Comparing initial diagnostic excision biopsy of cutaneous malignant melanoma in primary versus secondary care: A study of Irish National data

Abstract

Initial excision biopsy carried out in general practice does not lead to a poorer outcome. ABSTRACT Background:The incidence of melanoma is rising worldwide. Current Irish guidelines from the National Cancer Control Programme state suspicious pigmented lesions should not be removed in primary care. There are conflicting guidelines and research advising who should remove possible melanomas. Objectives: To determine whether initial diagnostic excision biopsy of cutaneous malignant melanoma in primary versus secondary care leads to poorer survival. Methods: Analysis of data comprising 7116 cases of cutaneous malignant melanoma from the National Cancer Registry Ireland between January 2002 and December 2011. Single predictor variables were examined by the chi-square or Mann-Whitney U test. The effects of single predictor variables on survival were examined by Cox proportionate hazards modelling and a multivariate Cox model of survival based on excision in a non-hospital setting versus hospital setting was derived with adjusted and unadjusted hazard ratios. Results: Over a 10-year period 8.5% of melanomas in Ireland were removed in a non-hospital setting. When comparing melanoma death between the hospital and non-hospital groups, the adjusted hazard ratio was 1.56 (95%CI: 1.08-2.26); (P ¼ .02), indicating a non-inferior outcome for the melanoma cases initially treated in the non-hospital group, after adjustment for significant covariates. Conclusion: This study suggests that initial excision biopsy carried out in general practice does not lead to a poorer outcome.

Is initial excision of cutaneous melanoma by General Practitioners (GPs) dangerous? Comparing patient outcomes following excision of melanoma by GPs or in hospital using national datasets and meta-analysis

“…Finally, using the published estimates, a pooled estimate of the relative hazard of death after having a melanoma excised in secondary care versus primary care (as the reference group) for the 9367 Scottish and the 7116 Irish patients [13] was calculated. In order to utilise the published risk estimates from Doherty et al [13], we had to swap our reference group to be primary care in this pooled analysis.…”

“…This study reported that 8.5% of melanomas in Ireland were removed in primary care with a non-inferior outcome, but adjusted for a limited number of potential confounders. [13] Using linked national data, we investigated whether patients diagnosed with cutaneous melanoma in Scotland between 2005 and 2013 had different mortality and morbidity outcomes depending on whether excision was performed in primary or secondary care. We controlled for a greater number of confounders and also produced the first international pooled estimate of relative mortality for those having a melanoma initially excised in primary versus secondary care.…”

“…Forest plot of hazard ratio (95% CI) of all-cause mortality from Doherty et al, 2016 and current studyScottish model included: Setting (hospital/secondary vs non-hospital/primary), gender, age, anatomical position, stage (Breslow thickness, Clark level and metastatic status) Doherty et al [2016]. model included: Setting, sex, age, anatomical position, AJCC pathological stage, smoking status and marital status.Overall (I-squared = 38.7%, p = 0.202)…”

Diagnostic biopsy of cutaneous melanoma, sentinel lymph node biopsy and indications for lymphadenectomy

“…It resects the lesion beyond its margins to an extent of 1-3 mm according to NCCN (National Comprehensive Cancer Network) guidelines or 1-2 mm according to AJCC guidelines. This limit is crucial, given that avoiding lymphatic destruction ensures feasible detection of sentinel lymph nodes[ 6 - 8 ]. The other types of biopsy can potentially lead to misdiagnosis and inaccurate staging.…”

Minor surgery in general practice in Ireland- a report of workload and safety

“…Several studies from the United Kingdom (UK) have reported poorer quality of surgery for skin cancers in general practice compared to hospital settings [6][7][8][9], although one study showed that GPs compared favourably to skin specialists and outperformed hospital non-specialists in the excision of squamous cell carcinomas [10]. In studies from both the UK [11] and Ireland [12], the outcomes for primary excision of malignant melanoma were shown to be equivalent between GP and hospital providers. A community-based surgery audit from the UK, which examined 6138 procedures, concluded that GP minor surgery was safe and prompt and that GPs working within a managed framework performed better than less well-supported GPs [13].…”