A novel, less-intensive monitoring schedule for patients with localized primary cutaneous melanoma appears to reduce follow-up visits without affecting the rate of detection of new primary or recurrent melanomas, according to an analysis of data from an inception cohort of 3,081 patients.
Given that follow-up care for melanoma patients in the United States costs up to $500 million per year, the findings could have important implications for cost savings, according to Robin M. Turner, Ph.D., and colleagues.
Using data from the Melanoma Institute Australia on the inception cohort, which included consecutive patients with stage I or II melanoma first diagnosed between January 1985 and December 2009, the investigators modeled the delay in diagnosis of a new primary melanoma or recurrence with two different monitoring schedules.
Schedule one was based on 2008 Australian and New Zealand guidelines, which recommend follow-up every 6 months for 5 years, then annually for 5 years for patients with stage 1A and 1B disease, or every 3 months for 5 years, then annually for 5 years in patients with stages IIA, IIB, or IIC.
Schedule two, the novel monitoring arm, called for annual follow-up for 10 years for patients with stage I disease; every 6 months for 2 years, and then annually for 8 years, for patients with stage IIA disease; and every 4 months for 2 years, every 6 months in year 3, and then annually for 5 years, for patients with stages IIB and IIC disease.
Within 10 years, the total number of recurrences was 229 for every 1,000 patients, and the number of new primary melanomas was 61 for every 1,000 patients.
Compared with the 2008 Australia and New Zealand guidelines for monitoring, the novel schedule, which required almost 3,000 fewer visits per 1,000 patients (8,044 vs. 5,221 visits), resulted in a delay in the detection – by at least 2 months – of an additional 44.9 recurrences per 1,000 patients, and an additional 9.6 new primary melanomas, Robin M. Turner, Ph.D., of the School of Public Health at the University of Sydney, Australia, and colleagues reported online in the Journal of Clinical Oncology (2011 Nov. 7 [doi:10.1200/JCO.2010.34.2956]).
"If we assume self-detection rates based on published estimates [75% for recurrence and 50% for new primary], use of schedule two rather than schedule one results in only a small number of additional patients experiencing a delay in recurrence diagnosis (up to [a] maximum of 3 months; extra 11.3 patients per 1,000 with delay [greater than] 2 months) and even fewer experiencing a delay in new primary diagnosis (up to [a] maximum of 6 months; extra 4.9 per 1,000)," the investigators wrote.
Moreover, if there were no patients lost to follow-up and they attended all visits until diagnosis or 10 years, the total number of visits for schedule one would be 19,546, compared with 12,303 for schedule two.
"Not only would these fewer monitoring visits reduce the burden on patients in terms of time and expense in attendance and possible unnecessary anxiety, but they would also represent substantial savings for the health care system," the investigators wrote.
Individualized Follow-Up Requires New PartnershipIn an accompanying editorial, Dr. Vernon K. Sondak and Dr. Sancy A.
Leachman wrote that the findings of Dr. Turner and colleagues "have
begun to move us down the path toward data-driven, personalized
follow-up guidelines."
This path is an important one, because in
the current era of personalized medicine, too little attention has been
paid to personalizing follow-up for patients after curative treatment of
cancer, including localized cutaneous melanoma, they noted (J. Clin.
Oncol. 2011 Nov. 7 [doi:10.1200/JCO.2011.37.6681]).
Success,
however, will require new partnerships and collaborations. Specifically,
the ultimate solution should involve shared follow-up with physicians
in the community, as well as with the patient and the patient’s family,
through education designed to maximize their ability to identify
recurrent and new melanomas.
Shared follow-up with local
dermatologists of patients with melanoma would address the goal of
detecting recurrences and new primary melanomas while simultaneously
decreasing the frequency of visits to surgical or medical oncologists.
Focusing
the lens of personalized medicine onto follow-up strategies, and
pursuing new partnerships and collaborations, will provide "a golden
opportunity to deliver the right care to the right patients at the right
time and in the right place," they concluded.
Dr. Sondak is with the Moffitt Cancer Center and the University of South Florida, Tampa. Dr. Leachman is with the Huntsman Cancer Institute and the University of Utah, Salt Lake City. Dr. Sondak reported serving as a consultant or adviser to Merck/Schering Plough, and receiving honoraria from Merck. Dr. Leachman reported no relevant financial disclosures.
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