Many skin cancer patients do not receive sentinel lymph node biopsy

Although clinical practice guidelines recommend sentinel lymph node (SLN) biopsy for many patients with clinically node-negative melanoma, a new analysis from the National Cancer Database (NCDB) of the American College of Surgeons (ACS) has found approximately half of patients do not receive recommended evaluation of their lymph nodes and that the type of health insurance a patient has, the type of hospital delivering treatment, and the hospital's geographic region are all associated with provider compliance with those guidelines.

In 1998, the National Comprehensive Cancer Network (NCCN) adopted the practice guideline that physicians should offer sentinel lymph node biopsy to patients with Clinical Stage IB or II melanoma as a tool to stage the disease and help guide treatment decisions. This new NCDB study confirmed previous findings that only about half of eligible patients actually undergo the procedure.

"There obviously needs to be education of providers at multiple levels-the primary care physician, the dermatologist, and even the surgeon-that sentinel lymph node biopsy is not only acceptable but is beneficial in staging and clinical decision making for patients with Stage IB or II melanomas," according to lead author Karl Bilimoria, MD, MS, who was an American College of Surgeons (ACS) Research Fellow based at the Feinberg School of Medicine, Northwestern University, Chicago, IL, at the time the study was conducted.

The NDCB study findings were recently published online in the Journal of Clinical Oncology, and will appear in a print version of the journal later this year. Dr. Bilimoria and colleagues analyzed hospital data from the NCDB on 16,598 patients with melanoma. "Variance in adherence to cancer care guidelines can be a call for improved provider education or reconsideration of health policy," according to senior author Julie Lange, MD, ScM, FACS, associate professor of surgery, oncology and dermatology at Johns Hopkins Medicine in Baltimore, MD, and a member of the NCCN Melanoma Committee.

The researchers found that patients with Clinical Stage IB or II melanoma were far more likely to undergo SLN biopsy if they were treated at NCCN centers or National Cancer Institute-designated centers: 60 percent for this group compared with 25 percent at Veterans Affairs centers and 43 percent at community hospitals.

The ACS researchers also found that a significantly higher percentage of melanoma patients with private insurance had sentinel lymph node biopsy for Stage IB or II disease compared with those on Medicare or Medicaid. Likewise, the researchers identified regional variances in the proportion of melanoma patients who had sentinel lymph node biopsy. For example, patients treated in the South and Northeast had the lowest proportional rates of SLN biopsy, while the Pacific and Great Lakes regions had the highest.

"Most surgical oncologists recognize the importance of sentinel node biopsy, but we need to make sure that our colleagues in other fields also understand why we're performing sentinel lymph node biopsy and why it's important for our patients," Dr. Lange said. "On an institutional and national level, we need to continue the discussion on how to make this happen."

One solution may be to have the NCDB more readily share its data with providers. "By sending that data back to hospitals, we can show them how their performance compares with that of the other hospitals in the United States," Dr. Bilimoria concluded.

In addition to Drs. Bilimoria and Lange, contributing authors were Charles M. Balch, MD, FACS, (Johns Hopkins Medicine); Jeffrey D. Wayne, MD, FACS, (Northwestern University); David C. Chang, PhD, MBA, (Johns Hopkins Medicine); Bryan E. Palis, (American College of Surgeons Commission on Cancer); and Sydney M. Dy, MD, (Johns Hopkins Medicine).

The National Cancer Database, a joint program of the ACS Commission on Cancer and the American Cancer Society, is recognized as the largest clinical registry in the world. It is a nationwide oncology outcomes database for more than 1,430 ACS Commission on Cancer accredited cancer programs in the United States and Puerto Rico, and captures approximately 70 percent of all new invasive cancers diagnosed annually.

The study was supported by the American College of Surgeons Clinical Scholars in Residence program and the Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.

Citation: Karl Y. Bilimoria, Charles M. Balch, Jeffrey D. Wayne, David C. Chang, Bryan E. Palis, Sydney M. Dy, and Julie R. Lange. Health Care System and Socioeconomic Factors Associated With Variance in Use of Sentinel Lymph Node Biopsy for Melanoma in the United States. JCO Mar 9 2009: doi:10.1200/JCO.2008.18.7567