Analyzing Controversies in Management and Surveillance of Early-Stage Melanoma

Abstract

The incidence of cutaneous melanoma continues to rise dramatically worldwide, presenting a significant burden to the healthcare system. Despite this, there is still controversy in the guidelines regarding follow-up surveillance for patients with thin melanoma. Since there are no randomized clinical trials to support evidence-based guidelines for follow-up surveillance, dermatologic and oncologic organizations have developed their own recommendations based on expert opinion. However, these recommendations differ widely and are often vague, resulting in considerable variability in the management of early-stage melanoma among clinicians. The benefits of frequent follow-up visits are early detection of recurrent lesions, lower cost of early-stage melanoma compared to that of late-stage melanoma, decreased need for sentinel lymph node biopsy and adjuvant therapies, and the opportunity to educate patients on self-examination and sun protection. However, the high cost of screening and potential increased rates of biopsy, as well as over-imaging and overtreating, pose serious concerns about this approach. While more rigorous research is needed to resolve this controversy, currently clinicians should follow a relatively universal recommendation to tailor the follow-up regimen based on the patient's relative risk of recurrence and comfort.

Conventional versus Reduced-Frequency Follow-Up in Early-Stage Melanoma Survivors: A Systematic Review with Meta-Analysis

“…The conventional approach also has its disadvantages—it can burden patients with too-frequent visits that negatively affect the medical benefit for the patient—especially in the era of the COVID-19 pandemic, which poses a risk of cross-infection [ 6 , 7 , 8 , 9 ]. Increasing the frequency of visits may also have a negative impact on hospital facilities, as it increases the cost of medical care, which globally has limited resources both in economic terms and in terms of manpower [ 10 ]. Another disadvantage for the patient is over-imaging, which increases the risk of exposure to radiation and overtreating [ 10 ].…”

“…Increasing the frequency of visits may also have a negative impact on hospital facilities, as it increases the cost of medical care, which globally has limited resources both in economic terms and in terms of manpower [ 10 ]. Another disadvantage for the patient is over-imaging, which increases the risk of exposure to radiation and overtreating [ 10 ].…”

“…This seems to be particularly important in the age of the COVID-19 pandemic, where every visit to the hospital or outpatient clinic is associated with a risk of cross-infection [ 9 ]. A higher frequency of follow-up visits raises the costs of healthcare, when funds might be redirected to more effective fields if lower-frequency follow-ups were proved to be non-inferior [ 10 ]. The concept of reduced-frequency follow-ups is of utmost importance, as the global health care is facing limited resources both economically and in terms of manpower.…”

Cutaneous Melanoma Systematic Diagnostic Workflows and Integrated Reflectance Confocal Microscopy Assessed with a Retrospective, Comparative Longitudinal (2009–2018) Study

“…However, Marushchak et al suggested that the high cost of screening and potentially increased rates of lesion excisions, as well as overimaging and overtreating, pose serious concerns [31]. The integration of RCM in the diagnostic patient pathway improves diagnostic power for melanoma detection through the addition of morphologic clues, thereby reducing unnecessary excisions compared to dermoscopy [20].…”

Overdiagnosis, Overtreatment or Oversurveillance of Melanoma: Is There a Way Out?

“…Only roughly 10%-20% of melanoma patients will be diagnosed with subsequent melanoma, whereby the risk of subsequent melanoma is highest within the first 3 years after initial melanoma diagnosis [5]. Notwithstanding this evidence, most guidelines and dermatologists advocate lifelong surveillance with at least annual visits for all melanoma, irrespective of tumor thickness, effective risk of recurrence/progression or presence of additional risk factors [6,7]. Addressing the problem of melanoma over-diagnosis in this light, which refers to early melanomas that will never cause symptoms or death during a person expected lifetime, the uncritical overtake of this practice results in long term over-surveillance of a significantly increasing cohort of virtually "cured" healthy individuals.…”