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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47 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 is, nonetheless, value in a multidisciplinary approach to melanoma surveillance, especially in cases of advanced disease. 4,7,14 A brief overview of the literature on surveillance adherence in other malignancies might provide additional insights into the challenges of and potential areas for further investigation in melanoma surveillance adherence. In hepatocellular carcinoma, optimally adherent patients were those with smaller tumor sizes, 24 while lower surveillance rates were reported in non-Caucasians and patients of lower socioeconomic status. 25 Although the future of the Affordable Care Act (ACA) remains uncertain at this time, similar to the ACA's effect on screening colonoscopies, policy incentives that mitigate financial barriers to melanoma surveillance experienced by those uninsured or under-insured may improve patient adherence to surveillance recommendations. 26 For patients with advanced disease who likely would benefit from a multidisciplinary management approach, a dedicated single- day melanoma surveillance visit might prove beneficial in improving surveillance adherence rates, as it has been reported with colorectal carcinoma. 27 Limitations. This study's single-institution retrospective design, in addition to its relatively small sample size, could limit the ability to generalize of our findings. Furthermore, patients' reasons for failing to show up for surveillance visits were not directly investigated. It is important to note that system-based patient reminders that might vary between institutions could also play a role in surveillance adherence rates, but have not been directly investigated in the current or previous studies. Prospectively designed, multicentered adherence studies, particularly those that examine patients receiving surveillance from multiple specialties, may address some of these limitations. CONCLUSION The present study highlights factors associated with increased likelihood of poor adherence to aggressive and conservative surveillance schedules in patients diagnosed with melanoma. Because of existing evidence that supports the value of patient-clinician information engagement in improving cancer surveillance adherence, 28 it would be reasonable to provide additional surveillance counseling targeted at younger melanoma patients, those with advanced disease, and those without health insurance. Although each patient is unique and a surveillance strategy tailored to an individual patient's recurrence risk has yet to be fully developed, 23 the present study builds onto the current knowledge tackling the complexity of patient adherence, specifically in the realm of cancer surveillance. ACKNOWLEDGMENTS The project described is supported in part by the Loyola Clinical Research Office (CRO) at Loyola University Chicago, Health Sciences Division, 2160 S. First Avenue, CTRE Bldg. 115, 2nd Floor, Room 253, Maywood, IL 60153. The TABLE 3. Surveillance adherence rates YEAR N SCHEDULED n (%) ADHERENT TO AGGRESSIVE SURVEILLANCE n (%) POORLY ADHERENT TO AGGRESSIVE SURVEILLANCE n (%) POORLY ADHERENT TO CONSERVATIVE SURVEILLANCE 1 165 120 (72.7%) 33 (20.0%) 12 (7.3%) 2 145 108 (74.5%) 15 (10.3%) 22 (15.2%) 3 125 88 (70.4%) 23 (18.4%) 14 (11.2%) 4 105 70 (66.7%) 22 (21.0%) 13 (12.4%) 5 89 52 (58.4%) 16 (18.0%) 21 (23.6%) n: number TABLE 4. Unadjusted and adjusted odds ratios predicting poorer surveillance adherence CHARACTERISTICS UNADJUSTED ODDS RATIO (95% CONFIDENCE INTERVAL) ADJUSTED ODDS RATIO (95% CONFIDENCE INTERVAL) AGE AT DIAGNOSIS <50 years 1.65 (0.98, 2.75) 2.11 (1.13, 3.93)* ≥50 years 1 (Reference) 1 (Reference) SEX Female 1 (Reference) 1 (Reference) Male 1.41 (0.85, 2.34) 1.35 (0.77, 2.37) RACE White 1 (Reference) 1 (Reference) Non-white 1.84 (0.72, 4.74) 1.78 (0.71, 4.44) INSURANCE Private 1 (Reference) 1 (Reference) Medicare/Medicaid 1.31 (0.77, 2.24) 1.62 (0.86, 3.08) Uninsured 2.60 (0.87, 7.78) 3.08 (1.09, 8.68)* TANNING BED USE No 1 (Reference) 1 (Reference) Yes 1.68 (0.81, 3.49) 1.69 (0.78, 3.64) STAGE 0–IIA 1 (Reference) 1 (Reference) IIB–IV 2.54 (1.46, 4.41)** 3.21 (1.36, 7.58)** *p<0.05; **p<0.01

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