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The optimal frequency of postmelanoma surveillance has never been defined by empiric research. Currently, higher-risk tumors receive more intense scrutiny than lower-risk lesions, and intervals between follow-up examinations are shorter in the beginning, given the greater number of expected events within the first 5 years. Investigators in Australia compared two models of follow-up schedules to determine the effects of reducing surveillance in 2998 patients.
Stage IA or IB disease:
Every 6 months for 5 years, then annually for 5 years
Stages IIA, IIB, and IIC disease
Every 3 months for 5 years, then annually for 5 years
Stage I disease:
Annually for 10 years
Stage IIA disease:
Every 6 months for 2 years, then annually for 8 years
Stages IIB and IIC
Every 4 months for 2 years, every 6 months during year 3, then annually for 5 years
For every 1000 patients with stage I or II disease, 229.2 developed a recurrent melanoma and 61.0 developed a new primary melanoma within 10 years. Absent unscheduled visits, more schedule II patients would have experienced delayed diagnosis of recurrence. An estimated extra 44.9 patients per 1000 would have experienced a delay of more than 2 months compared with schedule I. Similarly, more patients would have experienced delayed diagnosis of new primary melanomas under schedule II; an estimated 9.6 extra patients per 1000. Approximately 3000 fewer visits would be made for every 1000 newly diagnosed patients under schedule II — approximately 3 fewer visits per patient over 10 years.
Turner RM et al. Optimizing the frequency of follow-up visits for patients treated for localized primary cutaneous melanoma. J Clin Oncol 2011 Dec 10; 29:4641.
Comment
Routine care is inexpensive compared with treatment for advanced disease. Few individuals (4%) would experience delayed detection of metastatic disease of longer than 2 months under schedule II, which is probably acceptable; the rate of delay for a second primary lesion (1%) is even lower. However, there is a risk that a rapidly growing primary melanoma would transition from curable to incurable in that time frame.
Despite some extraordinary mathematical gymnastics, I was still left uncertain of the proper surveillance schedule. With a limited number of available slots in any dermatologist's appointment schedule, urgent add-on slots and routine surveillance slots must be balanced. In my practice, the surveillance schedule is closer to schedule I. Schedule II may be feasible with access within 1 to 2 weeks for urgent cases. Use of teledermatology and physician extenders for follow-up is under exploration.