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Sentinel Lymph Node Biopsy in Early Melanoma: Comment on “What the Surgeon Should Have Said to My Patient With Thin Malignant Melanoma”

Sentinel Lymph Node Biopsy in Early Melanoma: Comment on “What the Surgeon Should Have Said to My... Sentinel node biopsy may be a useful prognostic tool for a subset of melanomas of intermediate stage.1 The Perspective by Benjamin and Froom,2 however, highlights the problems with its use in a different situation: a patient with an early stage IA melanoma, 0.5 mm in depth, without ulceration or a high mitotic rate. This patient has an excellent prognosis, with a 98% expected survival at 15 years and a greater than 97% chance of having clear lymph nodes.3,4 Neither the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Melanoma nor the American Joint Committee on Cancer guidelines recommend sentinel node biopsy for stage IA melanomas without concerning histologic features. Indeed, melanomas this thin have been typically excluded from studies examining the prognostic accuracy of sentinel node biopsy. Most clinicians would agree that recommending a sentinel node biopsy for the profiled patient is unnecessary. The patient and his physician gain a minimal (at best) amount of additional prognostic benefit, particularly when weighed against the potential surgical risks. My first reaction to this Perspective2 was, “Is this just an isolated example of overtreatment? How often does this really happen?” The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute collects detailed clinical information on melanoma, including sentinel node biopsies. In a SEER analysis by Cormier et al5 including over 18 499 patients with melanoma from 1998 to 2001, the authors report that almost 10% of stage IA melanomas are overtreated, with either sentinel node biopsy (7.1%) or lymph node dissection (1.8%). However, because these early stage melanomas are by far the most common and the fastest growing group of melanomas,6 use in this subset actually corresponds to almost 20% of all sentinel node biopsies carried out for melanoma. With more than 30 000 new stage IA melanomas diagnosed annually, there are potentially thousands of unnecessary sentinel node biopsies performed each year in the United States. Next, I wondered what are the real downsides of performing sentinel node biopsy in a patient who does not need it? The adverse effects of sentinel node biopsy are well characterized and include wound infection or dehiscence, seroma or hematoma formation, nerve injury, as well as local complications of pain, lymphedema, and decreased range of motion. These adverse effects occur in about 10% of patients.7 Looking beyond the risks to the individual patient, it is important to consider the population-level adverse effects. Sentinel node biopsy is not cost-effective for thin melanomas.8 Charges for sentinel node biopsy were estimated at $10 000 to $15 000 in the late 1990s, almost 10 times more expensive than the recommended treatment of wide local excision alone.8 So why are we not following guidelines and still performing sentinel node biopsy for tumors that do not need it? This question extends beyond cutaneous oncology, to all medical specialties. A review of 120 surveys identified almost 300 barriers to physician guideline adherence.9 Physicians were not familiar or disagreed with the guidelines or were reluctant to change their practice habits. Patient preference as well as lack of time, reimbursement issues, and availability of resources were other examples of barriers to guideline adherence. In the case of sentinel node biopsy for early melanoma, I suspect the desire for more prognostic information by both patients and their physicians is the main motivator for these procedures. Perhaps providing individualized prognostic information may prevent overuse of sentinel node biopsy. Using data from the Massachusetts General Hospital, validated in SEER, this online calculator displays individual life expectancy and cancer-free survival in an intuitive way (http://lifemath.net/cancer/melanoma/outcome/index.php). This is an example of a free and easy prognostic tool that carries no adverse effects. Further research in creating tools for risk communication and shared decision making is a cost-effective investment. Back to top Article Information Correspondence: Dr Linos, Department of Dermatology, University of California, San Francisco, 2340 Sutter St, San Francisco, CA 84143 (linose@derm.ucsf.edu). Additional Contributions: Amy Markowitz, JD, and Mary-Margaret Chren, MD, from University of California, San Francisco, and James Michaelson, PhD, and Elizabeth Linos, BA, from Harvard University helped in editing prior drafts of the manuscript. Financial Disclosure: None reported. References 1. Morton DL, Thompson JF, Cochran AJ, et al; MSLT Group. Sentinel-node biopsy or nodal observation in melanoma. N Engl J Med. 2006;355(13):1307-131717005948PubMedGoogle ScholarCrossref 2. Benjamin MF, Froom P. What the surgeon should have said to my patient with thin malignant melanoma. Arch Intern Med. 2012;172(12):906Google ScholarCrossref 3. Chen LL, Nolan ME, Silverstein MJ, et al. The impact of primary tumor size, lymph node status, and other prognostic factors on the risk of cancer death. Cancer. 2009;115(21):5071-508319658184PubMedGoogle ScholarCrossref 4. Andtbacka RH, Gershenwald JE. Role of sentinel lymph node biopsy in patients with thin melanoma. J Natl Compr Canc Netw. 2009;7(3):308-31719401063PubMedGoogle Scholar 5. Cormier JN, Xing Y, Ding M, et al. Population-based assessment of surgical treatment trends for patients with melanoma in the era of sentinel lymph node biopsy. J Clin Oncol. 2005;23(25):6054-606216135473PubMedGoogle ScholarCrossref 6. Linos E, Swetter SM, Cockburn MG, Colditz GA, Clarke CA. Increasing burden of melanoma in the United States. J Invest Dermatol. 2009;129(7):1666-167419131946PubMedGoogle ScholarCrossref 7. Morton DL, Cochran AJ, Thompson JF, et al; Multicenter Selective Lymphadenectomy Trial Group. Sentinel node biopsy for early-stage melanoma: accuracy and morbidity in MSLT-I, an international multicenter trial. Ann Surg. 2005;242(3):302-31316135917PubMedGoogle Scholar 8. Agnese DM, Abdessalam SF, Burak WE Jr, Magro CM, Pozderac RV, Walker MJ. Cost-effectiveness of sentinel lymph node biopsy in thin melanomas. Surgery. 2003;134(4):542-54814605613PubMedGoogle ScholarCrossref 9. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? a framework for improvement. JAMA. 1999;282(15):1458-146510535437PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Sentinel Lymph Node Biopsy in Early Melanoma: Comment on “What the Surgeon Should Have Said to My Patient With Thin Malignant Melanoma”

Archives of Internal Medicine , Volume 172 (12) – Jun 25, 2012

Sentinel Lymph Node Biopsy in Early Melanoma: Comment on “What the Surgeon Should Have Said to My Patient With Thin Malignant Melanoma”

Abstract

Sentinel node biopsy may be a useful prognostic tool for a subset of melanomas of intermediate stage.1 The Perspective by Benjamin and Froom,2 however, highlights the problems with its use in a different situation: a patient with an early stage IA melanoma, 0.5 mm in depth, without ulceration or a high mitotic rate. This patient has an excellent prognosis, with a 98% expected survival at 15 years and a greater than 97% chance of having clear lymph nodes.3,4 Neither the National Comprehensive...
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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.1905
Publisher site
See Article on Publisher Site

Abstract

Sentinel node biopsy may be a useful prognostic tool for a subset of melanomas of intermediate stage.1 The Perspective by Benjamin and Froom,2 however, highlights the problems with its use in a different situation: a patient with an early stage IA melanoma, 0.5 mm in depth, without ulceration or a high mitotic rate. This patient has an excellent prognosis, with a 98% expected survival at 15 years and a greater than 97% chance of having clear lymph nodes.3,4 Neither the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Melanoma nor the American Joint Committee on Cancer guidelines recommend sentinel node biopsy for stage IA melanomas without concerning histologic features. Indeed, melanomas this thin have been typically excluded from studies examining the prognostic accuracy of sentinel node biopsy. Most clinicians would agree that recommending a sentinel node biopsy for the profiled patient is unnecessary. The patient and his physician gain a minimal (at best) amount of additional prognostic benefit, particularly when weighed against the potential surgical risks. My first reaction to this Perspective2 was, “Is this just an isolated example of overtreatment? How often does this really happen?” The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute collects detailed clinical information on melanoma, including sentinel node biopsies. In a SEER analysis by Cormier et al5 including over 18 499 patients with melanoma from 1998 to 2001, the authors report that almost 10% of stage IA melanomas are overtreated, with either sentinel node biopsy (7.1%) or lymph node dissection (1.8%). However, because these early stage melanomas are by far the most common and the fastest growing group of melanomas,6 use in this subset actually corresponds to almost 20% of all sentinel node biopsies carried out for melanoma. With more than 30 000 new stage IA melanomas diagnosed annually, there are potentially thousands of unnecessary sentinel node biopsies performed each year in the United States. Next, I wondered what are the real downsides of performing sentinel node biopsy in a patient who does not need it? The adverse effects of sentinel node biopsy are well characterized and include wound infection or dehiscence, seroma or hematoma formation, nerve injury, as well as local complications of pain, lymphedema, and decreased range of motion. These adverse effects occur in about 10% of patients.7 Looking beyond the risks to the individual patient, it is important to consider the population-level adverse effects. Sentinel node biopsy is not cost-effective for thin melanomas.8 Charges for sentinel node biopsy were estimated at $10 000 to $15 000 in the late 1990s, almost 10 times more expensive than the recommended treatment of wide local excision alone.8 So why are we not following guidelines and still performing sentinel node biopsy for tumors that do not need it? This question extends beyond cutaneous oncology, to all medical specialties. A review of 120 surveys identified almost 300 barriers to physician guideline adherence.9 Physicians were not familiar or disagreed with the guidelines or were reluctant to change their practice habits. Patient preference as well as lack of time, reimbursement issues, and availability of resources were other examples of barriers to guideline adherence. In the case of sentinel node biopsy for early melanoma, I suspect the desire for more prognostic information by both patients and their physicians is the main motivator for these procedures. Perhaps providing individualized prognostic information may prevent overuse of sentinel node biopsy. Using data from the Massachusetts General Hospital, validated in SEER, this online calculator displays individual life expectancy and cancer-free survival in an intuitive way (http://lifemath.net/cancer/melanoma/outcome/index.php). This is an example of a free and easy prognostic tool that carries no adverse effects. Further research in creating tools for risk communication and shared decision making is a cost-effective investment. Back to top Article Information Correspondence: Dr Linos, Department of Dermatology, University of California, San Francisco, 2340 Sutter St, San Francisco, CA 84143 (linose@derm.ucsf.edu). Additional Contributions: Amy Markowitz, JD, and Mary-Margaret Chren, MD, from University of California, San Francisco, and James Michaelson, PhD, and Elizabeth Linos, BA, from Harvard University helped in editing prior drafts of the manuscript. Financial Disclosure: None reported. References 1. Morton DL, Thompson JF, Cochran AJ, et al; MSLT Group. Sentinel-node biopsy or nodal observation in melanoma. N Engl J Med. 2006;355(13):1307-131717005948PubMedGoogle ScholarCrossref 2. Benjamin MF, Froom P. What the surgeon should have said to my patient with thin malignant melanoma. Arch Intern Med. 2012;172(12):906Google ScholarCrossref 3. Chen LL, Nolan ME, Silverstein MJ, et al. The impact of primary tumor size, lymph node status, and other prognostic factors on the risk of cancer death. Cancer. 2009;115(21):5071-508319658184PubMedGoogle ScholarCrossref 4. Andtbacka RH, Gershenwald JE. Role of sentinel lymph node biopsy in patients with thin melanoma. J Natl Compr Canc Netw. 2009;7(3):308-31719401063PubMedGoogle Scholar 5. Cormier JN, Xing Y, Ding M, et al. Population-based assessment of surgical treatment trends for patients with melanoma in the era of sentinel lymph node biopsy. J Clin Oncol. 2005;23(25):6054-606216135473PubMedGoogle ScholarCrossref 6. Linos E, Swetter SM, Cockburn MG, Colditz GA, Clarke CA. Increasing burden of melanoma in the United States. J Invest Dermatol. 2009;129(7):1666-167419131946PubMedGoogle ScholarCrossref 7. Morton DL, Cochran AJ, Thompson JF, et al; Multicenter Selective Lymphadenectomy Trial Group. Sentinel node biopsy for early-stage melanoma: accuracy and morbidity in MSLT-I, an international multicenter trial. Ann Surg. 2005;242(3):302-31316135917PubMedGoogle Scholar 8. Agnese DM, Abdessalam SF, Burak WE Jr, Magro CM, Pozderac RV, Walker MJ. Cost-effectiveness of sentinel lymph node biopsy in thin melanomas. Surgery. 2003;134(4):542-54814605613PubMedGoogle ScholarCrossref 9. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? a framework for improvement. JAMA. 1999;282(15):1458-146510535437PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jun 25, 2012

Keywords: melanoma,sentinel lymph node biopsy,surgeons

References