Surgeons Turn Deaf Ear to NCCN Melanoma Guidelines

The National Comprehensive Cancer Network has clear guidelines for the management of cutaneous malignant melanoma. Unfortunately, few treating physicians seem to be listening. 

An analysis of 35,126 patients in the Surveillance, Epidemiology, and End Results database from 2004 to 2006 found that noncompliance with recommended resection margin management guidelines occurred in 64% of patients. 

An excisional biopsy was the only surgical resection performed in 11% of patients, Dr. Nabil Wasif and colleagues from the Mayo Clinic in Phoenix reported at the American Society of Clinical Oncology annual meeting. 

Among 14,031 patients eligible for sentinel lymph node biopsy, 53% underwent the procedure. 

 In patients with a positive SLN biopsy, completion regional nodal dissection was performed in 73%.  

The analysis excluded patients with in situ and stage IV disease. SLN biopsy is not indicated for in situ or melanoma less than 1 mm thick with no ulceration and no mitosis.  

“There is significant and worrisome heterogeneity in the surgical management of cutaneous melanoma in the United States,” the researchers concluded. “Guidelines supported by randomized trials are not being adhered to.” 

In a multivariate analysis, age older than 60 years, female sex, T1 stage, and having a head and neck primary were found to predict noncompliance. 

A possible solution may be found in the abstract’s provocative title: “…Time for remedial classes?” 

In addition to physician education, the authors suggest patient education and perhaps regionalization of melanoma is needed to improve compliance and potential outcomes. 

-Patrice Wendling (on Twitter @pwendl)