Reconstructive burden and financial implications of wider excision margins for invasive primary cutaneous melanoma

Abstract

For invasive primary cutaneous melanoma, wider excision is advocated to reduce local recurrence risk and improve patient outcomes. Excision detail is controversial, especially in intermediate- and high-risk primary melanoma (AJCC pT2-pT4). Guidance varies from sizes 1 to 3cm (translating into large defects of 2-6cm). The aim of this study was to determine the reconstructive and resource burden of wider excision margins (EMs). Data analysis from our prospective database (2008-2017) included 1184 patients (563F:621M) with cutaneous melanoma (pT1b-pT4b). Procedure tariff data were sourced from our financial services department. Two hundred twenty-nine patients had a narrower EM (1cm) and 995 (80.7%) had a wider EM (2-3cm). Reconstructive requirement significantly increased with a wider EM collectively (11.3% vs 29.3%, odds ratio (OR)=3.2; p<0.0001), in the extremities (15.2% vs 42.0%; p<0.0001), and in the head and neck (H&N) (23.5% vs 64.7%; p<0.0001). Reconstruction significantly increased hospitalisation rates (26.6% vs 63.0%, OR=4.7; p<0.0001) collectively, in the H&N (26.8% vs 53.9%), and in the upper (18.9% vs 42.3%) and lower extremities (34.8% vs 77.3%). Narrower EMs significantly reduced hospitalisation rates in the upper and lower extremities (7.1% vs 28.5%; p = 0.004, 37.9% vs 58.5%; p = 0.005, respectively). Overall procedure cost significantly increased by £180 (mean, p<0.0001) and £346 (median, p = 0.0004) per patient when reconstruction was required. Our data suggest substantial impact of wider EM on patients, which more than doubled in the functionally and cosmetically sensitive extremities and the H&N region. Reconstructions add significant financial and healthcare service burden. Without randomised controlled trial (RCT) evidence demonstrating increased efficacy of wider EM, narrower EM is advocated whilst awaiting future planned RCT results specifically investigating on this.