New Standards Needed to Lessen Surgery Delays in Melanoma

Joseph J. Skitzki, MD

Joseph J. Skitzki, MD

A delay between the diagnosis of melanoma and needed surgery may evoke anxiety and psychological stress; although the impact on morbidity and mortality remains controversial.¹A study published inThe Journal of the American Medical Association(JAMA) examined the issue of delay between diagnosis and surgery in Medicare patients with melanoma.

Study Methods

“The major strength of this study is that the researchers specifically identified a delay in timely care in 20% of patients with melanoma who treated under Medicare. A significant finding in this elderly, Medicare melanoma population is that their delay in care was common and influenced by the type of medical practitioner providing service,” said Joseph J. Skitzki, MD, assistant professor of surgical oncology and immunology, Roswell Park Cancer Institute, Buffalo, New York.  This was a retrospective cohort study using the Surveillance Epidemiology and End Results (SEER) Medicare database. Patients diagnosed with primary cutaneous melanoma between January 1, 2000, and December 31, 2009, were included. The inclusion criteria comprised the date of diagnosis, patients enrolled in fee-for-service Medicare parts A and B 2 years before and 1 year after diagnosis, and more than 1 melanoma. Exclusion criteria included 2 or more melanomas within 1 year. The primary endpoint was the delay in surgery quantified as the time interval from biopsy to surgery. Covariates relevant to the study analysis were age, sex, race, marital status, and income. Patient access to primary care was defined by a history of influenza vaccination and comorbidities were identified by International Classification of Diseases (ICD)-9 codes. Covariates included tumor stage and location, and the specialty of the physicians performing the biopsies and the surgical excisions.

The Patients

The Delay From Biopsy to Surgery: Greater Than 1.5 months

“Additional strengths of this study were that it examined a large number of melanoma cases (32,501) in the Medicare population and attempted to control for biological factors, including age, melanoma stage, melanoma site, and medical comorbidities, while also factoring in social factors such as annual income and marital status,” explained Skitzki.The study analyzed cases of primary cutaneous melanoma. Most patients were male (63.1%) and white (95.4%), had no history of melanoma (93.7%), and about 60% were ≥75 years of age. The greatest proportion of melanomas were found on the head and neck and (40.5%), and the greatest number of melanomas were classified as stage I or I/II (25.5% and 14.4%, respectively).  The delay from biopsy to surgery ranged from 4 to 450 days, with a median of 27 days, and a mean of 44.3 days. A delay to surgery of less than 1.5 months was experienced by 25,269 of 32,501 (77.7%) of patients. “These results are somewhat encouraging; close to three-quarters are getting surgery within 6 weeks,” said Jason Lott, MD, lead author of the study and postdoctoral fellow in the Robert Wood Johnson Foundation Clinical Scholars Program at Yale School of Medicine.²

For 22.3% (approximately 1 in 5) of patients, however, the delay was greater than 1.5 months and more than 3 months for 8.1%. “Delay for melanoma surgery in this population is more common than we expected,” commented Lott.³

In the unadjusted risk analysis, a delay greater than 1.5 months was significantly associated with age, comorbidity burden, SEER historical stage, and anatomic location (P <.001). Prior melanoma and marital status were also significantly associated with delay >1.5 months (P = .001), as were race (P = .01), and median annual income (P =.004).

Physician Specialty

Table 1. Breakdown of Dermatologists Versus Non-Dermatologists in Analysis

Physician Specialty

% Patients Biopsied

Dermatologist

88.4

Non-Dermatologist

11.6

Table 2. Physician Specialties Involved in Biopsy and Surgery in Analysis

Physician Specialty

% Melanoma Surgically Excised

Dermatologists

41.9

General/Plastic surgeon

30.5

Mohs surgeon

9.1

Primary care physician

1.2

Other/unknown

27.3

Table 3. Percentages of Patients Experiencing More Than 1.5 Months Delay

Physician Specialty Performing Surgery

% Patients With Delay to Surgery >1.5 months

Dermatologist

16.5

Mohs surgeon

24.0

General/Plastic surgeon

26.4

Primary care physicians

30.7

Other/unknown

27.5

Upon adjusted risk analysis, a delay of more than 1.5 months was significantly associated with age &ge;85 years versus those <65 years (odds ratio [OR], 1.28; 95% CI, 1.05-1.55; P = .02), prior melanoma (OR 1.20; 95% CI, 1.08-1.34; P = .001), and the presence of 1-2 (OR, 1.10; 95% CI, 1.04-1.17; P = .002); or &ge;3 comorbidities OR, 1.18; 95% CI, 1.09-1.27; P <.001).Tables 1 and 2 identify the physician specialties involved in the biopsy and surgical stages of melanoma management in the analysis.Dermatologists were predominantly responsible for biopsy (Table 1) and for surgical excision (Table 2).When considering surgery and specific physician specialty, the percentages of patients experiencing more than 1.5 months delay (unadjusted risk analysis) are shown in Table 3.

The Delay From Biopsy to Surgery: Greater Than 3 Months

Table 4. Percentages of Patients Experiencing More Than 3.0 Months Delay

Physician Specialty Performing Surgery

% Patients With Delay to Surgery >3 Months

Dermatologist

7.5

Mohs surgeon

7.0

General/Plastic surgeon

7.7

Primary care physicians

21.1

Other/unknown

9.9

Minimizing the Delays

Adjusted risk analysis further confirmed that the risk of surgical delay >1.5 months was significantly reduced when the biopsy was performed by a dermatologist versus a non-dermatologist (OR, 0.68; 95% CI, 0.57-0.82; P <.001). If a primary care physician (PCP) versus a dermatologist performed the surgery, the risk for delay was significantly increased (OR, 1.49; 95% CI, 1.08-2.08; P = .02). The risk for delay was also increased if a dermatologist performed the biopsy but subsequent surgery was performed by a general/plastic surgeon, compared with both procedures being performed by a dermatologist (OR, 1.49; 95% CI, 1.19-1.87, P <.001). Combinations of specialties performing the procedures were analyzed (marginal risk adjusted delay) and showed that the maximum probability of delay was encountered if a non-dermatologist or a dermatologist carried out the biopsy but a PCP performed the surgery (probability of delay, 31% in each scenario, P <.001, P <.001, respectively). The minimum probability of delay was just 16% (P <.001) if a dermatologist carried out both procedures.The authors also examined the adjusted risk for a surgical delay of longer than 3 months, and the results were similar to the >1.5-month delay results. The percentages of patients experiencing more than 3.0 months delay (unadjusted risk analysis) are shown in Table 4.The risk for delay for patients ˃75 years of age was significantly increased compared with patients ˂65 years of age. If a dermatologist performed the biopsy, then the minimum risk-adjusted marginal probability of a delay was 6% if the following surgery was performed by a Mohs surgeon or a general/plastic surgeon (P <.001). The maximum probability of delay was 22% if a dermatologist performed the biopsy, but a PCP carried out the surgery (P <.001).Discussing the data, the authors pointed to the value of a specialized approach to diagnosis and appropriately timed surgery. The data highlight the efficiency achievable between practitioners of the same specialty. Delays when non-dermatologists are involved may reflect several factors, such as referral and consultation issues.

In considering this, Skitzki commented, &ldquo;The timing of definitive surgery for melanoma depends on many factors, some of which can be controlled and others not. For professionals dedicated to melanoma treatment, the initial diagnostic biopsy is typically performed elsewhere by caregivers who may have variable experience with melanoma.&rdquo; He pointed out that the time taken for a patient to be referred to a specialist cannot be controlled by the specialist, but by the referring physician, adding that, &ldquo;Once the patient is referred with a diagnosis of melanoma, the stage, the age, and the need for further evaluation may influence how quickly patients are taken for definitive surgery. My preference is to have melanoma patients scheduled for definitive surgery within 3 weeks of their referral, with the majority scheduled within 2 weeks.&rdquo;

Future Improvement

Lott and colleagues also remarked that the decision to perform surgery is not straightforward for elderly patients diagnosed with melanoma of the head and neck, and Skitzki pointed out, &ldquo;Also, if the surgery requires more than just local anesthesia, patients may need to be evaluated for their ability to tolerate anesthesia, which can lead to further delays—especially in older patients who may have multiple comorbidities, and this is likely a contributing factor to the study&rsquo;s findings.&rdquo;The authors contend that key steps to minimizing delay include better access to dermatologic care and improved coordination of care between physicians of different specialties.

&ldquo;Having the care of melanoma patients directed by a dermatologist or a dedicated melanoma specialist would likely improve upon the delays that were noted in this study,&rdquo; said Skitzki, adding, &ldquo;More importantly for all cancer care, establishing a standard for cancer patients to receive definitive treatment within a defined time frame from their cancer diagnosis would be ideal.&rdquo; However, Skitzki cautioned, &ldquo;Unfortunately, tumor biology may have more of an influence on outcome than any potential delay in treatment and this would be difficult to generalize across populations.&rdquo;

References

1. Lott JP, Narayan D, Soulos PR, et al. Delay of surgery for melanoma among Medicare beneficiaries [published online April 8, 2015].JAMA Dermatol. doi: 10.1001/jamadermatol.2015.119.
2. MedlinePlus. http://www.nlm.nih.gov/medlineplus/news/fullstory_151911.html. Accessed April 12, 2015.
3. Yale News. http://news.yale.edu/2015/04/08/melanoma-surgery-delays-are-common-medicare-patients. Accessed April 12, 2015.

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