Compliance with guidelines in the surgical management of cutaneous melanoma across the USA

摘要

The National Comprehensive Cancer Network has formulated guidelines for the management of cutaneous malignant melanoma with regard to resection margins (RMs) and regional staging. The aim of this study was to assess compliance with these recommendations in the general population of the USA. The Surveillance, Epidemiology and End-Results database was examined to identify 60 194 patients with malignant melanoma from 2004 to 2008. Multivariate logistic regression analysis was used to identify factors predictive of RM less than 1 cm and noncompliance with sentinel lymph node biopsy (SLNB). The median age of the population was 60 years and the mean Breslow thickness was 1.20±0.16 mm. The majority of patients had a RM of less than 1 cm (58%) and only 53% of eligible patients had undergone SLNB. Regional nodal dissection was performed in 69% of patients with a positive SLNB and in 78% with palpable lymphadenopathy. On multivariate analysis age more than 80 years [odds ratio (OR) 1.3, 95% confidence interval (CI) 1.2-1.4], T1 stage (OR 1.5, 95% CI 1.4-1.6), and head and neck primary (OR 1.4, 95% CI 1.3-1.4) all predicted RM of less than 1 cm. Factors predictive of noncompliance with SLNB recommendations included age more than 60 years (OR 1.6, 95% CI 1.5-1.8), T1 stage (OR 2.0, 95% CI 1.8-2.2), head and neck primary (OR 2.0, 95% CI 1.9-2.2), and RM less than 1 cm (OR 2.1, 95% CI 2.0-2.2). RMs and appropriate SLNB are inadequate in the majority of patients currently being treated for malignant melanoma in the USA. A combination of patient and physician education and perhaps regionalization of melanoma care is needed to improve compliance.