Timing Is Everything: Could Surveillance Imaging Intensity Influence Survival in High-Risk Melanoma?
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EDITORIAL – MELANOMA
Timing Is Everything: Could Surveillance Imaging Intensity Influence Survival in High-Risk Melanoma? Madalyn G. Neuwirth, MD1
, and Edmund K. Bartlett, MD1,2
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York; 2Memorial Sloan Kettering Cancer Center, New York, NY 1
Ibrahim et al.1 present a single-center retrospective study of high-risk melanoma patients after surgical resection and describe the association between surveillance imaging and patient outcomes. The utility of surveillance imaging for melanoma is remarkably understudied and has become increasingly interesting in this era of effective systemic therapy, with some data suggesting that treatment is more effective with a lower disease burden2,3. The authors distinguish between patients whose recurrence is detected radiologically as asymptomatic surveillance-detected recurrence (ASDR) and those who present with clinical, or symptomatic, recurrence (SR). Importantly, the authors found that patients with ASDR had shorter median follow-up periods and were more likely to undergo subsequent systemic therapy than those with SR at presentation. Furthermore, patients with ASDR had better overall survival than those with SR (median, 39.2 vs 23.2 months; p = 0.02), and this difference persisted after multivariate adjustment for numerous prognostic factors. This finding suggests that ASDR may be an important prognostic factor at the time of recurrence that can be incorporated into the counseling of patients and future riskmodeling studies.
In response to Ibrahim et al. Impact of Imaging Intensity and Survival Outcomes in High-Risk Resected Melanoma Treated by Systemic Therapy at Recurrence. ASO-2019-10-2465.R1. Ó Society of Surgical Oncology 2020 First Received: 3 April 2020; Published Online: 28 May 2020 E. K. Bartlett, MD e-mail: [email protected]
No clear consensus exists on which imaging methods should be used for surveillance. Most of the patients in this study underwent axial imaging in the form of computed tomography (CT) or positron emission tomography (PET)/ CT, without significant differences between the ASDR and SR groups. Outside the scope of this study, but critical in the decision to image patients, is the cost of the imaging4,5. This cost is not solely financial, but additionally includes false-positives with subsequent tests/biopsies, patient anxiety, and radiation exposure. It must be recognized that these harms are incurred by all patients, not only by the subset that experiences recurrence6. Thus, the authors’ conclusion calling for an ‘‘optimal risk-adapted imaging frequency’’ is a thoughtful approach to ensure that the threshold for imaging is appropriate to the number of anticipated events. Finally, Ibrahim et al.1 demonstrate an association between imaging intensity and ASRD as well as between ASRD and disease outcome for treated patients. This finding raises the possibility of a causal relationship between more intensive imaging and oncologic outcome, presumably resulting from greater efficaciousness
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