Variability in melanoma post-treatment surveillance practices by country and physician specialty

Abstract

Background There are no evidence-based guidelines for surveillance of patients with melanoma following surgical treatment. We performed a systematic review to identify current stage-specific surveillance practices for patients with melanoma by country and physician specialty. Methods Three major medical indices, MEDLINE, the Cochrane Library database, and Scopus, were reviewed to identify articles published in January 1970 to October 2011 that included detailed information about surveillance of patients with melanoma after initial surgical treatment. Data on surveillance intervals and recommended evaluation were extracted and categorized by country and, when reported, physician specialty. Results One hundred four articles from 10 countries and 4 physician specialties (dermatology, surgical oncology, medical oncology, and general practice) met the inclusion criteria, including 43 providing specific patient-level data. The articles showed wide variation with respect to surveillance intervals and recommended evaluations. Variation was greatest for patients with stage I disease, for whom follow-up frequency ranged from 1 to 6 visits per year during years 1 and 2 after treatment. All 4 physician specialties agreed that for years 1–3, the follow-up frequency should be 4 times per year for all patients. For years 4 and 5, surgical oncologists recommended 2 follow-up visits per year, whereas general practitioners, dermatologists, and medical oncologists recommended 4 visits per year. Recommended imaging and laboratory evaluations were most intense in the United Kingdom and most minimalist in The Netherlands. While general practitioners did not recommend routine laboratory or imaging tests for surveillance, all other specialties utilized both in their surveillance practice. Self skin-examination was recommended for surveillance in all countries and by all practitioner specialties. Conclusions There is significant intercountry and interspecialty variation in surveillance of patients with melanoma. As the number of melanoma survivors increases, it will be critical to examine the benefits and costs of various follow-up strategies to establish consensus guidelines for melanoma post-treatment surveillance.

Surviving Cutaneous Melanoma

“…Approximately 1–8% of melanoma survivors will develop a second primary melanoma in their lifetime, which is often thinner than the first primary (25). Physicians, more often than patients, detect the second primary melanoma.…”

“…Cromwell et al . (25) recently performed a systemic review of published surveillance strategies from 1970 to 2011; they found significant variation in follow-up relative to disease state, country of origin, and physician specialty. Greatest variation in surveillance frequency was noted in stage I patients, which ranged from 1–6 visits/year for the first 2 years of treatment, and with regard to the use of routine diagnostic imaging and laboratory evaluations.…”

“…Greatest variation in surveillance frequency was noted in stage I patients, which ranged from 1–6 visits/year for the first 2 years of treatment, and with regard to the use of routine diagnostic imaging and laboratory evaluations. Universal agreement was reached for all patients to perform self-examinations and to decrease visits to annual surveillance after 5 years of disease-free follow-up (25). …”

“…The duration of follow-up continues to be debated, and ranges from years to a lifetime of surveillance. Table 2 compares surveillance recommendations by the National Comprehensive Cancer Network® (NCCN®) and other organizations with published guidelines (19,25,28). …”

Melanoma follow up: time to generate the evidence

“…17 There is evidence that~30% of melanoma patients report clinically relevant psychological distress. 18 Although there is some evidence that early detection of recurrence can improve patient survival 15,19,20 and the benefit of detecting early a new primary melanoma is generally accepted, 21 evidence is inconclusive whether intensive surveillance can meaningfully contribute to early detection; 2 75% of patients detect their own recurrence outside of scheduled follow-up visits. 2,9 Evidence first needs to be generated on current follow-up practices to identify models of care (e.g.…”