Follow-up in patients with localised primary cutaneous melanoma

Summary

Follow-up services for patients with localised cutaneous melanoma are widely discussed but there is no international consensus. Our aim was to discuss frequency and duration of follow-up, type of health professional involved, optimum intensity of routine investigation, and patients' satisfaction with follow-up. Searches of the published work were directed at publications between January, 1985, and February, 2004 on recurrences, subsequent primary melanoma, routine tests, and patients' satisfaction. In a selection of 72 articles, 2142 (6·6%) recurrences were reported, 62% of which were detected by the patients themselves. 2.6% of patients developed a subsequent primary melanoma. Most investigators do not support high-intensity routine follow-up investigations. Of the various follow-up investigations requested by physicians, only medical history and physical examination seem to be cost effective. Lymph-node sonography seems to be a promising method for detection, although survival benefit remains to be proven. Patients were found to be anxious about follow-up visits, although other research showed that provision of information to patients was much appreciated. Published work on the follow-up of patients with cutaneous melanoma has mainly been retrospective and descriptive. Recommendations can be given with only a low grade of evidence. For meaningful guidelines to be developed, prospective, high-quality methodological research is needed.

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).