Earlier diagnosis of second primary melanoma confirms the benefits of patient education and routine postoperative follow-up

Abstract

BACKGROUND Rising health care costs have caused providers to question the benefit of regular follow‐up after treatment for patients with early stage cutaneous melanoma. The authors hypothesized that routine reassessment and careful education of these patients would facilitate earlier diagnosis of a subsequent second primary melanoma, as reflected by reduced thickness of that lesion. METHODS A prospective melanoma data base was used to identify patients who developed a second primary melanoma after treatment for American Joint Committee on Cancer (AJCC) Stage I or II cutaneous melanoma. After excision of the initial primary melanoma, all patients underwent routine biannual follow‐up for new primary lesions. Follow‐up consisted of a questionnaire and a complete skin examination by a physician. In addition, patients were regularly educated regarding the increased risk of developing a second melanoma. A paired t test was used to examine AJCC stage, thickness, and level of invasion of the initial melanoma compared with the second primary melanoma. RESULTS Of 3310 patients with AJCC Stage I or II melanoma, 114 patients (3.4%) developed a second primary melanoma. AJCC staging of both first and second melanomas was available in 82 patients (72%). When the AJCC stages of first and second melanomas were compared, 39 of 82 patients (48%) had lower stage second primary lesions, and 41 (50%) had same‐stage second primary lesions. The mean tumor thickness was 1.32 ± 1.02 mm for the initial melanoma, decreasing to 0.63 ± 0.52 mm for the second melanoma; in fact, tumor thickness increased in only 4 of 51 patients (8%) whose records contained data for both first and second melanomas. Similarly, the level of invasion decreased in 60% of patients, remained the same in 27% of patients, and increased in only 13% of patients. By paired t test, the differences in AJCC stage, tumor thickness, and level of invasion between first and second melanomas were each highly significant (P = 0.0001). CONCLUSIONS In this study, the second primary melanoma in patients with a prior cutaneous melanoma was significantly thinner than the initial primary lesion. This is evidence that careful follow‐up and patient education allow earlier diagnosis. All patients diagnosed with cutaneous melanoma should be counseled regarding the risks of second melanoma and should undergo lifelong follow‐up at biannual intervals. Cancer 2001;91:1520–4. © 2001 American Cancer Society.

Single versus multiple primary melanomas

“…10,[12][13][14] The initial melanoma in patients who have multiple primary melanomas (MPM) usually is the thickest of the melanomas that eventually develop. 3,6,7,9,12,[15][16][17][18][19][20][21] The 2 competing explanations for this trend include early detection of subsequent melanomas and less aggressive tumor biology in patients with MPM. Supporting the early detection hypothesis, a 2010 retrospective study by de Giorgi et al suggested that patients with MPM who did not adhere to regular follow-up had significantly thicker melanomas than patients who attended regular follow-up (mean thickness, 1.22 mm vs 0.36 mm).…”

“…3,6,7,9,12,[15][16][17][18][19][20] A study from the John Wayne Cancer Institute examined the first 2 primary melanomas in 114 patients with MPM who were identified from a melanoma database and demonstrated that there were significant differences between AJCC stage, mean tumor thickness, and Clark level of invasion between the first and second melanomas, and the second melanoma was thinner. 21 Our results indicating that the thickness of the first primary melanoma is significantly greater compared with the thickness of the second melanoma are consistent with previously reported findings. Two hypotheses have been proposed to explain why subsequent melanomas in patients with MPM are thinner: 1) close surveillance of patients who had a previous melanoma, leading to the early detection of any additional melanomas 15,21,22 ; and 2) distinct tumor biology in MPM versus SPM, because melanomas in patients with MPM have less aggressive tumor biology than melanomas in patients with SPM.…”

“…21 Our results indicating that the thickness of the first primary melanoma is significantly greater compared with the thickness of the second melanoma are consistent with previously reported findings. Two hypotheses have been proposed to explain why subsequent melanomas in patients with MPM are thinner: 1) close surveillance of patients who had a previous melanoma, leading to the early detection of any additional melanomas 15,21,22 ; and 2) distinct tumor biology in MPM versus SPM, because melanomas in patients with MPM have less aggressive tumor biology than melanomas in patients with SPM. 12 The hypothesis that close surveillance of patients with melanoma may lead to thinner melanomas is supported by a recent retrospective study, which indicated that patients with MPM who received regular follow-up had thinner melanomas than those who were not followed regularly.…”

“…42 The current study is 1 of a few studies that have prospectively examined clinicopathologic variables in patients with SPM and MPM. 12,14,21,43 Among the variables examined was the anatomic location of tumors in the patients with MPM. Previous investigators suggested that there may be a ''field effect of cancerization'' near the site of the first primary tumor.…”

High constant incidence rates of second cutaneous melanomas

“…15 This is consistent with the overall 3.4% frequency of second CMM in the American Joint Committee on Cancer stage I or II cutaneous melanoma, which also showed that second CMMs are thinner than first lesions. 16 The present work therefore confirms and further quantifies that the risk of CMM is substantially increased in subjects diagnosed with a CMM. More important, this study indicates that the relative risk is greater at younger age and declines with advancing age.…”