A comprehensive computer-aided search of the databases of the medical literature (PubMed, MEDLINE, Embase) was done. Searches of medical subject headings and free-term searches were focused on follow-up surveillance in relation to four subtopics: development and detection of recurrences; development and detection of second primary melanoma; routine follow-up investigations; and reassurance, preferences, and education of patients. Reference searches of identified articles were carried out
ReviewFollow-up in patients with localised primary cutaneous melanoma
Introduction
Provision of routine follow-up services for patients after treatment for cutaneous melanoma is standard practice in most countries. The main purpose of follow-up services is early detection of recurrent disease (figure 1) and subsequent primary tumours, which could be treated successfully by surgery or other modalities.1, 2 Secondary aims include offering education, reassurance, and treatment surveillance. The latter is important for medical audit and research purposes.
Follow-up services for patients with cutaneous melanoma are associated with several difficulties and controversies. First, the prevalence of cutaneous melanoma has risen over the past decades.3 This increase is thought to be an effect of the overall rising proportion of patients with melanoma of American Joint Committee on Cancer stage 0, IA–B, and IIA who have a good outlook. As well as the increasing prevalence of thin melanoma, these patients will probably need follow-up surveillance for a longer time because of their longer survival. These effects have resulted in doubling of the patient population who need follow-up surveillance.3, 4, 5, 6 Second, most patients detect recurrence themselves. Therefore, the value of high-frequency follow-up surveillance has been questioned.7, 8 However, patients with a history of melanoma are not necessarily in the best position to detect a second primary melanoma.9 Also, for disseminated disease, no convincing treatment exists and therefore a cure cannot be guaranteed when a patient is diagnosed with recurrent melanoma.10 Third, the focus on cost-effectiveness in health care has resulted in questioning of regular follow-up services.11, 12
During the past few decades, many recommendations and proposals for follow-up services have been issued, but consensus was not achieved. Recommendations mostly give guidance on the intensity (including tests), the frequency, and the length of follow-up. Almost all recommendations were made on the basis of retrospective assessment of historical cohorts. The only prospective study, by Garbe and colleagues,13 had several shortcomings in the selection of patients. The investigators included all patients who presented to their clinic, including those who already had metastatic disease. Inclusion of such patients might have caused length-time bias and lead-time bias in their results.14, 15
Furthermore, several patient-related features, such as the definition of a patient-detected recurrence and a survival benefit of recurrences detected by physician or patient, were not discussed. In most studies, patient-related features—eg, reassurance of patients—are hardly mentioned and this issue has barely been investigated for patients with melanoma, and even less in relation to follow-up surveillance.
The aim of this structured review of the published work was to identify and integrate evidence on the effectiveness of follow-up strategies for patients treated successfully for their primary localised melanoma. Searches of the published work were done to find out the optimum frequency and length of follow-up services, the type of health professional who should provide follow-up care, the optimum intensity of routine follow-up investigation, and what is known about reassurance for patients and their satisfaction with follow-up services.
A comprehensive computer-aided search of the databases of the published work (PubMed, MEDLINE, Embase) was done (table 1). 72 articles were included in the final review, selected from 2206 articles initially identified by the different searches (figure 2).
Section snippets
Development and detection of recurrence
Table 2 shows characteristics of articles included in this review. All but one study13 had a retrospective design; one study38 included a questionnaire for patients. In these studies, several features of follow-up surveillance were assessed; recurrence rates, recurrence detection, and follow-up schedules. This approach is also used here.
Follow-up schedules
During the past few decades, several attempts have been made to introduce a new follow-up schedule that would find international consensus. Most follow-up schedules are proposed on the basis of the yearly risk of recurrence. Others are based on the pattern of recurrences, the result of patients' adherence with follow-up, or the opinion of experts (table 5).8, 11, 12, 13, 17, 19, 20, 21, 22, 36, 39, 40 In this overview a couple of features become evident; all investigators recommended more
Development and detection of second primary melanoma
Table 6 shows the scope of follow-up surveillance and subsequent primary melanoma.
The incidence of subsequent primary melanoma varied from 2% to 7%.9, 13, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 The risk of developing a subsequent primary melanoma is therefore much the same as the risk of recurrence for melanoma of AJCC clinical stage I.21, 36, 37
Although many investigators have reported on screening and detection of primary melanomas, not much is known about the detection of subsequent primary
Follow-up surveillance and routine investigations
Several studies11, 12, 13, 23, 25, 51, 52, 53, 54, 55 have assessed the use of routine investigations in follow-up surveillance. Most studies investigating many diagnostic entities were retrospective (table 7). Many investigators conclude that history taking and physical examination result in the most detections and are therefore most cost effective for patients with stage I and II melanoma as defined by the AJCC.11, 12, 23, 25 On the other hand, Garbe and colleagues13 recommended blood tests
Lymph-node sonography
Several prospective studies56, 57, 58, 59, 60, 61, 62, 63 have investigated the use of lymph-node sonography in the follow-up of melanoma. This subject was reviewed by Bafounta and co-workers.64 When we reviewed the studies on lymph-node sonography, we came to much the same conclusions and therefore no details are repeated here. Lymph-node sonography seems to be a promising investigation in follow-up surveillance, although survival benefit remains to be proven. Machet and colleagues65 responded
Who should provide follow-up?
Ten of the 30 articles reviewed here were reported by dermatologists, ten studies by surgeons, six by plastic surgeons, and four by medical oncologists or radiotherapists. A third of the total 30 studies were done in cancer units or even skin-cancer or melanoma units. 7, 8, 11, 12, 13, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40
Several investigators have asked physicians about their follow-up surveillance practice to investigate how the
Routine chest radiographs
Two studies assessed the use of chest radiography as a routine investigation. Mooney and co-workers70 did a cost-effectiveness analysis and Tsao and colleagues71 a survey to find out the survival benefit of chest radiographic screening as a possible result of early detection (table 7). Although Mooney and co-workers concluded only that screening should not continue after 10 years for financial reasons, Tsao and colleagues did not support chest radiographic screening. They found no survival
Patients' wellbeing
Few studies have investigated patients' wellbeing and hardly any in the follow-up surveillance. Table 9 summarises the studies assessed for this review. Baughan and co-workers8 assessed the value of follow-up surveillance experienced by patients by use of a questionnaire. They concluded that 86% of the patients found follow-up surveillance worthwhile. Only 5% of the 133 patients in their study found the follow-up visit a waste of time. However, more than half the patients in their study
Conclusion
Although many studies have been done on follow-up surveillance in patients with melanoma, there is no evidence to support any form of follow-up surveillance. However, most studies were retrospective or had poor methods. Therefore, higher-quality prospective research is needed to establish evidence-based guidelines for follow-up surveillance in melanoma.
Optimum frequency and length of follow-up services
According to the articles reviewed here, there is no true evidence for follow-up surveillance in localised melanoma. Overall, 62% of patients detected their first recurrence themselves. Moreover, no study has shown any benefit in disease-free or overall survival associated with follow-up surveillance, although one study showed a survival benefit of doctor-detected (asymptomatic) recurrences.
From the (retrospective) assessment of yearly risk of recurrence in patients with stage I and II melanoma
Who should provide follow-up care?
No research has been done on the type of health professional who should give follow-up care in patients with melanoma. General surgeons, dermatologists, plastic surgeons, and general practitioners are involved in the service, which varies between countries. In the published work reviewed here; dermatologists and surgeons produced similar amounts of data. In practice, nurse practitioners are gaining responsibilities in melanoma care. McKenna and co-workers80 discussed the treatment of patients
Optimum intensity of routine follow-up investigation
Studies on patients with stages I and II melanoma as defined by the AJCC have shown that most recurrences are detected by the patient or through history taking and physical examination by the physician. Only this type of follow-up surveillance seems to be cost effective.12, 25 There is no evidence to justify screening with chest radiography.70, 71
Ultrasonography of the regional lymph-nodes is the only routine investigation that might become more important. Several prospective diagnostic trials
Reassurance for patients and satisfaction with follow-up services
Little information is available about the effect of follow-up surveillance on patients. Only a few studies have investigated the psychological effect of follow-up. The overall conclusion was that regular check-ups have a positive effect on most patients, and most are satisfied with the additional information they are given.8, 75, 83 However, the aims and methods of these studies were inconsistent and therefore give only premature indications on patients' experience with follow-up.
More
Follow-up practice, guidelines, and evidence
Follow-up services for patients with melanoma are common in melanoma care worldwide. In many countries, the format of this service is based on common-sense or historical practice. However, in other countries, guidelines have been issued and renewed in the past decade. Some guidelines are formulated by national consensus, others are used in a local context. Among others, follow-up guidelines have been developed in the UK, Germany, the Netherlands, the USA, Switzerland, and Australia.88, 89, 90,
Search strategy and selection criteria
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