Follow-Up of Melanoma Patients: The Need for Evidence-Based Protocols

Abstract

Over the past decade it has become clear that sensible, safe, evidence-based guidelines are required for the followup of cancer patients. Patient expectations for high-quality care have increased, although ever-increasing restrictions are being imposed on expensive health care resources. Therefore the need for constructive, cost-effective, highquality guidelines for patients with a range of cancer types has now become urgent. For patients who have had a melanoma frequent clinical consultation and regular imaging studies are still common practice in many centres, despite a lack of evidence regarding their influence on overall survival, disease-free survival or quality of life. Why is this so? In the first place we cling to historical precedent. It is well known that this form of cancer is unpredictable, and the assumption has therefore been made that it should be monitored frequently and carefully. Secondly, it seems appropriate to detect recurrence at an early stage, since effective treatment of local, in-transit and regional node metastases offers the possibility of cure, and long-term survival can also follow complete resection of systemic metastases. Third, patient satisfaction and patient reassurance are provided by frequent clinical consultation. In this and a recent issue of Annals of Surgical Oncology two interesting studies are reported. The study of Meyer et al. is a retrospective report of 118 American Joint Committee on Cancer (AJCC) stage II and III melanoma patients who underwent regular structural imaging with a minimum follow-up of 2 years. Recurrence occurred in 35% (n = 43), of which 43% (n = 15) were distant metastases. However, only 7% (n = 3) of these patients were asymptomatic and had their recurrence detected by routine imaging. Another 26% (n = 11) were detected by routine clinical follow-up, including medical history and physical examination. This study is consistent with previous reports that found two-thirds of melanoma recurrences were patient detected. The study of Morton et al. evaluated 108 patients with AJCC stage IIIA and IIIB melanoma who were prospectively enrolled in a monitoring schedule of 6-monthly chest X-rays (CXR) in addition to clinical follow-up. They found metastases in 21% (n = 23) of the patients, which were detected in 48% (n = 11) by surveillance CXR. The other pulmonary metastases were not detected by CXR surveillance. The authors found sensitivity and specificity for surveillance CXR was 48% [95% confidence interval (CI) 0.27–0.68] and 78% (95%CI 0.77–0.79), respectively. In only 13% (n = 3) was metastasectomy considered appropriate. Moreover, 19 patients had a false-positive result for melanoma metastasis, 10 of whom underwent a pulmonary biopsy. This study confirms earlier results of retrospective studies: routine CXR does not seem to contribute to an improvement in survival of melanoma patients, nor is it cost effective. The results of these two valuable studies underscore the limited value of routine imaging in the follow-up of melanoma patients. However, both studies have their shortcomings. First the retrospective nature by the study of Meyer et al. and the lack of a control group in the study by Morton et al. reduce the level of evidence according to standard methodology. Second, the low number of patients in both studies makes them underpowered due to the low rate of events. Nevertheless, this type of clinical report is of great importance since large-scale prospective studies and appropriately designed randomised studies are extremely difficult to perform in this particular field; they might even be a waste of time and money based on current knowledge. The Author(s) 2009. This article is published with open access at Springerlink.com