Evaluation of patients with clinically suspected melanoma recurrence: current practice patterns of plastic surgeons

The optimal extent-of-disease evaluation for patients with clinically suspected melanoma recurrence is not known. The available modalities are numerous and many are expensive. We documented the extent of work-up carried out by plastic surgeons when their patients with melanoma develop clinical recurrence. A custom-designed questionnaire was mailed to a random sample (n=3,032) of the 4,320 members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Subjects were asked which specific laboratory tests and imaging studies they would order for a patient with initial T2N0M0 disease treated with curative intent who later presented with either regional nodal metastases or pulmonary metastases. We measured the variability in practice patterns among surgeons and estimated the effects of physician age, U.S. census region, health maintenance organization (HMO) penetration rates, and type of recurrence (regional versus systemic) on work-up intensity. Of the 1,142 questionnaires completed (38%), 395 (35%) were evaluable. Non-evaluability was usually due to lack of melanoma patient follow-up in surgeons' practices. Lesion biopsy, chest X-ray, complete blood count, liver function tests, and computed tomography were frequently used, but there was no consensus for most modalities. More tests, particularly computed tomography, were utilized for evaluating systemic recurrence than for regional recurrence (p<0.05). The intensity of work-up differed significantly (p<0.05) by surgeon age for three diagnostic tests but not by U.S. census region or HMO penetration rate. This is the first empirical data on this subject from a large sample of an international society of highly credentialed experts. The lack of consensus for most tests in current practice is presumably due to multiple factors, including the lack of evidence supporting any particular strategy.