Kristy K Broman1, Joshua Richman2, Smita Bhatia2. 1. Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, AL. Electronic address: kristybroman@uabmc.edu. 2. Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, AL.
Abstract
BACKGROUND: Melanoma clinical trials demonstrated that completion lymph node dissection is low value for most sentinel lymph node-positive patients. Contemporaneous trials of adjuvant systemic immunotherapy and BRAF/MEK targeted therapy showed improved recurrence-free survival in high-risk sentinel lymph node-positive patients. To better understand how oncologic evidence is incorporated into practice (implementation), we evaluated factors associated with discontinuation of completion lymph node dissection and adoption of systemic treatment at United States Commission on Cancer-accredited centers. METHODS: In a retrospective cohort study of adults with sentinel lymph node-positive melanoma treated from 2012 to 2017 using the National Cancer Database, we evaluated use of completion lymph node dissection and adjuvant systemic treatment using mixed-effects logistic regression, reporting results as odds ratios with 95% confidence intervals. RESULTS: Among 10,240 sentinel lymph node-positive melanoma patients, performance of completion lymph node dissection declined from 60% to 27%. Adjuvant systemic treatment increased from 29% to 43% (37% in stage IIIA patients, 46% in IIIB-C). Completion lymph node dissection was less common with lower extremity tumors (odds ratio = 0.53, 95% confidence interval = 0.44-0.64) and more common with multiple positive sentinel lymph nodes (odds ratio = 2.36, 95% confidence interval = 2.08-2.67), treatment at a high- or moderate-volume center (odds ratiohigh = 1.49, 95% confidence interval = 1.05-2.12; odds ratiomoderate = 1.32, 95% confidence interval = 1.05-1.64), and receipt of systemic therapy (odds ratio = 1.44, 95% confidence interval = 1.27-1.63). The increased likelihood of completion lymph node dissection in patients receiving adjuvant systemic treatment persisted in the most recent study years and in patients with a single positive sentinel lymph node. CONCLUSION: At a population level, completion lymph node dissection declined and adjuvant systemic treatment increased, reflecting evidence-responsive care. Variation in persistent use of completion lymph node dissection and in provision of adjuvant treatment for lower risk patients highlights residual gaps in both evidence and implementation.
BACKGROUND: Melanoma clinical trials demonstrated that completion lymph node dissection is low value for most sentinel lymph node-positive patients. Contemporaneous trials of adjuvant systemic immunotherapy and BRAF/MEK targeted therapy showed improved recurrence-free survival in high-risk sentinel lymph node-positive patients. To better understand how oncologic evidence is incorporated into practice (implementation), we evaluated factors associated with discontinuation of completion lymph node dissection and adoption of systemic treatment at United States Commission on Cancer-accredited centers. METHODS: In a retrospective cohort study of adults with sentinel lymph node-positive melanoma treated from 2012 to 2017 using the National Cancer Database, we evaluated use of completion lymph node dissection and adjuvant systemic treatment using mixed-effects logistic regression, reporting results as odds ratios with 95% confidence intervals. RESULTS: Among 10,240 sentinel lymph node-positive melanoma patients, performance of completion lymph node dissection declined from 60% to 27%. Adjuvant systemic treatment increased from 29% to 43% (37% in stage IIIA patients, 46% in IIIB-C). Completion lymph node dissection was less common with lower extremity tumors (odds ratio = 0.53, 95% confidence interval = 0.44-0.64) and more common with multiple positive sentinel lymph nodes (odds ratio = 2.36, 95% confidence interval = 2.08-2.67), treatment at a high- or moderate-volume center (odds ratiohigh = 1.49, 95% confidence interval = 1.05-2.12; odds ratiomoderate = 1.32, 95% confidence interval = 1.05-1.64), and receipt of systemic therapy (odds ratio = 1.44, 95% confidence interval = 1.27-1.63). The increased likelihood of completion lymph node dissection in patients receiving adjuvant systemic treatment persisted in the most recent study years and in patients with a single positive sentinel lymph node. CONCLUSION: At a population level, completion lymph node dissection declined and adjuvant systemic treatment increased, reflecting evidence-responsive care. Variation in persistent use of completion lymph node dissection and in provision of adjuvant treatment for lower risk patients highlights residual gaps in both evidence and implementation.
Authors: Christina A Minami; Jeffrey D Wayne; Anthony D Yang; Mary C Martini; Pedram Gerami; Sunandana Chandra; Timothy M Kuzel; David P Winchester; Bryan E Palis; Karl Y Bilimoria Journal: Ann Surg Oncol Date: 2016-06-08 Impact factor: 5.344
Authors: Carlo Riccardo Rossi; Simone Mocellin; Luca Giovanni Campana; Lorenzo Borgognoni; Serena Sestini; Giuseppe Giudice; Corrado Caracò; Adriana Cordova; Nicola Solari; Dario Piazzalunga; Paolo Carcoforo; Pietro Quaglino; Virginia Caliendo; Simone Ribero Journal: Ann Surg Oncol Date: 2017-10-24 Impact factor: 5.344
Authors: Karl Y Bilimoria; Charles M Balch; Jeffrey D Wayne; David C Chang; Bryan E Palis; Sydney M Dy; Julie R Lange Journal: J Clin Oncol Date: 2009-03-09 Impact factor: 44.544
Authors: Georgina V Long; Axel Hauschild; Mario Santinami; Victoria Atkinson; Mario Mandalà; Vanna Chiarion-Sileni; James Larkin; Marta Nyakas; Caroline Dutriaux; Andrew Haydon; Caroline Robert; Laurent Mortier; Jacob Schachter; Dirk Schadendorf; Thierry Lesimple; Ruth Plummer; Ran Ji; Pingkuan Zhang; Bijoyesh Mookerjee; Jeff Legos; Richard Kefford; Reinhard Dummer; John M Kirkwood Journal: N Engl J Med Date: 2017-09-10 Impact factor: 91.245
Authors: Zubin M Bamboat; Ioannis T Konstantinidis; Deborah Kuk; Charlotte E Ariyan; Mary Sue Brady; Daniel G Coit Journal: Ann Surg Oncol Date: 2014-05-16 Impact factor: 5.344
Authors: Nicole Mott; Ton Wang; Jacquelyn Miller; Nicholas L Berlin; Sarah Hawley; Reshma Jagsi; Brian J Zikmund-Fisher; Lesly A Dossett Journal: Ann Surg Oncol Date: 2020-07-27 Impact factor: 5.344
Authors: Kristy Kummerow Broman; Tasha Hughes; Lesly Dossett; James Sun; Dennis Kirichenko; Michael J Carr; Avinash Sharma; Edmund K Bartlett; Amanda A G Nijhuis; John F Thompson; Tina J Hieken; Lisa Kottschade; Jennifer Downs; David E Gyorki; Emma Stahlie; Alexander van Akkooi; David W Ollila; Jill Frank; Yun Song; Giorgos Karakousis; Marc Moncrieff; Jenny Nobes; John Vetto; Dale Han; Jeffrey M Farma; Jeremiah L Deneve; Martin D Fleming; Matthew C Perez; Michael C Lowe; Roger Olofsson Bagge; Jan Mattsson; Ann Y Lee; Russell S Berman; Harvey Chai; Hidde M Kroon; Juri Teras; Roland M Teras; Norma E Farrow; Georgia Beasley; Jane Yuet Ching Hui; Lukas Been; Schelto Kruijff; Youngchul Kim; Syeda Mahrukh Hussnain Naqvi; Amod A Sarnaik; Vernon K Sondak; Jonathan S Zager Journal: Cancer Date: 2021-04-07 Impact factor: 6.921
Authors: Kristy K Broman; Tasha M Hughes; Lesly A Dossett; James Sun; Michael J Carr; Dennis A Kirichenko; Avinash Sharma; Edmund K Bartlett; Amanda Ag Nijhuis; John F Thompson; Tina J Hieken; Lisa Kottschade; Jennifer Downs; David E Gyorki; Emma Stahlie; Alexander van Akkooi; David W Ollila; Jill Frank; Yun Song; Giorgos Karakousis; Marc Moncrieff; Jenny Nobes; John Vetto; Dale Han; Jeffrey Farma; Jeremiah L Deneve; Martin D Fleming; Matthew Perez; Kirsten Baecher; Michael Lowe; Roger Olofsson Bagge; Jan Mattsson; Ann Y Lee; Russell S Berman; Harvey Chai; Hidde M Kroon; Roland M Teras; Juri Teras; Norma E Farrow; Georgia M Beasley; Jane Yc Hui; Lukas Been; Schelto Kruijff; David Boulware; Amod A Sarnaik; Vernon K Sondak; Jonathan S Zager Journal: J Am Coll Surg Date: 2020-12-13 Impact factor: 6.532