This is an interesting article looking at how melanoma was managed before and after the introduction of melanoma management guidelines. It makes depressing reading. The guidelines had little effect but perhaps this was due to not enough time between issuing them and this survey. They look at biopsy type, excision margins etc. Worth reading in full HERE. It would be interesting to carry this survey out on members of the Society. Perhaps the audit can look at this.IMCC
The management of primary cutaneous melanoma in Victoria in 1996 and 2000
John W Kelly, Michael A Henderson, Vicky J Thursfield, John Slavin, Jill Ainslie and Graham G Giles
Abstract
Objective:
To describe tumour characteristics and clinical management of melanomas newly diagnosed in 1996 and in 2000 — before and after publication of the clinical practice Guidelines for the management of cutaneous melanoma by the Australian Cancer Network (1997), and their endorsement by the National Health and Medical Research Council (NHMRC) and republication (1999).
Design and setting:
Survey of clinicians involved in the management of patients with melanoma sampled from the Victorian Cancer Registry. The Registry is notified of all cases of cancer diagnosed by pathology laboratories and hospitals in both the public and private health sectors in the state of Victoria.
Patients:
People with a cutaneous melanoma newly diagnosed in 1996 and 2000. All invasive melanomas > 1.50 mm in thickness were included, and for each year random samples were selected of 100 each of invasive melanomas 0.76–1.50 mm in thickness, invasive melanomas ≤ 0.75 mm, and in-situ melanomas, plus 50 melanomas of unknown thickness.
Main outcome measures:
Biopsy method, adequacy of pathology reporting, adequacy of definitive excision (compared with margins recommended by the Guidelines), and follow-up procedures.
Results:
The use of partial biopsies increased between 1996 and 2000. Recommended margins of definitive excision were used in only 33.6% of cases. Margins were smaller than recommended for 36% of in-situ melanomas, risking recurrence of primary melanoma. Documented follow-up examinations for subsequent primary skin malignancy were uncommon (6%).
Conclusions:
Many aspects of the management of primary cutaneous melanoma appear not to meet the recommendations of the published Guidelines. Further studies to explore the reasons for failure to meet the Guideline recommendations are needed.
3 comments:
Particularly depressing are:
Narrow margins on Level 1. For lesions with a 100% cure rate for only 5mm margins, this is more than perplexing.
the 6% incidence of total body examinations at followup. 6%!!! Surely this can't be correct?
If I am reading this correctly, all specialties are equally culpable.
Are there figures for number of melanoma deaths for primaries subsequent to the first? Virtually all of these should be preventable by ongoing full checks of all melanoma patients. I can't help but speculate that this number is high enough to justify a major public health program similar in proportion to the Pap smear program.
Whilst these figures are disturbing, there are a number of inconsistencies, the figures seem to be skewed to represent thicker melanoma with the figures quoted not being representative of actual practice. Surely the most important factor is how thin melanomas are treated. As far as I am aware too, there are no reliable figures on margins in Melanoma in situ.
Not withstanding all this, the figures are so far removed from our experience of practice to be very disturbing. I had not previously thought of this as a problem, practically, ethically and medico-legally the guidelines are very clear, deviation is asking for trouble. Also think about it, when was the last time you excised a melanoma with 2mm margins, then did a definitive re-excision, when you found residual melanoma in the subsequent widely excised specimen.
I would estimated <5% of my melanomas are > 1.0mm in thickness.
I try to spell out the NHMRC f/u guidleines to all MM patients, but I have secondarily lost a few melanoma follow ups.
Nonetheless I have had Dermatologists state that a clearance margin for MMIS is unnecessary as tumour has no metastatic potential .Patients have come to me recalling that the plastic surgeon dismissed them from follow up after a single check at 3 mths
Mistaken intention or mis communication ?
I too have been lax and lost a few to follow up those whom I thought I hospital was following up when they thought I was .
So I would see 80-90 successfully in f/u . Lose 94 % unbelievable !
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