Evidence-Based Follow-up for the Patient with Melanoma

ATLAS: A positive, high-yield review of patient symptoms most significantly associated with melanoma recurrence

BACKGROUND

No standardized, evidence-based surveillance practices exist to guide and optimize recurrence detection in patients with cutaneous melanoma.

OBJECTIVE

To determine the most high-yield positive review of systems for signaling recurrence in patients with cutaneous melanoma.

METHODS

This retrospective cohort study assessed patients with a history of cutaneous melanoma and compared demographic and clinical characteristics, including a comprehensive review of systems, among those who experienced recurrence and those who did not.

RESULTS

A high-yield positive review of systems associated with cutaneous melanoma recurrence can be remembered using the mnemonic "ATLAS": Appetite change, Tiredness, Lymph node enlargement, Abdominal pain, and Shortness of breath LIMITATIONS: Retrospective design, limited sample size, and variability in follow-up time between recurrent and nonrecurrent cohorts.

CONCLUSION

Any treating physician using this model may have a greater opportunity to detect recurrent cutaneous melanoma and improve outcomes while limiting cost and morbidity.

Association between dermatology follow-up and melanoma survival: A population-based cohort study

BACKGROUND

Guidelines recommend that patients with melanoma undergo dermatologic examination at least annually. Adherence to follow-up and its impact on survival are unclear.

OBJECTIVE

To determine the level of adherence to annual dermatologic follow-up in patients with primary cutaneous melanoma, identify predictors for better adherence, and evaluate whether adherence was associated with melanoma-related mortality.

METHODS

Retrospective inception cohort analysis of adults with primary invasive melanoma in Ontario, Canada from 2010 to 2013 with follow-up until December 31, 2018.

RESULTS

Adherence to dermatologic follow-up was variable with only 28.0% of patients seeing a dermatologist at least annually (median follow-up 5.0 years). Younger age, female sex, higher income, greater access to dermatology care, stage 2/3 melanoma, prior keratinocyte carcinoma, fewer comorbidities, and any outpatient visit in the 12 months prior to melanoma diagnosis were predictors for adherence. Greater adherence to annual dermatology visits was associated with reduced melanoma-specific mortality compared with lower levels of adherence (adjusted hazard ratio 0.64, 95% CI 0.52-0.78).

LIMITATIONS

Observational study design and inability to identify skin examinations performed by non-dermatologists.

CONCLUSION

Adherence to annual dermatology visits after melanoma diagnosis was low. Greater adherence may promote better patient survival but warrants confirmation in further research including randomized trials.

18 F-FDG positron emission tomography-computed tomography has a low positive predictive value for detecting occult recurrence in asymptomatic patients with high-risk Stages IIB, IIC, and IIIA melanoma

BACKGROUND AND OBJECTIVES

High recurrence rates of Stages II and IIIA melanoma make close follow-up essential, especially with new adjuvant therapies for metastatic disease. However, there are currently no consensus guidelines for routine imaging for Stages IIB, IIC, and IIIA melanoma. The study's aim is to determine the utility of 18 F-fluorodeoxyglucose (18 F-FDG) positron emission tomography/computed tomography (PET/CT) for detecting asymptomatic recurrence of melanoma after primary surgical resection.

METHODS

This retrospective cohort study included 158 patients with the American Joint Committee on Cancer 8th edition Stages IIB, IIC, or IIIA cutaneous melanoma who underwent an 18 F-FDG PET/CT from 2010 to 2020. We retrospectively analyzed clinical data after a median follow-up time of 39 months.

RESULTS

We calculated a positive predictive value (PPV) of 32% (95% confidence interval: 11%-53%) for 154 routine PET/CTs, including six true positives and 13 false positives (FPs). PPV was 33% for Stage IIB, 50% for Stage IIC, and 14% for Stage IIIA. FPs were mostly benign or inflammatory foci (75%), and some other malignancies were found (21%).

CONCLUSIONS

This cohort of patients imaged for high-risk melanoma demonstrated a high FP rate and low PPV. These findings suggest that routine surveillance with 18 F-FDG PET/CT may not be indicated for monitoring recurrence in this population.

18F-FDG PET/CT and Melanoma: Value of Fourth and Subsequent Posttherapy Follow-up Scans for Patient Management

PURPOSE

We aimed to evaluate the added value of performing fourth and subsequent follow-up F-FDG-PET/CT scans to clinical assessment and impact on the patient's management in patients with melanoma.

METHODS

This was a retrospective study of 232 biopsy-proven melanoma patients who underwent F-FDG-PET/CT scans. Of these, 71 patients had 4 or more follow-up F-FDG-PET/CT scans after completion of primary treatment, with a total of 246 fourth or subsequent follow-up PET/CT scans. The added value of each follow-up PET/CT scan to the patient's clinical assessment and treatment management was established. Kaplan-Meier plots with a Mantel-Cox log-rank test were used to establish the patient's overall survival.

RESULTS

Of the 246 fourth and subsequent follow-up PET/CT scans, 61% (150/246) were negative for malignancy, and 39.0% (96/246) were positive for recurrence/metastases. FDG-PET/CT was helpful in identifying malignancy in 6.5% of the scans performed without prior clinical suspicion, which ruled out malignancy in 28.5% of the scans obtained with prior clinical signs suggestive of recurrence or for secondary therapy assessment. The PET/CT scan resulted in change of the patient's management in approximately 16.7% (41/246) of the scans. Change in management was significantly greater in patients whose scans were done with prior clinical signs suggestive of malignancy, or for therapy assessment than without prior clinical suspicion (29.3% vs 4.1%; P < 0.0001). Statistically significant difference was seen in the overall survival between patients with at least 1 positive and all negative fourth and subsequent follow-up PET/CT scans at patient level (P = 0.001).

CONCLUSIONS

The fourth and subsequent F-FDG-PET/CT scans obtained after completion of primary treatment added value to clinical assessment in patients with melanoma. Patients with clinical signs suggestive of recurrence or metastases or being monitored for treatment response are more likely to benefit from the fourth or subsequent FDG PET/CT than those without prior clinical suspicion.

(18)F-FDG PET/CT and Melanoma: Staging, Immune Modulation and Mutation-Targeted Therapy Assessment, and Prognosis

OBJECTIVE

Monoclonal antibodies that target the programmed cell death 1 (PD-1) immune checkpoint protein and its associated ligands, PD-L1 and PD-L2, and targeted inhibitors of mutated signal transduction molecules such as BRAF inhibitors show immense promise in treating patients with melanoma. We discuss the use of (18)F-FDG PET/CT for assessing therapy effectiveness, staging advanced disease, and determining prognosis of patients with melanoma.

CONCLUSION

FDG PET/CT is useful in staging disease, assessing therapy, and determining prognosis in patients with melanoma.

Follow-up in melanoma patients

Due to lack of evidence from prospective clinical trials, the diagnostic procedures, their frequency, as well as the length of the follow-up period in cutaneous melanoma patients should be based on the individual risk of disease recurrence, which is strongly dependent on the stage of disease at the time of diagnosis. In the paper we propose the current recommendations for follow-up strategy. Nowadays, new effective treatment options with biological agents justify the closer monitoring of high risk melanoma patients.

Burden of disease due to cutaneous melanoma has increased in the Netherlands since 1991

BACKGROUND

The burden of disease, describing loss of health and death due to a disease, has not been fully studied for melanoma in the general population over time.

OBJECTIVES

To determine the burden of disease due to melanoma in the Netherlands.

METHODS

Age- and sex-specific incidence data from all patients with melanoma in the Netherlands between 1991 and 2010 were obtained from the Netherlands Cancer Registry. Melanoma-specific mortality and life expectancy data were obtained from Statistics Netherlands. Melanoma duration was calculated using the DISMOD software from the World Health Organization. The years of life lived with disability (YLD) and years of life lost (YLL) due to melanoma were calculated using Dutch disability weights, incidence and mortality of melanoma, and the life expectancy from the general population. The number of disability-adjusted life-years (DALYs) was estimated by adding YLD and YLL.

RESULTS

The world-standardized incidence rates of melanoma have more than doubled for both men (7·1 per 100 000 inhabitants in 1991 to 17·0 in 2010) and women (9·4 per 100 000 inhabitants in 1991 to 19·8 in 2010). Likewise, the burden of melanoma to society has increased rapidly. The YLD for men increased from 4795 (1991-4) to 12 441 (2007-10), and for women from 7513 (1991-4) to 16 544 (2007-10). In 2007-10 the total YLL due to melanoma was 30 651 for men and 26 244 for women compared with 17 238 and 16 900, respectively, in 1991-4. The DALYs increased by 96% for men, from 22 033 (1991-4) to 43 092 (2007-10), and by 75% for women, from 24 413 (1991-4) to 42 788 (2007-10).

CONCLUSIONS

Melanoma is becoming a great burden to Dutch society.

Variability in melanoma post-treatment surveillance practices by country and physician specialty: a systematic review

There are no evidence-based guidelines for the surveillance of patients with melanoma following surgical treatment. We carried out a systematic review to identify by country and physician specialty the current stage-specific surveillance practices for patients with melanoma. Three major medical indices, MEDLINE, the Cochrane Library database, and Scopus, were reviewed to identify articles published from January 1970 to October 2011 that included detailed information about the surveillance of patients with melanoma after the initial surgical treatment. Data on surveillance intervals and recommended evaluation were extracted and categorized by country and, when reported, physician specialty. One hundred and four articles from 10 countries and four physician specialties (dermatology, surgical oncology, medical oncology, and general practice) fulfilled the inclusion criteria, including 43 providing specific patient-level data. The articles showed a wide variation with respect to the surveillance intervals and recommended evaluations. The variation was greatest for patients with stage I disease, for whom the follow-up frequency ranged from one to six visits per year during years 1 and 2 after treatment. All four physician specialties agreed that for years 1-3, the follow-up frequency should be four times per year for all patients. For years 4 and 5, surgical oncologists recommended two follow-up visits per year, whereas general practitioners, dermatologists, and medical oncologists recommended four visits per year. Recommended imaging and laboratory evaluations were most intense in the UK and most minimalist in the Netherlands. Although 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. There are significant intercountry and interspecialty variations in the 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.

Follow-up of early stage melanoma: specialist clinician perspectives on the functions of follow-up and implications for extending follow-up intervals

BACKGROUND

There is limited evidence on the relative effectiveness of different follow-up schedules for patients with AJCC stage I or II melanoma, but less frequent follow-up than is currently recommended has been proposed.

OBJECTIVES

To describe melanoma clinicians' perspectives on the functions of follow-up, factors that influence follow-up intervals, and important considerations for extending intervals.

METHODS

Qualitative interviews with 16 clinicians (surgical oncologists, dermatologists, melanoma unit physicians) who conduct follow-up at two of Australia's largest specialist centers.

RESULTS

Follow-up is conducted for early detection of recurrences or new primary melanomas, to manage patient anxiety, support patient self-care, and as part of shared care. Recommended intervals are based on guidelines but account for each patient's clinical risk profile, level of anxiety, patient education requirements, capacity to engage in skin self-examination, and how the clinician prefers to manage any suspicious lesions.

CONCLUSIONS

To revise guidelines and implement change it is important to understand the rationale underpinning existing practice. Extended follow-up intervals for early stage melanoma are more likely to be adopted after the first year when patients are less anxious and sufficiently prepared to conduct self-examination. Clinicians may retain existing schedules for highly anxious patients or those unable to examine themselves.

Review of diagnostic imaging modalities for the surveillance of melanoma patients

As melanoma survival rates continue to increase, optimal surveillance strategies for recurrences are needed, as are effective imaging modalities. Therefore, we performed a meta-analysis to evaluate the current state of imaging modalities for surveillance of melanoma in the published medical literature to determine the sensitivity, specificity, and positive predictive values of ultrasonography, computed tomography (CT), positron emission tomography (PET), and CT-PET combined. Ultrasonography was found to be the most sensitive and specific for detecting lymph node metastases, and PET-CT was the most sensitive and specific for detecting distant metastases. In addition to identifying appropriate surveillance methods, future studies should focus on the most effective and cost-effective intervals for performing these tests. In addition, the results from the meta-analysis related to sensitivity and specificity of the tests should be made available to doctors in community practice.