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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46 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 were "adherent to aggressive surveillance," with decreasing rates over the five-year period (Figure 1). The percentage of patients categorized as "poorly adherent to conservative schedule" (7.3–23.6%) increased over time (Table 3). Demographics and clinicopathologic variables. Based on adjusted odds ratios, patients younger than 50 years of age are twice as likely as those older than 50 years of age to fall under the "poorly adherent to aggressive" category or "poorly adherent to conservative" category. Similarly, the uninsured and those with Stages IIB to IV disease are three times more likely to be poorly adherent to aggressive or conservative surveillance schedules. Table 4 summarizes unadjusted and adjusted ratios for poor adherence to aggressive and conservative surveillance schedules. DISCUSSION The number of patients requiring melanoma surveillance has grown as a result of its increasing incidence, partly due to earlier detection and improved prognosis. 20,21 The present study found surveillance adherence rates of up to 76 percent (including both "aggressive" and "conservative" schedules) at five years after diagnosis. Despite the present study including a "conservative" follow-up schedule, this five-year surveillance adherence rate is much higher than those previously reported by Kalimullah et al 15 (22%) and Kitler et al. 16 (55.3%). Apart from variations in follow- up schedule used, potential causes of such differences in reported adherence rates might, in part, be due to exclusion of melanomas thicker than 1.5mm. 16 Interestingly, we found our first- year rate for "poorly adherent to conservative schedule" to be 7.3 percent, a rate similar to the findings (7.8%) reported in a prospective, randomized, controlled trial comparing the effect of a reduced follow-up frequency with a conventional follow-up schedule as recommended by the Dutch melanoma guidelines. 18 Previous studies on melanoma surveillance adherence have reported conflicting findings, with one study showing positive correlation between Breslow thickness and surveillance adherence, 15 and others showing either no correlation 16 or even an inverse association. 22 The present study found younger age (i.e., <50 years), higher stage disease (i.e., IIB–IV), and lack of insurance coverage to be the strongest predictors of poor adherence to aggressive or conservative surveillance schedule. We posit that the intensity of visit frequency for higher stages of disease and the financial burdens of surveillance visits prevent these subgroups of melanoma patients from adhering to surveillance guidelines. Similar to our findings, tumor thickness (i.e., >1mm) has previously been associated with longer periods of follow- up, as has patients' residence proximity to the surveilling clinic location and the absence of co-morbidities. 22 Under the assumption that patients older than 50 years of age are more likely to have comorbid conditions, our findings support other authors' suppositions that patients with comorbidities might be more attuned to adhering to their melanoma surveillance visits as a consequence of their experience in handling multiple doctor visits for their other ailments. 22 Follow-up visits for melanoma may be performed by general practitioners or by specialists. 4,7,17 However, given dermatologists' skills and experience in performing full skin examinations, and because "many cancer specialists never ask melanoma patients to disrobe for a proper physical examination," 23 dermatologists should continue to play a central role in melanoma surveillance. However, in an attempt to eliminate potential confounding variables during analysis, the authors only analyzed dermatology follow-up visits and excluded patients also following up with oncology or other specialties. There TABLE 2. Patient characteristics CHARACTERISTICS N=186 (100.0%) AGE AT DIAGNOSIS <40 years 33 (17.5%) 40–49 years 40 (21.5%) 50–59 years 50 (26.9%) 60–69 years 37 (19.9%) ≥70 years 26 (14.0%) SEX Female 85 (45.7%) Male 101 (54.3%) RACE White 173 (93.0%) Hispanic 5 (2.7%) Black 2 (1.1%) Asian 1 (0.5%) Other 5 (2.7%) MARITAL STATUS Single 30 (16.2%) Married 141 (76.2%) Divorced/separated 6 (3.2%) Widowed 8 (4.3%) MEDIAN HOUSEHOLD INCOME (ZIP CODE-BASED) <$60,000 36 (19.4%) $60,000–$75,000 56 (30.1%) $75,000–$90,000 46 (24.7%) ≥$90,000 48 (25.8%) DISTANCE TO CLINIC 5 miles 33 (17.9%) 6–10 miles 40 (21.7%) 11–20 miles 53 (28.8%) ≥20 miles 58 (31.5%) INSURANCE Medicare/Medicaid 67 (36.0%) Private 109 (58.6%) Uninsured 10 (5.4%) OTHER History of non-melanoma skin cancer 39 (21.0%) History of other cancers 22 (11.8%) Family history of melanoma 56 (31.1%) Tanning bed use 22 (13.8%) History of blistering sunburns 30 (20.4%) Immunosuppression following transplant 5 (3.2%) STAGE 0 45 (24.2%) IA 50 (26.9%) IB 35 (18.8%) I (A or B) 28 (15.0%) IIA 11 (5.9%) IIB 6 (3.2%) IIC 4 (2.2%) III 6 (3.2%) IV 1 (0.5%) n: number Missing values: n=1 marital status; n=2 distance to clinic; n=6 family history of melanoma; n=27 tanning behavior; n=39 sunburns; n=28 immunosuppression FIGURE 1. Adherence rates over a five-year surveillance period

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