclusions. At the same time, future researchers should conduct a study where they use high-risk and low-risk population in terms of melanoma skin cancer as either control or intervention group. As determined above, the explored studies did not consider low-risk population which makes it hard to generalize the study. Importantly also, future researchers should conduct extensive studies on how each of the melanoma stage can be prevented or treated independently after its determination. At the same time, more technologies and innovative ideas are being explored and future researchers should take upon themselves to explore and investigate how they can significantly help patients with melanoma skin cancer. In addition, studies could be conducted to examine male/ female, black/ white’s probability of developing melanoma skin cancer. Their behaviors in relation to sun protection could be examined in-depth with an aim of developing adequate preventive measures that can caution against this type of cancer across the world. Moreover, studies can be conducted using children and adolescents upon obtaining consent from their parents and guides. Children and adolescents are at high risk of developing melanoma skin cancer and there is need to further explore how it can be mitigated against.

References
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Appendices
Evidence Table
Author Date of Publication Study Design Level of Evidence Study Population Therapy or Exposure Outcome Result
1) ArenbergerP. 2008 Case control 2 Patients from America, with melanoma stage IIB-IIIC Compared RNA with blood samples from healthy donors The multimarker quantitive real-time RT-PCR used is a sensitive method for the detection of circulating melanoma cells and could be used as a tool for early detection of metastatic process.
2) Chwirot BW. 2001 Cohort study 4 Patients from Torun, Warszawa, and Szczecin who were at risk for melanoma or other skin cancer Skin excited with 366nm UVA line of a high-pressure Xe-Hg lamp and emitted in the blue 475 nm band The fluorescence method of in situ detection of melanomas allows for long-term monitoring of the evolution of suspected lesions.
3) Dwyer T. 2003 Case control 3 Patientsages between 20-59 years of northern European ancestry in Australia. Compared cases with variants of the MC1R gene versus controls and their phenotypic characteristics that predict to risk of skin cancer. Four of the five variants of MC1R studied were associated with increased risk of skin cancer.
4) Gaiser M. 2013 Experimental study 2 Cutaneous melanomas from German patients BRAF V6ooE, cKIT, NRAS, PTEN, GNAQ/GNA11 BRAF V6ooE had the highest relevance for use of molecular diagnostic compared to the rest of the mutations.
5) Glanz K. 2013 Case control 1 American patients with a family history of melanoma Genetic counseling sessions with intervention Mutations in CDKN2A and MC1R are associated with increased risk of developing melanoma
6) Gonzalez M. 2017 Case Control 4 100 melanocytic neoplasms Melanomas and nevi Histopathologic features of melanoma in difficult-to-diagnose lesions vary in accuracy and reproducibility.

7) Martin-Algarra S. 2013 Experimental study 0 Pathology tests for biomarkers in melanoma BRAF, KIT, NRAS, GNAQ, GNA11, PTEN, MITF, CDKN2A Based on the data available, this group recommends testing patients with metastatic melanoma for BRAF mutation status.
8) Oldenburg R. 2008 Experimental study 0 American human blood from healthy volunteers Melanoma cells harboring point mutation in BRAF kinase Can readily identify mutant DNA from as few as 10 melanoma cells in 1 ml of human blood
9) Rocca B. 2013 Case control 2 Patients with papillary thyroid carcinoma and metastatic malignant melanoma Fine needle aspiration cytology Identified a genetic link in the BRAF oncogene between cutaneous melanoma and thyroid cancer
10) Tanioka M. 2007 Case control 4 16 cell strains derived from patients between 34 and 82 years old, clinically diagnosed with XerodermaPigmentosum Variant POLH gene The immunoprecipitation analysis of the POLH protein reveled a very useful method for screening patients suspected of XeroadermaPigmentosum Variant