Identifying Safe Windows for Melanoma Surgery Improves Survival

Expediting treatment in patients with stage 1 melanoma is associated with improved outcomes, however physicians must work toward finding a safe window to treat these patients following diagnosis, according to study results published in the Journal of the American Academy of Dermatology.

Although accelerating melanoma treatment, in particular surgery, is a priority for most patients, such urgency may exceed surgeon or hospital availability. Therefore, dermatologists must first consider the biology of a patient’s tumor.

“From a biologic standpoint, the earlier you get to melanoma, in terms of where it is starting from in the skin or even if it is in the lymph nodes and you’re trying to avoid it from going to the rest of the body, or if it is in the rest of the body and you are catching it still earlier it becomes even more burden of disease,” Brian R. Gastman, M.D., Director of Melanoma Surgery at Cleveland Clinic, said in an interview with CURE. “There are clear benefits.”

However, Gastman admitted that even speeding up surgery does not mean the dermatologist caught the disease early enough. “Even removing it as fast as you can may not avoid cancer that is [advanced] already,” he added. “We don’t know how much time has passed. So, for us as physicians it is always better to err on the side of caution.”

In addition to the biology of the tumor, psychology of the patient becomes a factor for dermatologists, in that they want their lesions removed as soon as possible following their biopsy. “There are clearly more patients than dermatologists and surgeons, and so, we can’t always accommodate patients immediately,” said Gastman.

Therefore, the researchers evaluated the impact of time to melanoma surgery on overall survival (OS) in 153,218 patients with stage 1 to stage 3 cutaneous melanoma.

Patients who were treated between 90 and 119 days after biopsy and more than 119 days after biopsy had a higher risk for mortality compared with those treated within 30 days of biopsy. To further evaluate survival, the researchers assessed this impact in the various disease stages. Patients with stage 1 disease had a higher mortality risk if they were treated within 30 to 59 days, 60 to 89 days, 90 to 119 days and more than 119 days after biopsy. Surgical timing did not affect survival in patients with stage 2 and stage 3 disease.

Gastman attributed this finding to the fact that a later diagnosis initially leads to advanced disease. “With stage 1, catching it so early, surgery really is curative at that point. But the longer you wait, that stage 1 patient starts to become more like a stage 2 or stage 3 patient and that is why they may be worse. Just because we didn’t show a difference for stage 2 and 3, does not mean there isn’t something there that time to treat doesn’t affect it.”

Regardless of disease stage, earlier treatment to cure melanoma may not be as simple as undergoing surgery as soon as possible. Patients must first regularly check themselves for lesions, and seek medical attention as soon as they think something may be wrong.

Gastman compared the process to that of passing off a baton: first, from the patient to their primary physician, which is then passed to a dermatologist for biopsies, and lately, to a surgeon to remove the malignant lesion. “Every baton hand off is time. So, by the time a patient gets to a surgeon, the delay has already occurred, and the surgeon is being asked to make up for that delay immediately,” he added.

“The discussion should start even earlier when the patient has a highly suspicious-looking lesion. Certainly when the patient and their physician feels this could be melanoma, at that point, is actually the best time to try to speed the process up.”