Melanoma Excision Mostly Timely in Medicare Recipients

Pam Harrison

April 08, 2015

About one in five Medicare beneficiaries experience a delay longer than 1.5 months between biopsy and the surgical excision of a melanoma, and approximately 8% wait longer than 3 months, a retrospective cohort study shows.

However, patients treated by a dermatologist are least likely to experience delay.

The study was published online April 8 in JAMA Dermatology.

"It's been shown for other types of solid malignancies that there is real potential for psychological stress and harm associated with a nondefinitely treated cancer, so I think we need to make sure that we deliver surgery to patients in a timely manner," said Jason Lott, MD, a dermatologist in New Haven, Connecticut, who was a fellow in the Robert Wood Johnson Foundation Clinical Schools Program at Yale University School of Medicine in New Haven when the study was conducted.

"We found that four out of five patients are getting surgery in a timely matter, so that's really positive and really encouraging," he told Medscape Medical News.

Investigators used the Surveillance, Epidemiology, and End Results (SEER)–Medicare database to conduct their retrospective study of Medicare beneficiaries diagnosed with melanoma from January 2000 to December 2009.

In the final sample of 32,501 cases of melanoma, 40.5% were located on the head and neck and 48.2% were staged as in situ disease.

Melanoma was classified as stage I in 25.5% of the cohort, as stage I/II in 14.4%, as stage II in 4.0%, as stage III in 5.4%, as stage IV in 0.7%, and as unknown in 1.8%.

Dermatologists conducted the biopsy in 88.4% of the cases and the excision in 41.9%.

The other excisions were conducted by general and plastic surgeons in 30.5% of the cases, Mohs surgeons in 9.1%, and primary care physicians in 1.2%. The remaining 17.3% of excisions were conducted by physicians of other or unknown specialties.

After clinical and demographic factors were accounted for, the adjusted risk for surgical delay longer than 1.5 months was 28% higher in patients 85 years and older than in patients younger than 85 (P = .02).

Having a previous melanoma was associated with a 20% greater risk for surgical delay for longer than 1.5 months (P = .001).

The presence of one or two comorbidities was associated with a 10% greater risk for surgical delay (P = .002), and the presence of three or more comorbidities was associated with an 18% greater risk (P < .001).

The risk for surgical delay was a significant 49% higher when a primary care physician performed the surgery than when a dermatologist performed the surgery (P = .02).

Similarly, the risk for surgical delay was 49% higher when a dermatologist performed the biopsy and a general or plastic surgeon performed the excision than when a dermatologist performed both procedures (P < .001).

Conversely, the adjusted risk for surgical delay longer than 1.5 months was 38% lower when a dermatologist performed the biopsy than when a nondermatologist performed the biopsy (P < .001).

"To our knowledge, there are no evidence-based guidelines regarding when a surgery should occur for melanoma, but 4 to 6 weeks is what we were hearing as a timely interlude from informal recommendations in the literature, as well as from specialists and colleagues," Dr Lott explained. "That's why we chose 1.5 months a priori as a cut-off."

"While I think we're doing a good job, there is an opportunity to do even better as both dermatologists and nondermatologist physicians get involved in the care of these patients," he noted.

Potential Practice Gap

This study identifies a potential practice gap in the effective coordination of care with other medical specialties, including plastic surgeons and primary care physicians, write Elaine Lin, BS, a medical student at Loma Linda University in California, and Jerry Brewer, MD, from the Mayo Clinic in Rochester, Minnesota, in an accompanying commentary.

"Closure of the gap could be achieved through increased interdisciplinary communication and more substantial effects regarding broad-reaching education about melanoma," they suggest.

Lin and Dr Brewer suggest that medical training should emphasize communication skills and multidisciplinary teamwork as elements of solid surgical follow-up.

However, "barriers to change may include the lack of evidence that this practice gap poses a risk to survival, disparities in access to care, and a shortage of manpower to accommodate timely surgical follow-up," they state.

They point out that patient indifference and lack of awareness of the severity of melanoma might also contribute to the practice gap.

This study was supported in part by the Robert Wood Johnson Foundation and the P30 Cancer Center Support Grant at the Yale Comprehensive Cancer Center. Dr Lott, Ms Lin, and Dr Brewer have disclosed no relevant financial relationships.

JAMA Dermatol. Published online April 8, 2015. Abstract, Commentary

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