In a study that included more than 32,000 cases of melanoma among Medicare patients, approximately 1 in 5 experienced a delay of surgery that was longer than 1.5 months, and about 8 percent of patients waited longer than 3 months for surgery, according to an article published online by JAMA Dermatology.
Melanoma is a leading cause of new cancer diagnoses in the United States, accounting for most skin cancer¬related deaths. Surgical excision is the primary therapy for melanoma. Surgical delay may result in the potential for increased illness and death from other malignant neoplasms, and may cause anxiety and stress. No guidelines exist regarding timely surgery for melanoma, although informal recommendations suggest that melanomas should be excised within 4 to 6 weeks of diagnostic biopsy. Population-based studies characterizing the delay of surgery for melanoma in the United States have not been performed, according to background information in the article.
Jason P. Lott, M.D., M.H.S., M.S.H.P., of the Yale University School of Medicine, New Haven, Conn., and colleagues examined surgical delay among Medicare beneficiaries diagnosed as having melanoma between January 2000 and December 2009, using the Surveillance, Epidemiology, and End Results-Medicare database. The researchers included all patients undergoing surgical excision of melanoma diagnosed by means of results of skin biopsy.
The study included 32,501 cases of melanoma; patients were more likely to be 75 years or older (61 percent) and to have no prior melanoma (94 percent). Of the total study population, 78 percent of melanoma cases underwent excision within 1.5 months, 22.3 percent underwent excision after 1.5 months, and 8.1 percent underwent excision after 3 months. Surgical delay longer than 1.5 months was significantly increased among patients 85 years or older compared with those younger than 65 years, those with a prior melanoma, and those with more co-existing medical conditions.
Melanomas that underwent biopsy and excision by dermatologists had the lowest likelihood of delay; the highest likelihood of delay occurred when the biopsy was performed by a nondermatologist and excised by a primary care physician.
"Our results show that a delay of surgery for melanoma may be relatively common among Medicare beneficiaries. Although no gold standard exists to judge appropriate vs inappropriate surgical delay, minimization of delay is an important patient¬centered objective of high-quality dermatologic care, especially given the potential harms of psychological stress associated with untreated malignant neoplasms. Our study highlights opportunities for quality improvement in dermatologic care and suggests that efforts to minimize the delay of surgery for melanoma might focus on increased access to dermatologic expertise and enhanced coordination of care among different specialists," the authors write.
Commentary: Timely Surgical Follow-up for Melanoma Among Medicare Beneficiaries
"Further research aimed at substantiating the consequences of surgical delay in the setting of melanoma may also improve a movement toward a standard of care and possible guidelines among all medical subspecialties," write Elaine Lin, B.S., a medical student at the School of Medicine, Loma Linda University, Loma Linda, Calif., and Jerry D. Brewer, M.D., of the Mayo Clinic, Rochester, Minn., in an accompanying commentary.
"In addition, medical training should emphasize heightened communication skills and the importance of multidisciplinary teamwork as an essential element to establishing solid surgical follow-up. Another interesting, technologically savvy option could include a 'Time to Treat' program integrated into the electronic medical records system to aid in prompt intervention."
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