Unchanging: Less Than Half of Patients with Melanoma Receive Recommended Biopsy
April 14, 2009 — Less than 50% of patients with melanoma with stage IB or II disease receive a sentinel lymph node biopsy, even though the procedure has been recommended in these patients by clinical practice guidelines since 1998.
This previously established finding has been confirmed by a new study, which also provides insight into the underuse of the procedure.
The use of the biopsy was associated with a variety of clinical factors, but was also associated with health-system factors, according to the authors of the study, which was published online March 9 in the Journal of Clinical Oncology.
"We found that the use of sentinel node biopsy is strongly associated with nonclinical factors, such as insurance coverage, type of hospital, and geographic region," senior author Julie Lange, MD, ScM, told Medscape Oncology. Dr Lange is an Associate Professor of Surgery, Oncology, and Dermatology at The Johns Hopkins Medicine in Baltimore, Maryland.
She explained that patients who are either covered by Medicaid and Medicare (and not private insurance) or who live in the Northeast, the South, or the West were less likely to undergo the procedure. Also, stage IB and II patients were significantly more likely to undergo the procedure if they were treated at National Comprehensive Cancer Network (NCCN)- or National Cancer Institute (NCI)-designated hospitals.
"There obviously needs to be education of providers at multiple levels—the primary care physician, the dermatologist, and even the surgeon—that sentinel lymph node biopsy is not only acceptable but is beneficial in staging and clinical decision-making for patients with stage IB or II melanomas," said lead author Karl Bilimoria, MD, in a statement. At the time of the study, Dr Bilimoria was an American College of Surgeons Research Fellow at the Feinberg School of Medicine of Northwestern University in Chicago, Illinois.
Sentinel lymph node biopsy is associated with improved regional disease control and improved disease-free survival, noted the authors.
However, Dr Lange noted that the procedure has not been proven to improve overall survival.
The researchers also found that the use of sentinel lymph node biopsy was less likely to be used in stage IB or II patients who were older than 75 years, had TIb tumors, and had no tumor ulcerations or head/neck/truncal ulcerations.
To uncover factors associated with sentinel lymph node biopsy use, the researchers used the National Cancer Data Base to identify 8525 patients treated for stage IB/II melanoma in 2004 and 2005. They also identified 8073 patients with stage IA disease to see what proportion were biopsied outside of the recommended NCCN guidelines.
For clinical stage IB or II melanoma, recommended sentinel lymph node biopsy use was reported in only 48.7% of patients. For clinical stage IA melanoma, 13.3% of patients had a biopsy.
The reasons behind the underuse of the biopsy in stage IB and II melanoma patients—which include Medicaid/Medicare status, regional preferences, and type of hospital—are not totally surprising, suggested the authors.
"Variance in cancer management related to socioeconomic and geographic factors has been shown in breast, colon, and prostate cancer, as well as other common malignancies," they wrote. However, before the current study, the factors associated with use and nonuse of the biopsy in melanoma were "poorly understood."
Sentinel lymph node biopsy is "widely accepted" in most high-volume melanoma centers, wrote the authors. Indeed, in the new study, 60% of patients with stage IB or II melanoma underwent sentinel lymph node biopsy if they were treated at NCCN- or NCI-designated centers, compared with 25% at Veterans Affairs centers and 43% at community hospitals.
Despite their findings about the factors associated with the less likely use of sentinel lymph node biopsy in appropriate patients, the authors searched for additional answers about the poor uptake of clinical guidelines on the matter.
"Reasons for the persistent underuse of [sentinel lymph node biopsy] in certain subsets is unclear," they wrote. "It is possible that the variances found in this study reflect a different level of acceptance of the stated guidelines among the different specialties," they added, noting that professionals involved in the care of these patients include dermatologists, general surgeons, surgical oncologists, plastic surgeons, otolaryngologists, medical oncologists, and radiation oncologists.
The purpose of the procedure might not be well understood, suggested the authors. "Some still question whether [sentinel lymph node biopsy] should be used routinely in the absence of clear documentation of an improvement in overall survival, even though the primary purpose of the procedure is to provide prognostic and staging information," they wrote.
Dr Lange does not believe that underuse of the biopsy can be explained by the harm/benefit ratio of the procedure.
"Sentinel node biopsy is a low-risk procedure, but not a no-risk procedure. It adds some time to the surgical procedure [compared with wide excision alone] and there are minor risks of infection and lymphocoele," she said. Furthermore, the risk for limb edema from a sentinel node biopsy is low, she said, adding that it was not, however, 0. "There are some cases in which, based on a patient's own medical history and concerns, a decision not to do a sentinel node biopsy is perfectly rational," she observed.
Source: Medscape Medical News
