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An Opportunity to Ensure High-Quality Melanoma Care Through the Use of a Preoperative Treatment Algorithm

  • Melanomas
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Studies have demonstrated variable adherence to published melanoma treatment guidelines. Payers have used algorithms to preapprove certain tests and treatments. Our objective was to develop a preoperative treatment assessment algorithm to ensure patients with melanoma receive recommended care.

Methods

A treatment algorithm was developed using existing guidelines. Records of patients presenting with melanoma between September 2010 and May 2012 were reviewed. Surgical care was classified as having been adherent or nonadherent with the guideline-based algorithm. The algorithm was incorporated into a Web site for preoperative treatment verification.

Results

A treatment algorithm was developed on the basis of three critical pieces of preoperative data: Breslow thickness, presence of adverse primary tumor prognostic factors, and regional lymph node metastases. Treatment options included wide local excision (WLE), sentinel lymph node biopsy (SLNB), and completion/formal lymph node dissection. Of 328 patients evaluated, 316 (96 %) were treated according to the guideline-based algorithm. Causes of variation from predicted treatment included patient preference, severe comorbidities, difficult tumor location, and uncertain depth. All departures (n = 12) were in clinically node-negative patients: six patients did not undergo SLNB as indicated, and six underwent SLNB that was not concordant with the algorithm. An algorithm-embedded Web site was designed for preoperative verification of planned procedures.

Conclusions

As a proof of principle, an algorithm was developed to preoperatively verify that proposed melanoma treatments are concordant with established guidelines. These three pieces of information could be required during precertification, and nonconcordant treatment plans could prompt a peer-to-peer discussion. After additional pilot testing, the algorithm could offer a novel approach for quality improvement and provide a preoperative, prospective safeguard to ensure high-quality care for melanoma patients.

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Acknowledgments

Supported in part by the Northwestern Institute for Comparative Effectiveness Research (NICER) in Oncology and a National Comprehensive Cancer Network Young Investigator Award (KYB).

Disclosure

The authors declare no conflict of interest.

Author information

Authors and Affiliations

  1. Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Benjamin S. Kester BS, Jeffrey D. Wayne MD, David J. Bentrem MD MS, Ryan P. Merkow MD MS & Karl Y. Bilimoria MD MS

  2. Northwestern Institute for Comparative Effectiveness Research (NICER) in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA

    Benjamin S. Kester BS, Jeffrey D. Wayne MD, David J. Bentrem MD MS, Ryan P. Merkow MD MS & Karl Y. Bilimoria MD MS

  3. Division of Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA

    Merrick I. Ross MD

  4. Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL, USA

    David J. Bentrem MD MS

Authors
  1. Benjamin S. Kester BS
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  2. Jeffrey D. Wayne MD
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  3. Merrick I. Ross MD
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  4. David J. Bentrem MD MS
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  5. Ryan P. Merkow MD MS
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  6. Karl Y. Bilimoria MD MS
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Corresponding author

Correspondence to Karl Y. Bilimoria MD MS.

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Kester, B.S., Wayne, J.D., Ross, M.I. et al. An Opportunity to Ensure High-Quality Melanoma Care Through the Use of a Preoperative Treatment Algorithm. Ann Surg Oncol 20, 3976–3983 (2013). https://doi.org/10.1245/s10434-013-3094-3

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  • DOI: https://doi.org/10.1245/s10434-013-3094-3

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