0
Research Letters |

Management of Melanoma in a Patient Population: Using Electronic Health Records to Enhance Postdiagnosis Surveillance FREE

Amy Reisenauer, MD; Brian J. Lee, MD; Kristie Akamine, MD; Michael Tabacchini, CT(ASCP); Spring Golden, MD
[+] Author Affiliations

Author Affiliations: Departments of Dermatology (Dr Reisenauer), Nephrology (Dr Lee), and Pathology (Mr Tabacchini), Hawaii Permanente Medical Group, Honolulu, Hawaii; and University of Hawaii John A. Burns School of Medicine, Honolulu (Drs Akamine and Golden).


JAMA Dermatol. 2013;149(3):365-366. doi:10.1001/jamadermatol.2013.1296.
Text Size: A A A
Published online

Early detection of melanoma reduces morbidity and mortality, yet research to evaluate the effectiveness of total-body skin examinations (TBSEs) is lacking. Because a history of melanoma confers a greater risk for developing subsequent primary melanomas (SPMs),1 the Dermatology Division of Kaiser Permanente Hawaii recommends at least annual TBSEs in these patients. Our study evaluated the benefit of using electronic health records (EHRs) to track patients with a history of melanoma to ensure annual TBSEs.

Individuals diagnosed as having an SPM between February 1, 2010, and February 28, 2011, were included using Kaiser Permanente's KP HealthConnect EHR. Chart review was performed to determine if the SPM was diagnosed during a Kaiser Permanente–initiated annual screening TBSE or a patient-initiated encounter. Patient awareness of the lesion was also assessed. One sample t test was used to determine whether the SPM incidence in the Kaiser Permanente Hawaii population differed from the baseline melanoma incidence in Hawaii. Multiple regression analysis using stepwise backward elimination evaluated age, sex, and patient awareness of lesion as predictors of Breslow thickness. Statistical analyses were performed using SAS software, version 9.1 (SAS Institute Inc). Kaiser Permanente Hawaii's institutional review board approved this study.

During our study period, 48 SPMs were diagnosed in 42 patients. The incidence of SPMs was significantly higher than the baseline melanoma incidence in Hawaii (P < .001).2

Of the 48 SPMs, 40 (83%) were diagnosed in patients who were contacted for a timely annual TBSE and an additional 4 (8%) were diagnosed in patients who were contacted because they were overdue for this examination. None of these patients were aware of their melanomas (Figure, groups A and B). Four SPMs (8%) were diagnosed in patients who were not due for TBSEs but who detected a worrisome lesion on themselves (Figure, group C).

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Second primary melanomas diagnosed during 13-month study period. PT indicates patient. *Kaiser Permanente–initiated appointment for screening total-body skin examination.

The time lapse between the SPM and the most recent prior melanoma ranged from 3 months to 31 years (mean, 4.4 years) (Table). The mean Breslow thickness of the invasive SPMs was 0.39 mm. Twenty-seven percent of SPMs were thicker than the most recent prior melanoma (13 of 48); 13% were the same thickness (6 of 48); 50% were thinner (24 of 48); and 10% had unknown prior melanoma thicknesses (5 of 48). Sixty-five percent of SPMs occurred on non–sun-exposed skin, presumably decreasing the ease of patient self-detection for these lesions.

Table Graphic Jump LocationTable. Characteristics of Subsequent Primary Melanomas by Group

With multivariate regression using stepwise backward elimination, age and gender were found not to predict Breslow thickness, but patient awareness of the lesion was a predictive factor. The melanomas detected by patients (group C, average Breslow thickness, 0.57 mm) were significantly thicker than those detected by the dermatologists during screening examinations (groups A and B, average Breslow thickness, 0.22 mm) (P < .01).

A history of melanoma confers an increased risk for SPMs, often occurring within a few months to 2 years after the primary melanoma is identified. However, some studies have shown significantly longer intervals between the initial and second primaries.3 The long interval found in our study lends support to the concept of lifelong annual follow-up.

Screening TBSEs performed by physicians during the SCREEN study4 resulted in an increase in melanoma incidence, proving TBSEs to be an effective screening tool. Brobeil et al5 found that 93% of SPMs were dermatologistdetected, which correlates with the 90% rate in our study. Given the high number of SPMs diagnosed in our patient population over 13 months, at least annual TBSEs for patients with a history of melanoma seems advisable.

Breslow thicknesses of SPMs detected through screening examinations are usually thinner than the initial melanomas, but a substantial minority (up to 30%) are thicker.3 Similarly, in our study, 50% of SPMs were thinner, while 27% were thicker than the most recent prior melanomas. This suggests that routine TBSEs lead to earlier detection of melanomas, thinner Breslow measurements, and therefore improved overall patient survival.

This study evaluated the effect of screening TBSEs on short-term disease detection rates in a high-risk population but did not address long-term effects on patient outcomes or cost-effectiveness. Incidence of SPM in this study is likely increased due to enhanced screening efforts.4 The utility of screening TBSEs in a low-risk patient population was not addressed. Furthermore, Kaiser Permanente patients may be more amenable to regular preventive health screenings. For dermatology practices without an EHR, a manual spreadsheet of patients with melanoma could be created to track annual follow-up visits.

In conclusion, this study lends further support to the hypothesis that annual TBSEs for patients with a history of melanoma leads to the detection of asymptomatic disease. Using an EHR to identify high-risk patients who are due or overdue for annual TBSEs leads to earlier detection of second primary melanomas and increases patient survival.

Correspondence: Dr Reisenauer, Kaiser Permanente, 80 Mahalani St, Wailuku, HI 96793 (amy.k.reisenauer@kp.org).

Accepted for Publication: August 21, 2012.

Author Contributions: Dr Reisenauer had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Reisenauer. Acquisition of data: Reisenauer, Lee, Akamine, Tabacchini, and Golden. Analysis and interpretation of data: Reisenauer, Lee, Akamine, and Golden. Drafting of the manuscript: Lee, Akamine, Tabacchini, and Golden. Critical revision of the manuscript for important intellectual content: Reisenauer, Lee, Akamine, and Golden. Statistical analysis: Lee. Administrative, technical, and material support: Lee and Tabacchini. Study supervision: Reisenauer.

Conflict of Interest Disclosures: None reported.

DiFronzo LA, Wanek LA, Elashoff R, Morton DL. Increased incidence of second primary melanoma in patients with a previous cutaneous melanoma.  Ann Surg Oncol. 1999;6(7):705-711
PubMed   |  Link to Article
Howlader NA, Krapcho M, Neyman N,  et al.  SEER Cancer Statistics Review, 1975-2008. http://seer.cancer.gov/csr/1975_2008/. Accessed July 16, 2011
Titus-Ernstoff L, Perry AE, Spencer SK,  et al.  Multiple primary melanoma: two-year results from a population-based study.  Arch Dermatol. 2006;142(4):433-438
PubMed   |  Link to Article
Waldmann A, Nolte S, Weinstock MA,  et al.  Skin cancer screening participation and impact on melanoma incidence in Germany: an observational study on incidence trends in regions with and without population-based screening.  Br J Cancer. 2012;106(5):970-974
PubMed   |  Link to Article
Brobeil A, Rapaport D, Wells K,  et al.  Multiple primary melanomas: implications for screening and follow-up programs for melanoma.  Ann Surg Oncol. 1997;4(1):19-23
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Second primary melanomas diagnosed during 13-month study period. PT indicates patient. *Kaiser Permanente–initiated appointment for screening total-body skin examination.

Tables

Table Graphic Jump LocationTable. Characteristics of Subsequent Primary Melanomas by Group

References

DiFronzo LA, Wanek LA, Elashoff R, Morton DL. Increased incidence of second primary melanoma in patients with a previous cutaneous melanoma.  Ann Surg Oncol. 1999;6(7):705-711
PubMed   |  Link to Article
Howlader NA, Krapcho M, Neyman N,  et al.  SEER Cancer Statistics Review, 1975-2008. http://seer.cancer.gov/csr/1975_2008/. Accessed July 16, 2011
Titus-Ernstoff L, Perry AE, Spencer SK,  et al.  Multiple primary melanoma: two-year results from a population-based study.  Arch Dermatol. 2006;142(4):433-438
PubMed   |  Link to Article
Waldmann A, Nolte S, Weinstock MA,  et al.  Skin cancer screening participation and impact on melanoma incidence in Germany: an observational study on incidence trends in regions with and without population-based screening.  Br J Cancer. 2012;106(5):970-974
PubMed   |  Link to Article
Brobeil A, Rapaport D, Wells K,  et al.  Multiple primary melanomas: implications for screening and follow-up programs for melanoma.  Ann Surg Oncol. 1997;4(1):19-23
PubMed   |  Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles
JAMAevidence.com

Users' Guides to the Medical Literature
Melanoma

The Rational Clinical Examination
Make the Diagnosis: Melanoma