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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45 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 studies investigating factors associated with poor patient adherence to melanoma surveillance. 15–17 However, recent evidence suggests that reduced frequency of follow-up visits in early-stage melanoma patients does not negatively affect recurrence, patients' psychological well-being, or detection of subsequent primary melanoma. 18,19 With the ultimate goal of identifying patients who might benefit from additional counseling on the importance of melanoma follow-up, we investigate factors associated with poor melanoma surveillance adherence using two follow-up schedules derived from the NCCN guidelines. METHODS A retrospective chart review was performed on patient records with diagnosis codes of melanoma of the skin (ICD-9 172.9) and personal history of melanoma (ICD-9 V10.82) between January 2005 and November 2015. Patients without an available pathology report on file to confirm a melanoma diagnosis were excluded. All study procedures were performed after obtaining approval by the institutional review board of Loyola University Chicago's Health Sciences Division. For patients diagnosed with melanoma within the Loyola University Health System (LUHS), dermatology clinic visits were reviewed for a span of five years starting from the date of initial diagnosis of melanoma. For patients with a known personal history of melanoma diagnosed outside of the LUHS, dermatology clinic visits were reviewed for a span of five years from initial contact with the LUHS. Only dermatology encounters were included in recording follow-up visits. Patients who failed to follow up with dermatology, but were seen in surveillance by oncology or other specialties, were excluded for the purposes of this study. Basic demographic data , including age, sex, race, marital status, proximity of residence to clinic, median household income (as determined by ZIP code), and health insurance status were obtained. Data on selected risk factors for melanoma were also abstracted from patients' electronic medical records, when available, including history of non-melanoma skin cancer, tanning bed use, and history of blistering sunburns. Each patient's clinical stage for melanoma was recorded based on available pathology reports, including data from wide local excision, sentinel lymph node biopsy, and completion lymphadenectomy. Criteria for aggressive and conservative surveillance adherence. The "aggressive" surveillance schedule was defined as follows: Stage 0 (melanoma in situ): at least one visit each year for five years; Stages IA to IIA: at least two visits each year for five years; Stages IIB to IV: at least four visits for Year 1, at least three visits for Year 2, and at least two visits for Years 3 to 5. The "conservative" surveillance adherence schedule was defined as follows: Stages 0 to IIA: at least one visit each year for five years; Stages IIB to IV: at least two visits in each of the first two years and at least one visit in the next three years. Patient adherence trends were divided into three groups (Table 1) in decreasing order of adherence: "adherent to aggressive surveillance" if they adhered to the "aggressive" surveillance schedule; "poorly adherent to aggressive surveillance" if they adhered to the "conservative" schedule but did not adhere to the "aggressive" adherence schedule; or "poorly adherent to conservative schedule" if they were not adherent to either schedule. Surveillance adherence was not calculated before patients first visited the LUHS, or after they left for another practice. Statistical analysis. Patient characteristics and annual adherence were presented as counts and percentages. The associations between patient characteristics and adherence were assessed in separate univariable proportional odds mixed models predicting poorer levels of adherence. A multivariable proportional odds regression mixed model included variables with p<0.25 in univariable analysis. The mixed models included random intercepts to account for within-patient correlation over up to five years of follow-up. RESULTS Patient characteristics. Of 186 patients included, the average age was 55 (standard deviation [SD]=15) years old, 45.7 percent (n=85) were female, 94.1 percent (n=175) were white, and 75.8 percent (n=141) were married. The majority of patients lived farther than 10 miles from the clinic (111/184, 60.3%) and had private insurance (n=109, 58.6%). Nearly all patients had between Stages 0 to IIA disease (n=169, 90.9%). A minority of patients had a history of tanning bed use (13.8%), blistering sunburns (20.4%), or non-melanoma skin cancer (21.0%). ZIP code- based household income varied, with 19.4 percent of patients living in ZIP codes with a median income of less than $60,000, 30.1 percent with $60,000 to $74,000, 24.7 percent with $75,000 to $90,000, and 25.8 percent with over $90,000 (Table 2). Surveillance adherence rates. Between 58.4 and 74.5 percent of patients TABLE 1. Surveillance adherence groups YEAR ADHERENT TO AGGRESSIVE SURVEILLANCE POORLY ADHERENT TO AGGRESSIVE SURVEILLANCE POORLY ADHERENT TO CONSERVATIVE SURVEILLANCE MIS IA-IIA IIB-IV MIS-IIA IIB-IV MIS-IIA IIB-IV 1 ≥1 visit per year ≥2 visits per year ≥4 visits per year ≥1 visit per year ≥2 visits per year <1 visit per year <2 visits per year 2 ≥1 visit per year ≥2 visits per year ≥4 visits per year ≥1 visit per year ≥2 visits per year <1 visit per year <2 visits per year 3 ≥1 visit per year ≥2 visits per year ≥3 visits per year ≥1 visit per year ≥1 visit per year <1 visit per year <1 visit per year 4 ≥1 visit per year ≥2 visits per year ≥3 visits per year ≥1 visit per year ≥1 visit per year <1 visit per year <1 visit per year 5 ≥1 visit per year ≥2 visits per year ≥3 visits per year ≥1 visit per year ≥1 visit per year <1 visit per year <1 visit per year MIS: melanoma in situ (stage 0)

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