Original article
Determination of the impact of melanoma surgical timing on survival using the National Cancer Database

https://doi.org/10.1016/j.jaad.2017.08.039Get rights and content

Background

The ideal timing for melanoma treatment, predominantly surgery, remains undetermined. Patient concern for receiving immediate treatment often exceeds surgeon or hospital availability, requiring establishment of a safe window for melanoma surgery.

Objective

To assess the impact of time to definitive melanoma surgery on overall survival.

Methods

Patients with stage I to III cutaneous melanoma and with available time to definitive surgery and overall survival were identified by using the National Cancer Database (N = 153,218). The t test and chi-square test were used to compare variables. Cox regression was used for multivariate analysis.

Results

In a multivariate analysis of patients in all stages who were treated between 90 and 119 days after biopsy (hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.01-1.18) and more than 119 days (HR, 1.12; 95% CI, 1.02-1.22) had a higher risk for mortality compared with those treated within 30 days of biopsy. In a subgroup analysis of stage I, higher mortality risk was found in patients treated within 30 to 59 days (HR, 1.05; 95% CI, 1.01-1.1), 60 to 89 days (HR, 1.16; 95% CI, 1.07-1.25), 90 to 119 days (HR, 1.29; 95% CI, 1.12-1.48), and more than 119 days after biopsy (HR, 1.41; 95% CI, 1.21-1.65). Surgical timing did not affect survival in stages II and III.

Limitations

Melanoma-specific survival was not available.

Conclusion

Expeditious treatment of stage I melanoma is associated with improved outcomes.

Section snippets

Methods and materials

The NCDB is a clinical oncology database established in 1989 as a joint project of the Commission on Cancer (CoC) of the American College of Surgeons and American Cancer Society. A business associate agreement, including a data use agreement, between the American College of Surgeons and CoC accredited facilities is in place. The NCDB is a facility-based database, representing 48.4% of all melanomas diagnosed in the United States.14, 15 This database contains cases of patients 18 or older who

Results

We identified 153,218 patients, of whom 71,950 were treated 30 days or more after biopsy. Specifically, 44.9% of stage I melanomas were treated 29 or more days after biopsy, as were 50.3% of stage II and 51.3% of stage III melanomas (Supplemental Fig 1; available at http://www.jaad.org). Furthermore 9% of stage I melanomas were treated 59 or more days after biopsy, as were 11.8% of stage II and 11.7% of stage III melanomas. Patients with a longer TTI tended to be older, be male, be using

Discussion

In this study, we were, to the best of our knowledge, the first to show that OS decreases in patients waiting longer than 90 days for definitive surgical treatment of melanoma regardless of stage. Moreover, we believe that we are reporting for the first time that delay of surgery beyond the first 29 days for stage I melanoma negatively OS when 30-day intervals are used. Furthermore, when TTI was analyzed in 2-week intervals for stage I, we found that the critical time point at which TTI in the

Conclusion

In conclusion, we found that definitive surgical treatment for stage I melanoma should be expeditious, whereas definitive surgical treatment for stage II and III may not affect OS in the current milieu of melanoma. Furthermore, expeditious patient identification and biopsy could migrate would-be stage II and III patients to stage I, where TTI optimization can be used to further improve their OS. On the basis of the available literature combined with our data, it is likely that these times are

References (35)

  • C.T. Murphy et al.

    Survival impact of increasing time to treatment initiation for patients with head and neck cancer in the United States

    J Clin Oncol

    (2016)
  • R.J. Bleicher et al.

    Time to surgery and breast cancer survival in the United States

    JAMA Oncol

    (2016)
  • D.B. McKenna et al.

    The time from diagnostic excision biopsy to wide local excision for primary cutaneous malignant melanoma may not affect patient survival

    Br J Dermatol

    (2002)
  • P.D. Baade et al.

    The relationship between melanoma thickness and time to diagnosis in a large population-based study

    Arch Dermatol

    (2006)
  • S. Hajdarevic et al.

    Health-care delay in malignant melanoma: various pathways to diagnosis and treatment

    Dermatol Res Pract

    (2014)
  • K.Y. Bilimoria et al.

    The National Cancer Data Base: a powerful initiative to improve cancer care in the United States

    Ann Surg Oncol

    (2008)
  • R.D. Neal et al.

    Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review

    Br J Cancer

    (2015)
  • Cited by (96)

    View all citing articles on Scopus

    Funding sources: None.

    Conflicts of interest: None declared.

    Reprints not available from the authors.

    View full text