Standardized, individualized care for melanoma does not have to be at odds

April 1, 2013

An individualized approach to medicine and standardized care in medicine do not necessarily have to be at odds when it comes to surgical management of melanoma.

Banff, Alberta - An individualized approach to medicine and standardized care in medicine do not necessarily have to be at odds when it comes to surgical management of melanoma.

“Personalized medicine is getting so much attention,” says Vernon K. Sondak, M.D., chairman, department of cutaneous oncology, Moffitt Cancer Center, Tampa, Fla. “At the same time, clinical guidelines suggest everyone should be treated the same. As much as we are proponents of individualized care, we should also be committed to standardized care, so that everyone gets the best care. It does not mean anyone should have any procedure performed that they want performed.”

Speaking at the annual Canadian Melanoma Conference, Dr. Sondak notes the American Society of Clinical Oncology and the Society of Surgical Oncology released joint clinical practice guidelines last summer regarding the use of lymphatic mapping and sentinel lymph node biopsy (SLNB) in staging patients with newly diagnosed melanoma (Wong SL, Balch CM, Hurley P, et al. J Clin Oncol. 2012;30(23):2912-2918).

Evidence-based guidelines

The guidelines are evidence-based and not a result of consensus based on common practices of clinicians, Dr. Sondak says. In addition, many of the clinicians who issued the guidelines are not surgeons.

“These recommendations are very evidence-based,” he says. “They have a great deal of value as a new benchmark.”

Disseminating the content of the guidelines to professionals in dermatology is a significant step, according to Dr. Sondak.

“It’s very important that the dermatologist community know the joint guidelines for SLN biopsy,” he says. “It is recommended for all patients with intermediate thickness melanoma and thick melanoma, but it should not be routine for patients with thin melanoma unless they have high-risk factors.”

Intermediate-thickness melanomas measure 1 mm to 4 mm; thick melanomas measure more than 4 mm; thin melanomas measure less than 1 mm, and very thin melanomas measure less than 0.76 mm.

The probability for finding a positive SLN is 2 to 4 percent or less for primary melanomas that measure less than 0.76 mm, but that figure rises to the 6 to 11 percent range for primary tumors that measure 0.76 mm to 1.00 mm. Other factors that influence the potential for a positive SLN include a mitotic rate of greater than or equal to 1/mm2.

Greater specificity desired

Dr. Sondak says his concern about the joint guidelines is that they are not specific enough in terms of recommendations about when to perform SLNB for melanomas measuring less than 1 mm. He and other clinicians authored an editorial discussing the challenge in defining guidelines for SLNB in patients presenting with thin primary cutaneous melanomas (Gershenwald JE, Coit DG, Sondak VK, Thompson JF. Ann Surg Oncol. 2012;19(11):3301-3303).

“The criticism that we have is that they (guidelines) did not go far enough in defining how we should make an individual decision for our patients,” he says.

Melanomas that measure between 0.76 mm and 1.0 mm will require SLNB in many instances, but some patient characteristics will influence the decision to perform a SLNB, Dr. Sondak stresses.

“It’s a personal decision that has to take into account how old a patient is, the state of health of the patient, how many years the patient will live, the yield of the procedure, and what the patient will do with the information that the biopsy provides,” he says. “The younger the patient is, the more predictive value the information will have and, generally speaking, the less risky the procedure is. These are factors that would make you more likely and not less likely to do the procedure.”

Surgical management of melanoma is currently individualized care, Dr. Sondak says. “We should individualize care, and we do now to a great degree,” he says. “We make decisions based on fractions of a millimeter differences in the thickness of a melanoma primary tumor. With other types of cancers, it’s 2 cm (in the size of a tumor) that makes a difference.”

It is vital for clinicians to determine the role of SLNB since the management of patients with primary cutaneous melanomas impacts healthcare resources necessary to manage patients with early-stage melanomas.

“We think the SLN biopsy is an extremely useful procedure, and dermatologists should be very aware of it,” Dr. Sondak says.

Disclosures: Dr. Sondak is a paid consultant for Merck and Navidea Biopharmaceuticals.