Implementation of Melanoma Guidelines in the Multidisciplinary Setting: A Qualitative Analysis

Abstract

INTRODUCTION: Treatment of advanced melanoma has evolved dramatically recently. Randomized trials now support omitting completion lymph node dissection (CLND) and offering adjuvant systemic therapy for many patients with sentinel lymph node–positive melanoma. Recent data from an international melanoma consortium suggest wide variation in CLND and adjuvant therapy utilization. We aimed to explore how providers consider multidisciplinary treatment options in this setting. METHODS: We conducted semi-structured interviews among surgical oncologists, medical oncologists, and otolaryngologists. Two researchers performed analysis through independent data abstraction of transcripts. Findings were discussed to reach consensus. RESULTS: All participants (n = 17) practiced at a cancer center in an academic setting. Melanoma comprised an estimated 30% to 80% of their practice (only 2% to 15% for otolaryngologists). Participants described melanoma care as inherently “multidisciplinary.” Many noted the importance of real-time conversations among providers, particularly those facilitated by shared clinic days or space, for everyday decision-making compared with formal tumor boards. Despite stating a belief that their practice mirrored other providers within and outside their institutions, participants revealed differing perspectives on CLND and adjuvant therapy (Table). Multidisciplinary care presented challenges for melanoma surveillance because surgical oncologists expressed desire to retain ownership of patients undergoing active surveillance but did not feel comfortable overseeing needs related to adjuvant therapy. Both surgical and medical oncologists noted potential redundancy in roles and burden to patients in the form of uncoordinated visits and scans. Table. - Differences in Perspectives on Completion Lymph Node Dissection (CLND) and Adjuvant Systemic Therapy Treatment option Representative example (surgical oncology) Representative example (medical oncology) Representative example (otolaryngology) Completion lymph node dissection At our institution almost never do patients get a [CLND]. Soon after the trials, there was some ambiguity about should some patients that may not have been as well represented in those trials be considered for completion, and there’s probably less issue there. Probably the main factor that pushes for dissection now would be ability to comply with routine surveillance. (Participant 7) I have seen somewhat of a push for surgery just because all of our adjuvant trials were done in patients who did have a nodal basin dissected. So it’s a little bit of a different population that we’re actually treating than was studied in [MSLT-II] because we may have patients who have residual disease. So to be more purely like the trial, there are sometimes people who push for a lymph node dissection. (Participant 1) Some of this really just relates to your philosophy of approaching cancer and surgical aggressiveness in general. I generally err on the side of being a more conservative surgeon, which applies not just to melanoma. So I am a bit more reticent to recommend a completion than some of my colleagues, but that’s not to say they’re wrong and I’m right. (Participant 14) Adjuvant systemic therapy So it’s really hard to give adjuvant therapy when there’s no survival benefit, and you see that the toxicity is so bad. From my standpoint, it’s very hard for me to think about let’s take a patient, let’s remove all of their disease, and then give them immunotherapy. Let’s boost the immune system. Oh—but I already took it all out. So the adjuvant therapy idea is hard for me. (Participant 2) We know with the Keynote 716 trial, pembrolizumab can be [used] in patients who have high risk stage II disease. Based on that trial, we are now recommending adjuvant immune therapy. So it’s kind of a continuum. Now we can justify [stage] IIIA patients that were excluded from the stage III trials. (Participant 15) A lot of these patients are going to get adjuvant therapy, no matter what, so both for immunotherapy and for like a dabrafenib or trametinib treatment. The question is not whether or not we do adjuvant therapy, the question is whether they get the [adjuvant] therapy with or without a completion lymphadenectomy. (Participant 10) CONCLUSION: Opportunities exist to improve multidisciplinary melanoma care through broader consensus of how to translate emerging data into patient care and delineating surveillance roles.