Delays in the surgical treatment of melanoma are associated with worsened overall and melanoma-specific mortality: A population-based analysis

TAKE-HOME MESSAGE

• Using the Surveillance, Epidemiology, and End Results database, the outcomes of patients with melanoma treated with local excision, Mohs micrographic surgery, or amputation were evaluated. The overall mortality across all stages increased with even a 1 to 2–month delay between diagnosis and treatment. Furthermore, the mortality risk increased concordantly with longer treatment delay. Notably, patients with stage I disease had a worse melanoma-specific and overall mortality, with delays in treatment over 30 days, compared with patients with stage II and stage III disease.
• Prompt treatment of melanoma should be prioritized, as delays in treatment lead to increased mortality.

–  Katherine M. Stiff, MD

Written by

 

 

David G. Brodland MD

This study endeavors to confirm what many might consider obvious…that delay of treatment for melanoma is associated with a worse outcome. The SEER database is used, which has some advantages over other large national databases but also has some very significant disadvantages, which can lead to invalid conclusions. Despite the massive study group size, several of the subgroups studied are small in number, which may also affect validity of conclusions. So, reader beware. 

The primary outcomes evaluated included overall mortality (OM) and melanoma specific mortality (MSM) as they relate to delay of definitive excisional treatment. Whenever I read this kind of paper pertaining to melanoma, I focus most intensely on melanoma specific data. In many such studies, the data that is not specific to melanoma tends to have overwhelming, uncontrolled, and confounding variables such that it renders these data points much less useful. As such, I will focus on MSM in review of this paper. 

Of all patients studied, approximately 77% were definitively treated within 1 month. This is probably a reasonable minimum standard that all entities can begin with to improve the quality of care provided to their melanoma patients.

Their findings show that cumulatively, univariate analysis of delays in definitive treatment show increased MSM for melanoma stages I, II, and III, with the most profound effect in stage I melanoma. On multivariate analysis, increasing delays still increased the hazard ratio of MSM for all stages. Of all variables assessed, Breslow's thickness is associated with the most profound increase in MSM. Again, stage I tumors with delayed treatment were the most profoundly affected in terms of MSM. Interestingly, stage III melanomas did not demonstrate statistically significant association between treatment delay and MSM. Also of note, OM was significantly worse for stage I patients even with as little as 1 month treatment delay.

To summarize, again focusing on MSM rather than OM, treatment delays may be associated with worsened MSM, and most significantly for stage I tumors. Their capsule summary concludes that, "patients with stage I disease suffer significantly worsened melanoma specific and overall mortality with treatment delays beyond 30 days." As such, this study emphasizes the importance of surgical wait times as an important datapoint for quality assurance.

Abstract

BACKGROUND

The effect of treatment delays on melanoma outcomes remains unclear.

OBJECTIVE

To assess the impact of surgical treatment delays on melanoma-specific mortality (MSM) and overall mortality (OM).

METHODS

Patients with stage I to III cutaneous melanoma were identified through the Surveillance, Epidemiology, and End Results database (N = 108,689). Included cases had time from diagnosis to definitive surgery and follow-up time. Cox proportional hazards and Fine-Gray competing risks analyses were used to assess the impact of treatment delays on mortality.

RESULTS

Across all stages, treatment delays of 3 to 5 months were associated with worse MSM and any delay beyond 1 month was associated with worse OM. In a subgroup analysis of patients with stage I disease, delays of 3 to 5 months were associated with worse MSM and any delay beyond 1 month was associated with worse OM. In patients with stage II disease, worse MSM was found with delays of 6+ months and worse OM was seen with delays of 3 to 5 months. No significant effect of treatment delays was noted in stage III disease.

LIMITATIONS

The Surveillance, Epidemiology, and End Results database does not collect comprehensive data on adjuvant treatments, disease recurrence, or treatment failure.

CONCLUSION

Timely treatment of melanoma may be associated with improved OM and MSM.

Journal of the American Academy of Dermatology

Delays in the surgical treatment of melanoma are associated with worsened overall and melanoma-specific mortality: A population-based analysis

J Am Acad Dermatol 2022 Jul 01;[EPub Ahead of Print], DD Xiong, P Barriera-Silvestrini, TJ Knackstedt 

Sent from my iPhone

Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

Please excuse the shortness of this message, as it has been sent from
a mobile device.