title: An assessment of clinical pathways and missed opportunities for the diagnosis of nodular melanoma versus superficial spreading melanoma.
abstract: BACKGROUND
  Missed opportunities in the diagnosis of nodular melanoma (NM) carry high prognostic penalties due to the rapid rate of NM growth. To date, an assessment of the pathways to diagnosis of NM versus superficial spreading melanoma (SSM) specifically comparing numbers of opportunities missed to undertake biopsy has not been performed.
  
  
  METHODS
  A retrospective questionnaire of 120 patients (60 NM patients, age and sex matched to 60 SSM patients) from the Victorian Melanoma Service (VMS) database was undertaken to assess pathways to diagnosis. The numbers of opportunities missed to undertake a biopsy and doctor behaviour at such encounters were recorded. Diagnostic delay (overall, patient's and doctor's delay) in terms of time was assessed.
  
  
  RESULTS
  Significant differences in opportunities missed to make a diagnosis of NM compared to SSM were found. In all, 43% of NM were biopsied at a first encounter compared to 70% of SSM. All SSM were diagnosed within three reviews. Overall, 33% of NM required at least three and up six reviews until biopsy. Patients with NM were more likely than those with SSM to be reassured that their lesions were benign. No significant differences in terms of time delay to diagnosis between NM and SSM were found.
  
  
  CONCLUSIONS
  NM contributes disproportionately to melanoma mortality in Australia. Addressing earlier diagnosis of NM with renewed focus may make the biggest impact on the overall mortality of melanoma. The message that a period of observation is not appropriate for patients re-presenting with lesions of concern must be more effectively communicated.
authors.affiliation: Victorian Melanoma Service, Alfred Hospital, Melbourne, Victoria, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Cicchiello
authors.affiliation: Victorian Melanoma Service, Alfred Hospital, Melbourne, Victoria, Australia.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Lin
authors.affiliation: Victorian Melanoma Service, Alfred Hospital, Melbourne, Victoria, Australia.
authors.forename: Yan
authors.initials: Y
authors.lastname: Pan
authors.affiliation: Victorian Melanoma Service, Alfred Hospital, Melbourne, Victoria, Australia.|Department of Anatomical Pathology, Alfred Hospital, Melbourne, Victoria, Australia.
authors.forename: Catriona
authors.initials: C
authors.lastname: McLean
authors.affiliation: Victorian Melanoma Service, Alfred Hospital, Melbourne, Victoria, Australia.
authors.forename: John W
authors.initials: JW
authors.lastname: Kelly
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D019091:Critical Pathways / Q000706:statistics & numerical data*; D057210:Delayed Diagnosis; D005260:Female; D006801:Humans; D008297:Male; D008545:Melanoma / Q000175:diagnosis / Q000473:pathology*; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D012878:Skin Neoplasms / Q000175:diagnosis / Q000473:pathology*; D013997:Time Factors
keywords: biopsy; clinical pathways; diagnostic delay; missed opportunities; nodular melanoma (NM); superficial spreading melanoma (SSM)