A comparison of current practice patterns of US dermatologists versus published guidelines for the biopsy, initial management, and follow up of patients with primary cutaneous melanoma
The American Academy of Dermatology and others have formulated guidelines for the management of melanoma. Aaron S. Farberg, MD and Darrell S. Rigel, MD conducted a study to evaluate current management of melanoma by US dermatologists and the variance from those guidelines. A knowledge gap may exist that represents an educational opportunity to better familiarize clinicians with guidelines for melanoma management.
- Survey instrument was validated and sent by e-mail in August 2015 to 6177 practicing US dermatologists. Of the dermatologists surveyed, 510 (8%) responded.
- The survey assessed each physician’s preferred biopsy methods for lesions suspicious for melanoma, margins used for excision, and recommended follow-up intervals.
- Guidelines for biopsy and excision are similar for both the NCCN and AAD. Excisional biopsies (elliptical, punch, or saucerization) with 1-3 mm margins is preferred according to the NCCN guidelines. AAD guidelines state that the preferred biopsy technique is using a narrow excisional biopsy that encompasses the entire breadth of the lesion using elliptical or punch excisions, or shave removal to a depth below the anticipated plane of the lesion if the suspicion for melanoma is low.
The study revealed material variations in dermatologists’ approaches to melanoma management as well as variance from current guidelines.
- Overall, shave biopsy (35%) was the most commonly used method followed by narrow excisional biopsy (less than 5 mm margins) (31%), then saucerization/scoop shave (12%), punch biopsy (11%), and wide excisional biopsy (3%). A 35% shave biopsy rate may reflect:
- a lower suspicion of melanoma in some cases in which shave is appropriate;
- biopsies of lentigo maligna in which case a shave biopsy may be appropriate given the often broad size of these lesions especially on the face. The AAD guidelines mention that scoop shave may be appropriate for lesions suspicious of lentigo maligna; however, only malignant melanoma (not subtypes) was specifically asked about in the survey. Also, lentigo maligna would typically not be the most common lesion encountered for most dermatologists, so it would probably not be the one thought of first when answering the survey;
- actual biopsy clinical preference.
- Excisional margins narrower than recommended were noted (14% of respondents used less than 1 cm margins for excising melanomas >1 mm in thickness) and follow-up intervals varied.
- There were significant management differences noted for dermatologists by practice setting and by years in practice. Findings demonstrated a significantly increased chance that physicians in an academic setting more frequently referred out their patients with melanomas for surgery than physicians in other practice settings. This may be due in part to readily available access of tertiary care, including oncologic surgeons for referral opportunities, in an academic university environment.
A plausible reason for the findings in this study is that the current guidelines are not 100% followed, and this further suggests an educational gap exists that may need to be addressed or that the guidelines may need to be reassessed. Adherence to evidence-based guidelines should lead to improved patient outcomes and quality of care. To achieve this goal, it is critical that the guidelines are used and adhered to in daily practice.