David A. Barzilai

Surgical excision margins for primary cutaneous melanoma

BACKGROUND: Cutaneous melanoma accounts for 75% of skin cancer deaths. Standard treatment is surgical excision with a safety margin some distance from the borders of the primary tumour. The purpose of the safety margin is to remove both the complete primary tumour and any melanoma cells that might have spread into the surrounding skin. Excision margins are important because there could be trade-off between a better cosmetic result but poorer long-term survival if margins become too narrow. The optimal width of excision margins remains unclear. This uncertainty warrants systematic review. OBJECTIVES: To assess the effects of different excision margins for primary cutaneous melanoma. SEARCH STRATEGY: In August 2009 we searched for relevant randomised trials in the Cochrane Skin Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2009), Medline, Embase, Lilacs, and other databases including Ongoing Trials Registers. SELECTION CRITERIA: We considered all randomized controlled trials (RCTs) of surgical excision of melanoma comparing different width excision margins. DATA COLLECTION AND ANALYSIS: We assessed trial quality, and extracted and analyzed data on survival and recurrence. We collected adverse effects information from included trials. MAIN RESULTS: We identified five trials. There were 1633 participants in the narrow excision margin group and 1664 in the wide excision margin group. Narrow margin definition ranged from 1 to 2 cm; wide margins ranged from 3 to 5 cm. Median follow-up ranged from 5 to 16 years. AUTHORS’ CONCLUSIONS: This systematic review summarises the evidence regarding width of excision margins for primary cutaneous melanoma. None of the five published trials, nor our meta-analysis, showed a statistically significant difference in overall survival between narrow or wide excision. The summary estimate for overall survival favoured wide excision by a small degree [Hazard Ratio 1.04; 95% confidence interval 0.95 to 1.15; P = 0.40], but the result was not significantly different. This result is compatible with both a 5% relative reduction in overall mortality favouring narrower excision and a 15% relative reduction in overall mortality favouring wider excision. Therefore, a small (but potentially important) difference in overall survival between wide and narrow excision margins cannot be confidently ruled out. The summary estimate for recurrence free survival favoured wide excision [Hazard Ratio 1.13; P = 0.06; 95% confidence interval 0.99 to 1.28] but again the result did not reach statistical significance (P < 0.05 level). Current randomized trial evidence is insufficient to address optimal excision margins for primary cutaneous melanoma. The review is fully available (through the Cochrane Journal Club) from: http://www.cochranejournalclub.com/surgical-excision-margins-clinical/pdf/JC2_excision_margins_full.pdf

Atopic dermatitis management: comparing the treatment patterns of dermatologists in Japan, U.S.A. and U.K.

Summary Background The incidence of atopic dermatitis (AD) is increasing worldwide. No large‐scale study has previously compared the therapeutic management of this condition in different countries.

The sensitivity of medicare data for identifying incident cases of invasive melanoma (United States)

Background: The completeness of Medicare claims for identifying patients with melanoma for purposes of conducting population-based studies of melanoma is unknown. Methods: Using a linked Surveillance, Epidemiology, and End Result (SEER) tumor registry-Medicare database, the sensitivity of Medicare claims for identifying 5372 patients age ≥65 years diagnosed with invasive melanoma between 1992 and 1996 was determined. Sensitivity was calculated as the proportion of incident cases of melanoma reported by SEER that was also captured by Medicare claim diagnostic codes. Results: The overall sensitivity of combined Part A and Part B Medicare for incident cases of melanoma was 90.1%. Part B Medicare and Part A Medicare alone had 89.5% and 16.5% sensitivity respectively. Sensitivity was lower for patients with unrecorded Breslow depth and for patients with unstaged or distant stage melanoma. Conclusions: Medicare Part B claims have a high sensitivity for detecting melanoma incidence; Medicare Part A has low sensitivity. This sharply contrasts with published studies of other cancers, for whom Part A rather than Part B Medicare captures the predominant portion of incident cases. Medicare Part B or combined Part A and Part B administrative data is a potentially valuable resource for population-based melanoma research in the elderly. Further research characterizing the specificity and predictive value of Medicare data is needed to assess the potential implications of false positive melanoma diagnostic codes.