title: Suboptimal Compliance With National Comprehensive Cancer Network Melanoma Guidelines: Who Is at Risk?
abstract: National Comprehensive Cancer Network (NCCN) melanoma treatment guidelines are based on best available literature. We evaluated NCCN excision margin and sentinel lymph node biopsy (SLNB) guideline adherence to identify patient populations at risk for suboptimal care.
  
  
  
  Retrospective review of prospectively maintained database of all patients who underwent operation for invasive melanoma from January 2005 to 2015.
  
  
  
  In total, 865 patients underwent operation for 522 thin (60.3%), 268 intermediate-thickness (31.0%), and 75 thick (8.7%) melanomas. Tumor location was 349 extremity (40.4%), 348 trunk (40.2%), and 168 head/neck (19.4%). SLNB was performed in 422 patients (48.8%); 75 (17.8%) were positive, and 67 (15.9%) underwent therapeutic lymphadenectomy. A total of 154 lesions (17.8%) were ulcerated; 444 had mitotic rate ≥1 (51.3%). In total, 788 patients (91.1%) fulfilled both NCCN guidelines. Recommended surgical margins were achieved in 837 patients (96.8%) and SLNB was performed as appropriate in 806 patients (93.2%); 10 patients (1.2%) were deficient for both. Deficient margins and lack of SLNB were associated with increased invasion depth and head/neck location; deficient SLNB was associated with age 80 and above (P<0.0001). Overall recurrence was 7.1%: 15 local (1.7%), 23 regional (2.7%), and 23 distant (2.7%) failures. Local recurrence was associated with head/neck location (P=0.031); all recurrence types were associated with increased tumor thickness.
  
  
  
  NCCN excision and SLNB guidelines were almost always met. Patients at risk for not meeting criteria included the elderly and those with head/neck tumors. Failure to meet NCCN criteria was not associated with increased disease recurrence. Surgeons must carefully balance the risks of not pursuing NCCN guidelines with treatment goals.
authors.affiliation: Department of Surgery, Rhode Island Hospital.|Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Blakely
authors.affiliation: Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI.
authors.forename: Danielle S
authors.initials: DS
authors.lastname: Comissiong
authors.affiliation: Department of Surgery, Rhode Island Hospital.|Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Vezeridis
authors.affiliation: Department of Surgery, Rhode Island Hospital.|Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Miner
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence / Q000592:standards* / Q000706:statistics & numerical data*; D006801:Humans; D008197:Lymph Node Excision / Q000706:statistics & numerical data; D008297:Male; D008545:Melanoma / Q000473:pathology* / Q000601:surgery; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D012307:Risk Factors; D021701:Sentinel Lymph Node Biopsy / Q000706:statistics & numerical data*; D012878:Skin Neoplasms / Q000473:pathology* / Q000601:surgery; D014481:United States; D000096142:Cutaneous Malignant Melanoma