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Figure. Second primary melanomas diagnosed during 13-month study period. PT indicates patient. *Kaiser Permanente–initiated appointment for screening total-body skin examination.

Figure. Second primary melanomas diagnosed during 13-month study period. PT indicates patient. *Kaiser Permanente–initiated appointment for screening total-body skin examination.

Table. Characteristics of Subsequent Primary Melanomas by Group
Table. Characteristics of Subsequent Primary Melanomas by Group
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DiFronzo LA, Wanek LA, Elashoff R, Morton DL. Increased incidence of second primary melanoma in patients with a previous cutaneous melanoma.  Ann Surg Oncol. 1999;6(7):705-711PubMedArticle
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Howlader NA, Krapcho M, Neyman N,  et al.  SEER Cancer Statistics Review, 1975-2008. http://seer.cancer.gov/csr/1975_2008/. Accessed July 16, 2011
3.
Titus-Ernstoff L, Perry AE, Spencer SK,  et al.  Multiple primary melanoma: two-year results from a population-based study.  Arch Dermatol. 2006;142(4):433-438PubMedArticle
4.
Waldmann A, Nolte S, Weinstock MA,  et al.  Skin cancer screening participation and impact on melanoma incidence in Germany: an observational study on incidence trends in regions with and without population-based screening.  Br J Cancer. 2012;106(5):970-974PubMedArticle
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Brobeil A, Rapaport D, Wells K,  et al.  Multiple primary melanomas: implications for screening and follow-up programs for melanoma.  Ann Surg Oncol. 1997;4(1):19-23PubMedArticle
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Research Letter
March 2013

Management of Melanoma in a Patient Population: Using Electronic Health Records to Enhance Postdiagnosis Surveillance

Author Affiliations

Author Affiliations: Departments of Dermatology (Dr Reisenauer), Nephrology (Dr Lee), and Pathology (Mr Tabacchini), Hawaii Permanente Medical Group, Honolulu, Hawaii; and University of Hawaii John A. Burns School of Medicine, Honolulu (Drs Akamine and Golden).

JAMA Dermatol. 2013;149(3):365-366. doi:10.1001/jamadermatol.2013.1296

Early detection of melanoma reduces morbidity and mortality, yet research to evaluate the effectiveness of total-body skin examinations (TBSEs) is lacking. Because a history of melanoma confers a greater risk for developing subsequent primary melanomas (SPMs),1 the Dermatology Division of Kaiser Permanente Hawaii recommends at least annual TBSEs in these patients. Our study evaluated the benefit of using electronic health records (EHRs) to track patients with a history of melanoma to ensure annual TBSEs.

Methods

Individuals diagnosed as having an SPM between February 1, 2010, and February 28, 2011, were included using Kaiser Permanente's KP HealthConnect EHR. Chart review was performed to determine if the SPM was diagnosed during a Kaiser Permanente–initiated annual screening TBSE or a patient-initiated encounter. Patient awareness of the lesion was also assessed. One sample t test was used to determine whether the SPM incidence in the Kaiser Permanente Hawaii population differed from the baseline melanoma incidence in Hawaii. Multiple regression analysis using stepwise backward elimination evaluated age, sex, and patient awareness of lesion as predictors of Breslow thickness. Statistical analyses were performed using SAS software, version 9.1 (SAS Institute Inc). Kaiser Permanente Hawaii's institutional review board approved this study.

Results

During our study period, 48 SPMs were diagnosed in 42 patients. The incidence of SPMs was significantly higher than the baseline melanoma incidence in Hawaii (P < .001).2

Of the 48 SPMs, 40 (83%) were diagnosed in patients who were contacted for a timely annual TBSE and an additional 4 (8%) were diagnosed in patients who were contacted because they were overdue for this examination. None of these patients were aware of their melanomas (Figure, groups A and B). Four SPMs (8%) were diagnosed in patients who were not due for TBSEs but who detected a worrisome lesion on themselves (Figure, group C).

The time lapse between the SPM and the most recent prior melanoma ranged from 3 months to 31 years (mean, 4.4 years) (Table). The mean Breslow thickness of the invasive SPMs was 0.39 mm. Twenty-seven percent of SPMs were thicker than the most recent prior melanoma (13 of 48); 13% were the same thickness (6 of 48); 50% were thinner (24 of 48); and 10% had unknown prior melanoma thicknesses (5 of 48). Sixty-five percent of SPMs occurred on non–sun-exposed skin, presumably decreasing the ease of patient self-detection for these lesions.

With multivariate regression using stepwise backward elimination, age and gender were found not to predict Breslow thickness, but patient awareness of the lesion was a predictive factor. The melanomas detected by patients (group C, average Breslow thickness, 0.57 mm) were significantly thicker than those detected by the dermatologists during screening examinations (groups A and B, average Breslow thickness, 0.22 mm) (P < .01).

Comment

A history of melanoma confers an increased risk for SPMs, often occurring within a few months to 2 years after the primary melanoma is identified. However, some studies have shown significantly longer intervals between the initial and second primaries.3 The long interval found in our study lends support to the concept of lifelong annual follow-up.

Screening TBSEs performed by physicians during the SCREEN study4 resulted in an increase in melanoma incidence, proving TBSEs to be an effective screening tool. Brobeil et al5 found that 93% of SPMs were dermatologistdetected, which correlates with the 90% rate in our study. Given the high number of SPMs diagnosed in our patient population over 13 months, at least annual TBSEs for patients with a history of melanoma seems advisable.

Breslow thicknesses of SPMs detected through screening examinations are usually thinner than the initial melanomas, but a substantial minority (up to 30%) are thicker.3 Similarly, in our study, 50% of SPMs were thinner, while 27% were thicker than the most recent prior melanomas. This suggests that routine TBSEs lead to earlier detection of melanomas, thinner Breslow measurements, and therefore improved overall patient survival.

This study evaluated the effect of screening TBSEs on short-term disease detection rates in a high-risk population but did not address long-term effects on patient outcomes or cost-effectiveness. Incidence of SPM in this study is likely increased due to enhanced screening efforts.4 The utility of screening TBSEs in a low-risk patient population was not addressed. Furthermore, Kaiser Permanente patients may be more amenable to regular preventive health screenings. For dermatology practices without an EHR, a manual spreadsheet of patients with melanoma could be created to track annual follow-up visits.

In conclusion, this study lends further support to the hypothesis that annual TBSEs for patients with a history of melanoma leads to the detection of asymptomatic disease. Using an EHR to identify high-risk patients who are due or overdue for annual TBSEs leads to earlier detection of second primary melanomas and increases patient survival.

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Article Information

Correspondence: Dr Reisenauer, Kaiser Permanente, 80 Mahalani St, Wailuku, HI 96793 (amy.k.reisenauer@kp.org).

Accepted for Publication: August 21, 2012.

Author Contributions: Dr Reisenauer had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Reisenauer. Acquisition of data: Reisenauer, Lee, Akamine, Tabacchini, and Golden. Analysis and interpretation of data: Reisenauer, Lee, Akamine, and Golden. Drafting of the manuscript: Lee, Akamine, Tabacchini, and Golden. Critical revision of the manuscript for important intellectual content: Reisenauer, Lee, Akamine, and Golden. Statistical analysis: Lee. Administrative, technical, and material support: Lee and Tabacchini. Study supervision: Reisenauer.

Conflict of Interest Disclosures: None reported.

References
1.
DiFronzo LA, Wanek LA, Elashoff R, Morton DL. Increased incidence of second primary melanoma in patients with a previous cutaneous melanoma.  Ann Surg Oncol. 1999;6(7):705-711PubMedArticle
2.
Howlader NA, Krapcho M, Neyman N,  et al.  SEER Cancer Statistics Review, 1975-2008. http://seer.cancer.gov/csr/1975_2008/. Accessed July 16, 2011
3.
Titus-Ernstoff L, Perry AE, Spencer SK,  et al.  Multiple primary melanoma: two-year results from a population-based study.  Arch Dermatol. 2006;142(4):433-438PubMedArticle
4.
Waldmann A, Nolte S, Weinstock MA,  et al.  Skin cancer screening participation and impact on melanoma incidence in Germany: an observational study on incidence trends in regions with and without population-based screening.  Br J Cancer. 2012;106(5):970-974PubMedArticle
5.
Brobeil A, Rapaport D, Wells K,  et al.  Multiple primary melanomas: implications for screening and follow-up programs for melanoma.  Ann Surg Oncol. 1997;4(1):19-23PubMedArticle
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