Racial, Geographic Factors Influence Melanoma Treatment

Kate Johnson

March 27, 2012

March 27, 2012 (San Diego, California) — Patients from racial and ethnic minorities are half as likely to receive recommended excision of melanoma in situ than white patients, according to a study reported here at American Academy of Dermatology (AAD) 70th Annual Meeting.

The large retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) national cancer database also found that 25% of all patients with melanoma in situ receive nonsurgical treatment, classified as any treatment other than wide local excision or Mohs surgery, including photodynamic therapy, cryosurgery, imiquimod, primary radiation, and electrofulguration.

"There is a need for standardization of care to help our patients get optimal outcomes," said presenter Abigail Donnelly, MD, from the Mayo Clinic in Scottsdale, Arizona. The researchers also noted wide geographic discrepancies in the United States for the likelihood of surgical treatment.

Last year, an AAD consensus statement recommended excision, with margins of 0.5 and 1.0 cm as the standard of care for all stages of primary cutaneous melanoma.

"There are a lot of reasons that surgical excision is preferred," she said. "With lentigo maligna and melanoma in situ, there's always the risk of missing and therefore undertreating the disease. Surgical excision has allowed us to have histologic margin control and has been correlated with reduced risk of local recurrence."

The study analyzed all histologically confirmed cases of melanoma in situ reported to the SEER database from 2004 to 2008.

The goal of the study was to determine if there was a variation in treatment and, if so, what tumor, socioeconomic, and geographic factors influenced that variation.

The SEER database represents about 26% of the population in the United States, and samples groups that are often overlooked, such as those living below the poverty level and those with less than a high-school education, she noted.

From 2004 to 2008, there were 49,331 cases of melanoma in situ in the SEER database. During this time period, the incidence increased about 20%.

Median patient age was 64 years, 57% of the cohort was male, and 92% was white. In all, 43% of the cancers were diagnosed and treated in hospital-based practices.

Atlanta, Georgia, was used as the reference point "strictly for alphabetical reasons." The odds ratio (OR) for surgical treatment varied widely across states, dipping to the lowest in New Mexico (OR, 0.2) and peaking in Utah (OR, 1.9).

More white than black patients underwent surgical excision (75% vs 64%).

In addition to race/ethnicity, predictors of surgical treatment were high-school education, hospital-based diagnosis, tumors not of the head or neck, and being younger than 50 years.

There were several significant limitations to the study, noted Dr. Donnelly. "The very nature of database reporting introduces the possibility of sampling bias. The SEER database does not code for specialties, so we were unable to report what percentage of these cases were treated by dermatologists, compared with other healthcare providers. We also have no information on recurrence rates" or health insurance status.

Asked to comment on the findings, Maria Hordinsky, MD, professor and chair of the Department of Dermatology at the University of Minnesota Medical School in Minneapolis, and moderator of the session in which the study was presented, said she finds the ethnic disparity findings "completely shocking."

"I find that really hard to believe," she told Medscape Medical News.

In contrast, patient age and location of lesion have a well-known influence on treatment decisions, she acknowledged.

"For elderly people with lesions on the face, many physicians may not want to treat those with surgery," Dr. Hordinsky explained.

Even younger patients with head and neck melanomas present surgical challenges.

"Our colleagues in ENT get furious with us if we don't do the right kind of biopsy. They want to make sure the lymphatic flow is not compromised. They just want saucerizations. It is complicated."

Dr. Donnelly has disclosed no relevant financial relationships. Dr. Hordinsky reports receiving investigator grants from Astellas Pharma US, Allergan, Johnson & Johnson Consumer Products, Lexington International, Medicis Pharmaceutical, and Novartis Pharmaceuticals.

American Academy of Dermatology (AAD) 70th Annual Meeting: Late-breaking abstract. Presented March 16, 2012.

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