Melanoma Follow-Up Rests On History, Physical Exam

SAN DIEGO — When it comes to follow-up surveillance of melanoma patients, history and physical examination remain the cornerstone of good care, with little solid evidence to support anything else.

"The literature on this aspect of melanoma management is incomplete, mainly because there are very few prospective studies," Dr. Peter R. Shumaker said at a melanoma update sponsored by the Scripps Clinic.

He discussed several goals for the postoperative follow-up of melanoma patients:

▸ Earliest possible detection of treatable recurrence. About one-quarter of patients with local disease and 60%–70% of patients with in-transit [and] nodal disease will develop recurrence, said Dr. Shumaker, clinical fellow in procedural dermatology at the Scripps Clinic in La Jolla, Calif.

One study that reviewed the rate of first recurrence after treatment for malignant melanoma among 250 Australian patients found that 52% of recurrences were in the regional lymph nodes, 17% were local, 8% were in-transit, and 23% were visceral (Plast. Reconstr. Surg. 1993;91:94–8).

"The majority of recurrences occur within the first couple of years," Dr. Shumaker said.

▸ Detection of other primary skin cancers. "These patients are at high risk for a second primary melanoma," he said.

▸ Patient education, emotional support, and reassurance. Most studies report that at least half of recurrences are found by the patients themselves, despite being in a structured follow-up program. "So these follow-ups, in addition to providing an opportunity to inspect and palpate lesions, also provide an opportunity to educate patients," Dr. Shumaker said.

▸ Quality assurance. By this Dr. Shumaker meant the collection of data to improve future treatment and surveillance, such as blood tests and imaging techniques.

Chest x-rays and blood tests are frequently used in the routine follow-up of melanoma patients, "but they offer little benefit in terms of cost effectiveness," Dr. Shumaker said. They generally provide low sensitivity and a high rate of false positives.

Dr. Shumaker considers

Ultrasound "appears to be more sensitive than physical exam in detecting tumor recurrence in in-transit routes and regional nodal basins," he said. "There is an increased likelihood of survival benefit from asymptomatic detection in these areas."

He noted that ultrasound can be combined with fine-needle aspiration to diagnose recurrent or metastatic disease, but there appears to be no role for abdominal ultrasound in routine follow-up.

At Scripps, Dr. Shumaker and his associates perform a comprehensive history and physical exam in melanoma patients every 3 months for 3 years, then every 6 months for life. "This includes baseline and an annual chest x-ray and lab tests," he said.

Most studies report that at least half of recurrences are found bythe patients themselves. DR. SHUMAKER