Journal of Clinical and Aesthetic Dermatology

DEC 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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44 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY December 2017 • Volume 10 • Number 12 O R I G I N A L R E S E A R C H T The incidence of a second melanoma is increased in melanoma survivors, with the cumulative risk ranging from 2 to 5 percent at periods from 5 to 20 years after initial diagnosis. 1–3 Although an optimal surveillance strategy after treatment of primary cutaneous melanoma has not been determined, several guidelines are available, though they vary slightly between specialty organizing bodies and between countries. 4,5 For instance, the National Comprehensive Cancer Network (NCCN) recommends lifelong full-skin examinations (FSE) at least annually for those with Stage 0 disease (melanoma in situ). 6 For stage IA disease, NCCN recommends a history and physical exam including FSE with lymph node examination every 3 to 12 months for the first five years and annually thereafter. Similar recommendations are set forth for patients with Stages IB to IV, although with more frequent follow-ups for the first two years (i.e., every 3–6 months). 6 Evidence presented in support of the rationale for surveillance visit frequencies has primarily been based on relapse profile over time. 7 Second primary melanomas occur at an estimated incidence of 11.4 percent over a five-year period, with one-half to three-fifths of these cases occurring within the first year. 8– 10 In an extensive review by Francken et al, 3 20 to 28 percent developed local or in-transit recurrences, 26 to 60 percent had regional recurrences, and 15 to 50 percent had distant metastases. Nearly two-thirds of relapses occur within the first two years, underscoring the importance of close surveillance for at least two years following initial diagnosis. 11 Because patient adherence is central to the effectiveness of any clinical intervention, 12,13 clinicians providing care to melanoma patients should be familiar with the complexities of patient adherence as it relates to melanoma surveillance. Much of this responsibility falls in the hands of physicians, mainly dermatologists, but might also be of greater effectiveness if executed in a multidisciplinary fashion. 4,7,14 Variations in follow-up visit frequency guidelines, retrospective study design, and small sample size might be at play in the conflicting findings of previous A B S T R A C T BACKGROUND: Melanoma surveillance serves to identify new primary melanomas and curable locoregional or early distant recurrences. Although an optimal melanoma surveillance strategy has not been determined, several clinical guidelines exist. OBJECTIVE: The aim of this study was to identify demographic and clinico-pathologic variables associated with poor adherence to National Comprehensive Cancer Network (NCCN) melanoma surveillance guidelines. DESIGN: We retrospectively reviewed the initial five-year dermatology follow-up visit frequencies of melanoma patients and extracted basic demographic and clinical data from their medical records. PARTICIPANTS: Of 186 patients included, the mean age was 55 (standard deviation=15); 47.5 percent (n=85) were female, 93.0 percent (n=173) were white, and 76.2 percent (n=141) were married. Sixty percent of patients lived at locations more than 10 miles from the clinic, and 58.6 percent had private insurance. MEASUREMENTS: "Aggressive" and "conservative" surveillance schedules were adapted from National Comprehensive Cancer Network visit frequency guidelines. RESULTS: Between 58.4 and 74.5 percent of patients adhered to "aggressive" surveillance, with decreasing rates over the five-year period. Annual rates of poor surveillance adherence (7.3–23.6%) increased over time. Based on adjusted odds ratios, patients younger than 50 years of age (odds ratios 2.11 [95% CI 1.13–3.93], p<0.05), those lacking health insurance (odds ratios 3.08 [95% CI 1.09–8.68], p<0.05), and those with at least Stage IIB disease (odds ratios 3.21 [95% CI 1.36–7.58], p<0.01) are more likely to be poorly adherent to melanoma surveillance. CONCLUSION: This study's findings highlight some variables associated with poor surveillance adherence among melanoma survivors that could help to guide efforts in counseling this at-risk population. KEYWORDS: Primary cutaneous melanoma, melanoma surveillance, follow-up visit A Retrospective Analysis of Surveillance Adherence of Patients after Treatment of Primary Cutaneous Melanoma by JEAVE RESERVA, MD; MONICA JANECZEK, BS; CARA JOYCE, PhD; AMANDA GOSLAWSKI, MA; HWALA HONG, BA; FENG-NING YUAN, BS; NEELAM BALASUBRAMANIAN, BA; LAURA WINTERFIELD, MD, MPH; JAMES SWAN, MD; and REBECCA TUNG, MD Drs. Reserva, Swan, and Tung are with the Division of Dermatology at Loyola University Chicago in Chicago, Illinois. Dr. Joyce and Ms. Balasubramanian are with the Biostatistics Core - Clinical Research Office at at Loyola University Chicago, Chicago, Illinois. Ms. Janeczek, Ms. Goslawski, Ms. Hong, and Mr. Yuan are with the Stritch School of Medicine in Maywood, Illinois. Dr. Winterfield is with the Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina in Charleston, South Carolina. J Clin Aesthet Dermatol. 2017;10(12):44–48 FUNDING: Partial funding was received from Loyola Clinical Research Office (CRO) at Loyola University Chicago, Health Sciences Division DISCLOSURES: The authors have no financial conflicts relevant to the content of this article. CORRESPONDENCE: Jeave Reserva, MD; Email: jeave.reserva@gmail.com

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