CHICAGO Adherence to national cancer treatment guidelines was associated with decreased local and regional recurrence, improved disease-free and overall survival, and decreased treatment-associated morbidity in a study of 327 consecutive clinically node-negative melanoma patients.
A review of cancer registry data at Rush North Shore Medical Center in Skokie, Ill., revealed that 72% of patients were treated in compliance with National Comprehensive Cancer Network (NCCN) recommendations for margins of excision, Dr. Jennifer Erickson Foster and colleagues reported at a symposium sponsored by the Society of Surgical Oncology.
Appropriate lymph node staging and treatment was received by 271 patients or 83%. Interestingly, when treatment was performed by a surgical oncologist, margin compliance was 95% and lymph node compliance 92%, said Dr. Foster, the lead investigator. A recommended completion lymph node dissection was performed for a positive sentinel lymph node in 78% of patients.
Patients treated in a noncompliant fashion with regard to margins had a threefold increase in postoperative complications in comparison with those treated in a compliant fashion. Similarly, patients treated in a lymph node-noncompliant fashion were 2.4 times more likely to have a postoperative complication. Both findings were statistically significant, said Dr. Erickson Foster, who reported no conflicts of interest for the investigators.
Noncompliance with NCCN guidelines for margins of excision was associated with increased locoregional (26% vs. 6%) and distant recurrence (8% vs. 6%), as compared with compliant cases. Locoregional disease alone as the first site of relapse was seen in 33% of lymph node-noncompliant cases vs. 6% of lymph node-compliant cases.
Five-year disease-free survival was higher among margin-compliant cases, compared with margin-noncompliant cases (86% vs. 68%), as was 5-year overall survival (93% vs. 83%). Similar increases in disease-free (85% vs. 54%) and overall (95% vs. 66%) survival were observed with compliance to lymph node staging and treatment recommendations.
The mean follow-up was 51 months (minimum 18 months) and mean age 66 years; 53% of the patients were women, and 32% of melanomas were located on the trunk, a finding consistent with cutaneous melanoma. Postoperative complications were reported in 55 patients (17%), with major complications in 4%, including one myocardial infarction, one pneumothorax, two cases of lymphedema, and two cases of facial nerve injury.
"These findings are provocative and suggest that compliance with NCCN guidelines improves outcomes in clinically node-negative melanoma patients," senior author Dr. Tina J. Hieken, of Rush Medical College, in Chicago, said in an interview. "We recommend that clinicians treating melanoma patients become familiar with these guidelines and utilize them to assist clinical decision making."
During the question-and-answer session, Dr. Foster noted that 20 different physicians representing nine specialties performed melanoma treatment in the study. Compliance did improve among specialties as time went on, but only surgical oncologists had greater than 90% compliance for margins of excision and lymph node staging and treatment.
Audience member Dr. Daniel G. Coit, who cochaired the NCCN guideline committee for melanoma, stressed that noncompliance with recommendations should not be equated with poor medical care. "Guidelines don't define best medical care; the doctors and patients define best medical care," he said.
Both Dr. Foster and Dr. Hieken agreed that physicians regularly depart from guidelines for a variety of reasons, such as aesthetic considerations, patient preferences, patient comorbidities, and tumor features.
"Guidelines are a point of departure," said Dr. Coit of Memorial Sloan-Kettering Cancer Center in New York. "They are not how we must do it, and we need to be very careful about how we define that, because there are other people who don't know that and will be looking at these kinds of presentations very carefully, and they're going to come to the wrong conclusion."