Indicators of the standard of care for melanoma: Tuscany data

Clinical performance indicators for monitoring the management of cutaneous melanoma: a population-based perspective

The prognosis of cutaneous malignant melanoma (CMM) is based on disease progression. The highly heterogeneous clinical-pathological characteristics of CMM necessitate standardized diagnostic and therapeutic interventions tailored to cancer's stage. This study utilizes clinical performance indicators to assess the quality of CMM care in Veneto (Northeast Italy). This population-based study focuses on all incidences of CMMs registered by the Veneto Cancer Registry in 2015 (1279 patients) and 2017 (1368 patients). An interdisciplinary panel of experts formulated a set of quality-monitoring indicators for diagnostic, therapeutic, and end-of-life clinical interventions for CMM. The quality of clinical care for patients was assessed by comparing the reference thresholds established by experts to the actual values obtained in clinical practice. The prevalence of stage I-CMM decreased significantly from 2015 to 2017 (from 71.8 to 62.4%; P < 0.001), and almost all the pathology reports mentioned the number of nodes dissected during a lymphadenectomy. More than 90% of advanced CMMs were promptly tested for molecular BRAF status, but the proportion of patients given targeted therapies fell short of the desired threshold (61.1%). The proportion of stage I-IIA CMM patients who inappropriately underwent computerized tomography/MRI/PET dropped from 17.4 to 3.3% ( P < 0.001). Less than 2% of patients received medical or surgical anticancer therapies in the month preceding their death. In the investigated regional context, CMM care exhibited both strengths and weaknesses. The evaluated clinical indicators shed essential insight on the clinical procedures requiring corrective action. It is crucial to monitor clinical care indicators to improve care for cancer patients and promote the sustainability of the healthcare system.

Quality assurance in melanoma care: guideline-based quality indicators for melanoma - implementation, evaluation and update process

BACKGROUND

In 2018, an update of the German evidence-based (S3) guidelines "Diagnosis, Therapy and Follow-up of Melanoma" first issued in 2013 was published under the auspices of the German Guideline Program in Oncology. The update also included a revision of existing guideline-based quality indicators (QIs).

PATIENTS AND METHODS

Using a standardized multi-step process, the guideline-derived QIs were revised by a multidisciplinary, interprofessional working group based on the strong (level A) recommendations contained in the guideline update as well as on a systematic literature search for international indicators and on the outcomes of existing QIs as reported by certified German skin cancer centers.

RESULTS

Based on the original set of twelve guideline-based QIs agreed upon in 2013, the working group developed an updated set containing nine indicators. Four QIs were kept unchanged; two were modified; two were removed; and three new QIs were added. Unlike 2013, the working group was now able to incorporate the outcomes of QIs previously implemented at the various skin cancer centers.

CONCLUSIONS

Close cooperation between guideline group and certification commission allows for the implementation of guideline-based QIs in cancer care. Measured outcomes form the basis for updating both the guidelines and the QI development process. They provide information about the care of cancer patients in a real-world setting as well as on guideline adherence and the feasibility of QIs themselves. This is a dynamic process that can be described in a transparent manner and that requires regular updating.

Dutch Melanoma Treatment Registry: Quality assurance in the care of patients with metastatic melanoma in the Netherlands

BACKGROUND

In recent years, the treatment of metastatic melanoma has changed dramatically due to the development of immune checkpoint and mitogen-activated protein (MAP) kinase inhibitors. A population-based registry, the Dutch Melanoma Treatment Registry (DMTR), was set up in July 2013 to assure the safety and quality of melanoma care in the Netherlands. This article describes the design and objectives of the DMTR and presents some results of the first 2 years of registration.

METHODS

The DMTR documents detailed information on all Dutch patients with unresectable stage IIIc or IV melanoma. This includes tumour and patient characteristics, treatment patterns, clinical outcomes, quality of life, healthcare utilisation, informal care and productivity losses. These data are used for clinical auditing, increasing the transparency of melanoma care, providing insights into real-world cost-effectiveness and creating a platform for research.

RESULTS

Within 1 year, all melanoma centres were participating in the DMTR. The quality performance indicators demonstrated that the BRAF inhibitors and ipilimumab have been safely introduced in the Netherlands with toxicity rates that were consistent with the phase III trials conducted. The median overall survival of patients treated with systemic therapy was 10.1 months (95% confidence interval [CI] 9.1-11.1) in the first registration year and 12.7 months (95% CI 11.6-13.7) in the second year.

CONCLUSION

The DMTR is the first comprehensive multipurpose nationwide registry and its collaboration with all stakeholders involved in melanoma care reflects an integrative view of cancer management. In future, the DMTR will provide insights into challenging questions regarding the definition of possible subsets of patients who benefit most from the new drugs.

Measuring the quality of melanoma surgery - Highlighting issues with standardization and quality assurance of care in surgical oncology

In an attempt to ensure high standards of cancer care, there is increasing interest in determining and monitoring the quality of interventions in surgical oncology. In recent years, this has been particularly the case for melanoma surgery. The vast majority of patients with melanoma undergo surgery. Usually, this is with combinations of wide excision, sentinel lymph node biopsy and lymphadenectomy. The indications for these procedures evolved during a time when no effective systemic adjuvant therapy was available, and whilst the rationale has been sound, the justification for differences in extent and thoroughness has generally been supported by inadequate or low-level evidence. This has led to a substantial variation among melanoma centres or even among surgeons within a centre in how these procedures are done. With recent rapid progress in the efficacy of systemic treatments that are impacting on overall survival, the prospect of long-term survival in these previously high risk patients means that more than ever long-term locoregional control of melanoma is imperative. Furthermore, the understanding of effects of systemic therapy on locoregional disease will only be interpretable if surgeons use standardized, high quality techniques. This article focuses on standardization and evolution of quality indicators for melanoma surgery and how these might have a positive impact on patient care.