Citation for published version (APA): Francken, A. B. (2007). Primary and metastatic melanoma: aspects of follow-up and staging s.n.

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1 University of Groningen Primary and metastatic melanoma Francken, Anne Brecht IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2007 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Francken, A. B. (2007). Primary and metastatic melanoma: aspects of follow-up and staging s.n. Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date:

2 Chapter 2 Detection of first relapse in cutaneous melanoma patients: implications for the formulation of evidence-based follow-up guidelines Anne Brecht Francken Helen M. Shaw Neil A. Accortt Seng-Jaw Soong Harald J. Hoekstra John F. Thompson Ann Surg Oncol 2007;14: Proefschrift.indb :57:30

3 Chapter 2 ABSTRACT Introduction The value of follow-up surveillance for patients with cutaneous melanoma remains uncertain. In this prospective study the frequency of detection of first melanoma relapse (FMR) by patient or doctor was analyzed, to assist in the future design of evidence-based follow-up guidelines. Methods Patients who had a recurrence of a previously treated AJCC Stage I-III primary melanoma (PM) were interviewed to ascertain how their PM and their FMR were detected. Factors predicting the detection of PM and FMR were analyzed. Results The study group comprised 211 patients. In 168 patients information on detection of their PM was available; 102 PMs (61%) were detected by the patient and 18 (11%) by their partner. Higher AJCC Stage, visible location for the patient and female gender were independent predictive factors for patient-detected PM (p-values 0.03, and 0.02 respectively). The FMR type was local - 28 (13%), in transit - 35 (17%), regional lymph node - 97 (46%) and distant - 51 (24%). 73% of all FMRs were detected by the patient. The presence of a symptom was the only independent predictor of a patient-detected FMR (p<0.0001). There was no significant survival difference between the patient-detected and doctor-detected FMRs. Conclusion Three-quarters of FMRs were detected by patients or their partners and it should be possible to improve this rate even further by better education. More frequent follow-up visits are thus unlikely to be valuable, whereas reductions in follow-up frequency may be safe and economically responsible. 60

4 Recurrence detection in melanoma patients INTRODUCTION Follow-up recommendations for patients who have been treated for a primary melanoma (PM) are not uniform. Over the past 20 years various follow-up schedules have been suggested, with large variations in the recommended frequencies of follow-up visits, but with no international consensus having been reached. 1 Proposals for follow-up schedules have been based on calculations of the risk of developing a melanoma recurrence (by analysis of retrospective follow-up data), cost-effectiveness considerations and the possibility of curing some patients who develop a recurrence. Several authors have recommended reductions in the intensity of follow-up regimens based on these factors. 2-5 However, some have taken the opposite view, proposing that more intensive follow-up will improve outcomes by earlier detection of recurrences. 6-8 In seeking to rationalize follow-up regimens, it is clear that the person detecting the first melanoma recurrence (FMR) should be taken into account. In an earlier Sydney Melanoma Unit (SMU) study 9 proposals for new follow-up intervals were based on the time distribution for developing a FMR, the extent of initial definitive treatment (elective lymph node dissection or no elective nodal treatment) and the probability of FMR detection at a follow-up visit. It was assumed that 50% of FMRs would be detected at a scheduled follow-up visit, although in other studies, all retrospective, this rate of patient FMR detection varied greatly, ranging from 33% to 90%. 2,4,5,10-15 The value of a follow-up visit has been expressed as the likelihood of detecting a FMR at a particular consultation. 9,12 This allows adjustment of follow-up schedules not only according to stage of disease and PM histology, but also according to the likelihood that the physician will indeed detect a FMR at the follow-up visit. In the current study, all patients in whom a FMR was detected were interviewed shortly after this relapse, the primary aim being to document the way in which the FMR was detected, and to compare this information with the way in which the PMs of the same patients were detected, in order to assist in the design of evidencebased guidelines for follow-up. PATIENTS AND METHODS Patient selection The following patients were selected: previously treated for a single PM, AJCC Stage I-III 16, and presenting to the SMU between July 2001 and February 2003 with a FMR. Patients with an occult primary melanoma and with a FMR diagnosed less than 6 weeks after PM diagnosis were excluded. 61

5 Chapter 2 Patients were divided into two Groups: Group A - patients able to be interviewed and Group B - patients unable to be interviewed due to death, severe illness or for some other reason (such as living outside Australia or having no telephone). Patients <18 or > 85 years of age were automatically assigned to Group B. Interview Group A patients were interviewed by telephone. Information was collected regarding the detection of the PM and FMR, whether they recalled receiving instruction on self-examination at the time of initial treatment, and what follow-up arrangements had been made. All information on Group B patients was retrieved from hospital medical records and the SMU database, with patients being included only if these sources gave complete and unambiguous information about their FMR detection. Primary melanoma characteristics and detection Age at PM diagnosis was coded as 1: <50 years; 2: years; 3: years; 4: 70 years. PM site was coded as 1: head and neck; 2: trunk; 3: upper extremity; 4: lower extremity. The person detecting the PM was coded as 1: patient; 2: partner; 3: family physician; 4: specialist physician; 5: other. The PMs were regarded as readily visible by the patient if they were located on any anterior area of the body or on the posterior aspect of the forearm or leg. All other sites were regarded as poorly visible by the patient (e.g. a lesion on the back or posterior thigh, or an internal metastasis). Primary tumor thickness, tumor ulcerative state and clinical stage were coded according to the current AJCC Staging System. 16 Variables investigated in relation to the person detecting the PM were: age at PM diagnosis, gender, PM histology (tumor thickness, Clark level of invasion, ulceration), AJCC stage, PM anatomic site and visibility for the patient. For statistical analysis the person detecting the PM was coded as 1: patient and 2: other (consisting of partners, friends, family physician, and others, but not doctors who performed specific skin screening). First relapse characteristics and detection Age at diagnosis of FMR was classified as for PM diagnosis. Recurrences were defined as 1: local (< 3 cm from the PM site); 2: in transit; 3: in regional lymph nodes; or 4: distant. The FMR location was classified as: 1. external (potentially detectable by inspection or palpation, including local, in transit, regional lymph node, and distant cutaneous or subcutaneous metastases) 2. internal. FMRs were regarded as readily visible by the patient according to the same criteria as those used for PMs. 62

6 Recurrence detection in melanoma patients The person detecting the FMR was coded as for PM detection. Patients were considered to have detected the FMR themselves if any symptom or sign relating to the FMR had resulted in a medical consultation (e.g. a lump or skin lesion, but also undefined symptoms such as a cough or neurologic deficit). Recurrence detection was broadly categorized as being detected by the patient or by a doctor. Patient detection was coded as by 1: formal self-examination; 2: noting a sign (e.g. accidentally detecting a symptomless lump); 3: symptoms (e.g. noting discomfort from a swollen lymph node). Detection by a doctor was coded as by 1: physical examination; 2: ultrasound; 3: chest X-ray; 4: computerized tomography (CT); or 5: other investigation. Any symptom(s) or sign(s) noted by the patient were coded as 1: no symptom or sign; 2: a sign, but no symptom (lump/swelling); 3: external pain/discomfort; 4: an internal and general symptom such as headache, cough, chest pain, abdominal pain, or general malaise. Variables statistically assessed in relation to the person detecting the FMR were: age at FMR, gender, and AJCC stage at PM diagnosis; symptoms, type, location of FMR and IP visibility, PM thickness, the time since the last follow-up visit (coded: 1: months, 2: months, 3: months, 4: > 12.0 months), the reported patient education and the person detecting the PM. For statistical purposes the person detecting the FMR was coded as 1: patient/ partner/relative; and 2: doctor at follow-up visit. The few FMRs detected by an unrelated person (e.g. hairdresser) was excluded from the multivariate analysis. Patient follow-up advice and education The follow up recommendations given to patients before and over the period of the study were based on the guidelines proposed by the SMU in a previous publication. 9 In general, all patients with tumors more than 1.0mm in thickness were advised to return for review at least twice a year for the first five years after treatment of their PM, and at least annually thereafter. At interview patients were asked if they recalled having received instructions on self-examination at the time of PM diagnosis and/or treatment. This was coded as 1: yes; 2: no. They were also asked to give their preference in regard to follow-up frequency during the first year after PM diagnosis. This was coded as 1: every month; 2: every 3 months; 3: every 6 months; 4: after one year; 5: only if medical reassurance was desired. Analyses and statistics Differences in distribution between Group A (interviewed patients) and Group B (those unable to be interviewed) were tested using the Mann-Whitney-U test for primary tumor thickness, AJCC stage and type of FMR. Differences in distribution of the person who detected the FMR between Groups A and B were determined 63

7 Chapter 2 using Fisher s exact test. Chi-squared and Fisher s exact tests were performed to determine the univariate relations between variables and the person detecting the PM or the FMR. A multivariate logistic regression model was used to determine which variables had an independent relationship with the person who detected the 1: PM and 2: FMR. Only variables which had a p-value <0.2 in the univariate analysis were brought into the regression model. A survival analysis was performed using the Kaplan Meier method and the log rank test to compare patients with non-symptomatic and symptomatic FMRs and patients with patient-detected and doctor-detected FMRs. Statistical significance for all tests was considered to exist if the p-value was < RESULTS Patient selection In total 262 SMU patients with a FMR detected were identified between July 2001 and February 2003 were identified. 211 were eligible for inclusion in the study (Figure 1). Clinical and pathologic variables and detection of PM Clinical and pathologic features of the PM are detailed in Table 1 (n = 211). The median time interval between PM detection and interview (Group A) was 34 months (range 5-336). Since 43 patients were unable to be interviewed, completely reliable information about the person who detected the PM was available for only 168 patients (Table 2). Seventy-one percent of the PMs were detected by the patient or their partner and 18% by a doctor. Distributions of clinical and pathologic factors according to the person detecting the PM are given in Table 3 (this analysis excluded 10 patients whose primary melanoma was detected by a physician undertaking routine skin screening). Univariate analysis showed a statistically significant relationship between the person detecting the PM and ready visibility of the PM site, clinical stage at PM diagnosis, tumor thickness and gender. Multivariate logistic regression showed the same variables to be statistically significant, except for tumor thickness (Table 4). First melanoma relapse characteristics and detection The median time to detection of a FMR was 28 months (range 2-322). Characteristics of the person detecting the FMR are given in Table 5. Recurrences in regional lymph node and at distant sites were most common. The distribution of distant 64

8 Recurrence detection in melanoma patients metastases was: intrathoracic (lung or mediastinum) 18 (35%), at multiple sites 11 (22%), hematogeneous intradermal / subcutaneous 9 (17%), lymph node at a distant site 5 (10%), brain 4 (8%), bone 2 (4%) and at other sites 2 (4%). Symptoms were present in 157 patients (74%). In 61 patients (39%) FMR detection was reported as a consequence of symptoms. Of 56 FMRs detected at a follow-up visit, 35 were by physical examination (63%), eight were by chest X-ray (14%; 4% of the total number of FMRs) and 6 (11%) by lymph node ultrasound examination (Table 6). The median time between FMR diagnosis and interview was 5.3 (range ) months. In 154 patients (73%) the detection was by either patient, partner or relative (67% by the patients themselves). In 57 patients, detection was by a doctor (27%), but in only 50 (24%) was this at a routine follow-up visit (Table 6). The last follow-up-interval before FMR detection was known in 201 patients (Table 7). Although most patients had attended for regular follow-up visits, 20 (10%) had not attended for follow-up 2 years prior to FMR detection. On multivariate analysis, only the presence of symptoms appeared to be an independent variable predicting the person detecting the FMR. Thus symptomatic patients were more likely to detect their own FMR (odds ratio 0.004) (Table 8). This analysis excluded 7 patients whose first melanoma recurrence was detected accidentally by someone not related to the patient. Survival analysis The mean survival time was 23.8 months. Ninety-six patients (47%) had died of melanoma in this period. Survival analysis comparing patients with non- Figure 1. Selection process for patients with a first melanoma recurrence. 65

9 Chapter 2 Table 1. Clinical and pathologic features of the primary melanoma in 211 patients Male n (%) Female n (%) Gender 131 (62) 80 (38) Anatomic site head and neck 27 (21) 15 (19) trunk 69 (53) 17 (21) upper extremities 12 (9) 13 (16) lower extremities 23 (18) 35 (44) total Age (median and range in years) 58 (4-87) 60 (19-84) Breslow tumor thickness (mm) Mean (total group) Median (range) (total group) 2.1 ( ) - < or equal to (18) 19 (26) (30) 19 (26) (32) 23 (32) > (20) 12 (16) total Missing values 5 7 Ulceration absent 59 (55) 39 (62) present 49 (45) 24 (38) total Missing values Clark level of invasion 2 10 (8) 5 (6) 3 36 (30) 17 (24) 4 54 (44) 43 (60) 5 22 (18) 7 (10) total Missing values 9 8 Clinical stage at primary diagnosis I 37 (29) 25 (33) II 69 (55) 34 (45) III 20 (16) 17 (22) total Missing values

10 Recurrence detection in melanoma patients Table 2. Person who detected the primary melanoma in 168 patients* n % patient 102 (61) partner 18 (11) general practitioner 21 (13) specialist 9 (5) other 18 (11) total 168 * missing values (Group B) 43 Table 3. Clinical and pathologic features of the primary melanoma in 158 patients* and its detection Patient Other p-value** n (%) n (%) Total 102 (65) 56 (35) Male gender 57 (56) 42 (75) 0.02 Age at primary melanoma diagnosis (years) 1.0 Anatomical site 0.9 Readily visible primary melanoma 68 (67) 23 (41) Breslow tumor thickness (mm) (18) 15 (28) (27) 18 (34) (35) 14 (26) > (20) 6 (11) total total missing values 7 4 Ulceration present 35 (43) 15 (35) 0.4 Clark level (6) 8 (15) 3 24 (27) 16 (30) 4 47 (53) 23 (43) 5 13 (15) 6 (11) total total missing values 12 4 Clinical stage at primary diagnosis 0.02 I 23 (24) 22 (42) II 49 (51) 24 (45) III 24 (24) 7 (13) total total missing values 6 3 * this analysis excludes 10 patients whose primary melanoma was detected by a doctor at a scheduled follow-up visit ** univariate analysis 67

11 Chapter 2 Table 4. Univariate and multivariate analyses of person who detected the primary melanoma (n=158)* Univariate p-value Multivariate p-value odds ratio lower upper Stage at primary melanoma diagnosis Readily visible site Gender Thickness 0.04 ns Clark level of invasion 0.08 ns ns=not significant * this analysis excludes 10 patients whose primary melanoma was detected by a physician at a specific screening visit. symptomatic and symptomatic FMRs showed no significant difference, nor was there any survival difference when patients with patient-detected and doctordetected FMRs were compared. Figures 2 and 3. Patient education and preferences Of the 165 patients for whom this information was available, 94(57%) recalled having received instruction about examining their skin and regional lymph node fields for recurrence at the time of PM diagnosis and treatment. Of the 96 interviewed patients, 57% expressed a preference for follow-up visits on a threemonthly basis in the first year after diagnosis. DISCUSSION The primary aim of this prospective study was to document how FMR was detected in melanoma patients. It was found that the patient or a partner or relative detected 73% of FMRs. Because of the study design, this information is likely to have been more accurately determined than in previous studies. We found that the detector could not be predicted on the basis of clinical or pathologic PM features and our high proportion of patient-detected FMRs casts doubt on the value and costeffectiveness of frequent follow-up checks. Thus our study could contribute to the development of more rigorously evidence-based recommendations than currently exist for follow-up of melanoma patients. PM detection Several previous studies have documented the person who detects a PM. Brady et al found that 270 of 471 PMs were patient-detected (57%) and Blum et al reported a similar percentage 58% (247/429). 17,18 The proportion of patient-detected PMs in the current study (61%) was slightly higher than previously reported, possibly 68

12 Recurrence detection in melanoma patients Table 5. Clinical features of first recurrences in 204* melanoma patients** and doctors detecting the recurrence Patient** n (%) Doctor n (%) P-value*** Total 154 (75) 50 (25) Male Gender 99 (64) 30 (60) 0.6 Age at recurrence diagnosis (years) 0.07 <50 38 (25) 8 (16) (24) 10 (20) (18) 8 (16) (34) 24 (48) Type of recurrence 0.7 local 21 (14) 7 (14) in transit 30 (20) 5 (10) regional lymph nodes 67 (44) 28 (56) distant 36 (23) 10 (20) Palpability of recurrence 0.7 palpable (1) 127 (83) 40 (80) non palpable (2) 27 (18) 10 (20) Symptoms recurrence < none reported 5 (3) 46 (92) lump/swelling 109 (71) 4 (8) pain/soreness 20 (13) 0 (0) other 20 (13) 0 (0) Readily visible recurrences 114 (75) 37 (74) 0.9 Patient reported education 70 (58) 23 (59) 0.9 Detection of primary melanoma 0.7 patient 76 (63) 23 (59) doctor/other 45 (37) 16 (41) total Breslow s tumor thickness (mm) (25) 6 (12) (29) 15 (30) (30) 15 (30) > (16) 14 (28) total missing values 12 0 Clarks level (10) 1 (2) 3 41 (30) 11 (22) 4 64 (46) 28 (56) 5 19 (14) 10 (20) total missing values 16 0 Ulceration present 54 (45) 16 (36) 0.3 Clinical stage at primary diagnosis 0.2 I 50 (35) 11 (22) II 70 (48) 29 (58) III 25 (17) 10 (20) total missing values 9 0 * This analysis excluded 7 patients whose first melanoma recurrence was detected incidentially by someone not related to the patient, 1) cutaneous, regional lymph nodes, ** patient, includes partner and/or relative, 2) distant metastases, *** univariate 69

13 Chapter 2 Table 6. Features of FMR* detection in 211 melanoma patients n (%) Person detecting FMR patient 142 (67) partner 8 (4) general practitioner 5 (2) specialist 51 (24) other 5 (2) total 211 Reported way of detection FMR patient sign(s) (incidentially detected) 55 (35) (self-)examination by patient/other 39 (25) symptom(s) 61 (39) total 155 doctor physical examination by doctor 35 (63) ultrasound 6 (11) chest X-ray 8 (14) computer tomography 5 (9) other investigation 2 (4) total 56 *FMR=first melanoma relapse due to the fact that only patients who had developed a recurrence were included. Previous reports have indicated that physicians are more likely to detect thinner lesions In our study the median tumor thickness was 2.1 mm and a relatively small proportion of patients interviewed had AJCC stage I disease. Skin cancer education programs, such as are carried out extensively in Australia, seem to be important in improving the ability of patients to detect malignant lesions. 21 Table 7. Follow-up factors in 189 melanoma patients and the person detecting the FMR* Last follow-up interval (19) n (%) p-value* (37) (20) > (25) total 189 Follow-up time patient doctor Mean time interval between last disease free follow-up visit and recurrence date (months) * FMR - First melanoma relapse ** univariate analysis 11.8 (0.3-64) 4.6 (1-18) 0.004

14 Recurrence detection in melanoma patients Table 8. Univariate and multivariate analyses of person who detected the FMR* (n=211)** Univariate p-value Multivariate p-value Odds ratio Confidence interval lower upper Symptoms < Time since last follow-up visit 0.02 ns Clark level of invasion 0.03 ns Breslow thickness 0.04 ns Age at recurrence diagnosis 0.07 ns Clinical stage at primary melanoma diagnosis 0.2 ns Palpability of recurrence 0.2 ns ns=not significant * FMR = first melanoma recurrence ** this analysis excludes 7 patients whose FMR was detected incidentally by someone not related to the patient Figure 2. Survival curves comparing patients with symptomatic and non-symptomatic first melanoma relapse (FRM). Figure 3. Survival curves comparing patients with patient and doctor-detected first melanoma relapse (FRM). In this study, the PMs most likely to have been detected by persons other than the patient were those in men, those of advanced stage and/or those in poorly visible sites, thus confirming previous findings of two factors associated with the detection of a PM - stage and gender ,22 Site has not been reported previously to be a predictor for the detecting PMs. Brady et al considered the possibility, but did not find that a readily visible site was a predictor for detection. 18 Finally, it 71

15 Chapter 2 must be noted that there was a long time interval between PM detection and the interview in some patients, so that recall bias may have influenced the results in this group. FMR characteristics, detection and follow-up Three quarters of the patients (or their partners or relatives) detected their own FMR, in agreement with some earlier studies on recurrence detection, 2,13,14 but the rate is much higher than in other studies. 11,12,23 In the latter, methodology used to assess the information on FMR detection was mainly retrospective, the design sometimes was not rigorous and there was little methodological consistency between them. 1 The current study shows a strong relationship between the person detecting the FMR and the existence of symptoms. However, more patients detected their own FMR than those who reported that they had detected the recurrence due to symptoms. Therefore, the confounding influence of the use of symptomatic lesions for patient-detected FMR is not likely to cause an over-estimation, but rather a lower estimate. Thus, patients may detect a FMR without the presence of a symptom (e.g. a painless lump). Less patients reported detection of their FMR as a result of self-examination (n= 39, 23%) than the number who reported receiving instruction about self-examination (n=94, 57%). Information on this aspect of FMR detection is very subjective and to verify the value of self-examination for FMR detection, a more detailed study would be required. Ideally every patient would be thoroughly instructed, remember these instructions and perform self-examination regularly. However, the fact that only 23% of the patients reported detecting the FMR by self-examination emphasizing the need to stress the value of self-examination to patients in future. At the time of initial treatment of their PM, all SMU patients are routinely given explicit advice about regular examination of their skin and regional lymph nodes for recurrence between scheduled follow up visits. It was therefore disappointing to find that only 57% recalled receiving this information. Clearly, more effective ways of communicating and reinforcing this advice are required. Use of a suitable printed brochure is one strategy that is currently being considered. The median time between last follow-up visit and FMR diagnosis was 4.5 months (range ). It was expected that, the longer the follow-up interval, the higher the chance the FMR would be detected by the patient. However, this variable was not found to be significantly related to the person detecting the FMR. This recurrence detection was not primarily determined by the frequency of scheduled follow-up visits. Forty-six patients (24%) exceeded the maximum 12 month follow-up interval currently recommended by the SMU. Based on a previous study, follow-up has 72

16 Recurrence detection in melanoma patients been recommended for at least 10 years, since after this only 3% of patients were found to recur, and follow-up surveillance was therefore considered difficult to justify on a cost-effectiveness basis. 9 Nevertheless, in the current study, the PM of 23 (11%) patients was diagnosed more than 10 years prior to the FMR detection. Patients preferences for follow-up frequency varied widely but most (n=96, 57%) wished to have three-monthly visits, perhaps indicating some anxiety and a lack of confidence in their ability to detect their own FMR. FMR detection and outcome On multivariate analysis only symptoms of a FMR independently predicted patient detection of a FMR, implying that no distinction for follow-up recommendations can be made between patients on the basis of demographic, clinical or PM features. Moreover, the results of this prospective study confirm previous retrospective studies. The majority of patients detected their FMR themselves despite frequent follow-up, and this will need be taken into account in the development of evidencebased follow-up schedules. Garbe et al classified FMRs as early- and late-detected, and related this to survival, finding a significantly higher survival rate amongst patients who had an earlydetected FMR. 7 However, they included patients with not only first relapses, and they did not relate this information to the person detecting the recurrence. In the current study we found that patients with doctor-detected recurrences or non-symptomatic recurrences had a worse prognosis, which is not surprising since most of these recurrences were distant metastases. Patients with patientdetected recurrences or symptomatic recurrences fared slightly better. However, the survival outcomes were not significantly different. Therefore, we do not think that this is a reason to modify follow-up frequency. Our results correspond with the findings of some other authors, who have found no difference in survival for symptomatic and non-symptomatic recurrences, 2,10 while results regarding survival and patient-initiated visits before the scheduled visit have been inconclusive and controversial. 4,15 Follow-up recommendations Follow-up in the management of melanoma patients has several purposes. It serves to detect FMRs, allows the physician or surgeon to assess treatment efficacy and plays an important role in the detection of second PMs, which develop in about 2-6 % of the melanoma patient population Also of great importance are patient reassurance and documentation of outcome for research purposes. Over the last two decades, strategies for the follow-up of melanoma patients have become a matter of increasing relevance due to escalating incidence rates 73

17 Chapter 2 in many countries. Currently recommended follow-up protocols are often of high frequency and intensity 1, and resources in many centers have become insufficient to deal with the ever-increasing patient load. In the present study, attempts were made to determine the value of follow-up consultations and to document the actual detection rate of FMRs in a more detailed and realistic way. With the results of this study, combined with comprehensive documentation of the risk of developing a melanoma recurrence, (manuscript in preparation), we hope to be able to recommend a follow-up schedule, that is truly evidence-based. A supplementary study on the detection of second PMs, in SMU patients is also in progress. In summary, patients/partners/relatives detected almost three quarters of the FMRs evaluated in this study. The presence of one or more symptoms was the only factor predicting FMR detection. This indicates that the frequency of followup visits proposed in an earlier SMU study 9 and by other groups 2,3,6,10,12,15,27-29 could be reduced for most patients. However, individual patient-related factors such as physical and mental health, travel distances and personal preferences will always need to be considered, and the extent of resources available to conduct follow-up programs may also be of relavance. Follow-up visits at a specialist center alternating with clinical checks by the patient s local family physician may be a rational solution. Finally, this study emphasizes the need for effective patient education and instruction. This aspect of follow-up will undoubtedly contribute to earlier detection of FMRs and is likely to play an increasingly important role in melanoma patient surveillance. Our concluding recommendations are that patient education be improved and that consideration be given to reducing the frequency of follow-up visits. Specific proposals in relation to follow-up visit frequencies will be reported separately. 74

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