Timing of Melanoma Diagnosis, Treatment Critical to Survival

A new Cleveland Clinic study underscores the importance of early detection and treatment of melanoma, the deadliest form of skin cancer. The research, published in the Journal of the American Academy of Dermatology, indicates that the sooner patients were treated, the better their survival, particularly for stage I melanoma.

Using the National Cancer Database, researchers from Cleveland Clinic’s Cancer Center and its Dermatology & Plastic Surgery Institute studied 153,218 adult patients diagnosed with stage I-III melanoma from 2004 to 2012. The investigators found that overall survival (OS) decreased in patients waiting longer than 90 days for surgical treatment, regardless of stage. In addition, the delay of surgery beyond the first 29 days negatively impacted overall survival for stage I melanoma, though not for stage II or III.

Graphic representation of adjusted and unadjusted hazard ratios by time to treatment initiation. Point estimates represent hazard ratios. Bars represent 95% confidence intervals. A, Unadjusted hazard ratios by time to treatment initiation. B, Unadjusted hazard ratio for days to treatment in stage I. C, Unadjusted hazard ratio for days to treatment in stage II. D, Unadjusted hazard ratio for days to treatment in stage III. Asterisks denote statistical significance.

Compared to patients who were treated within 30 days, patients with stage I melanoma were:

• 5 percent more likely to die when treated between 30 and 59 days (95% CI 1.01-1.1; P = 0.029);
• 16 percent more likely to die when treated between 60 and 89 days (95% CI 1.07-1.25; P > 0.001);
• 29 percent more likely to die when treated between 91 and 120 days (95% CI 1.12-1.48; P > 0.001); and
• 41 percent more likely to die when treated after 120 days (95% CI 1.21-1.65; P > 0.001).

Patients with a longer time to treatment initiation tended to be older and male, and have more comorbidities.

Graphic representation of adjusted hazard ratios by time to treatment initiation. Point estimates represent hazard ratios. Bars represent 95% confidence intervals. A, Adjusted hazard ratios by time to treatment initiation. B, Adjusted hazard ratio for days to treatment in stage I. C, Adjusted hazard ratio for days to treatment in stage II. D, Adjusted hazard ratio for days to treatment in stage III. Asterisks denote statistical significance.

According to the authors, it is likely that more advanced cases represent delays in diagnosis, and these delays overwhelm the impact of a speedier treatment. However, in early stage cases, early diagnosis allows for the opportunity to improve the chances of survival with a prompt surgery. Although many physicians treat melanoma surgically three to four weeks after diagnosis, there is no official recommendation on time to treatment.

“The ideal timing for melanoma treatment, predominantly surgery, had yet to be determined – until now,” said Brian Gastman, MD, medical and surgical director of melanoma and high-risk skin cancer program at Cleveland Clinic, and lead author on the study. “Patients and referring physicians are not only concerned with how a melanoma is removed, but also when it’s removed. We saw significantly worse prognoses and outcomes for those surgically treated after 30 days of stage 1 melanoma diagnosis. Knowing for certain that a more expedient time to surgery to remove an early melanoma improves the chances of survival is a game-changer in treating this life-threatening skin cancer.”