Melanoma Surgery: Why Don’t We Let the Guidelines Guide Practice?

Abstract

In the current era of evidence-based medicine, clinical practice guidelines (CPGs), care pathways, and best practice protocols are ubiquitous. CPGs are systematically developed statements, designed to assist clinicians and patients with decisions regarding appropriate care.1 Public health agencies and professional societies tasked with creating these guidelines are faced with the challenge of providing comprehensive, specific, understandable, and clinically usable recommendations. Underlying the tremendous effort of creating CPGs is the assumption that once the guideline is in place, it will be used to guide care.In this issue of Annals of Surgical Oncology, Varey and colleagues present a large, population-based, cross-sectional study evaluating adherence to the Australian Melanoma Management Guidelines.2 The authors note only 35% of wide local excisions (WLEs) were performed with margins concordant with the guidelines; 45% of WLEs had more aggressive margins than recommended and the remainder were excised with inadequate margins. While nearly two-thirds of patients received guidelinediscordant care, implications on rates of recurrence and disease-related morbidity/mortality were not examined in this study and are unknown. To place these findings in a larger context, we must understand why the guidelines are not being followed. Physician knowledge, behavior, and attitudes, as well as a guideline's underlying 'trustworthiness' have all been identified as barriers to the uptake of CPG recommendations. PHYSICIAN KNOWLEDGEIt stands to reason that 'expert' physicians would be more familiar with the guidelines, and the data presented on physician volume support this assertion. Surgeons with high annual melanoma caseloads ([30) were 27% more likely to perform a WLE concordant with the guideline than those with a lower caseload (1-5 cases annually).

Trends in Sentinel Lymph Node Biopsy Enactment for Cutaneous Melanoma

“…Explanations for this non-adherence in general can vary greatly, ranging from lack of familiarity to low outcome expectancy or disagreement 29. For melanoma-specific adherence to guidelines, Kang and Wong and Varey et al30,31 showed that for wide local excisions for melanoma, surgeons with a high melanoma caseload (> 30) were more likely to perform procedures concordant with the guidelines than those with a lower caseload. Another reason might be that Dutch guidelines have only advised on SLNB since 2005, and waited until 2012 to provide a recommendation, which is still not solid advice.…”