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Clinical Decisionmaking

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Increasing the excision margins around melanoma to recommended widths could substantially reduce mortality rates

According to the American Academy of Dermatology, more doctors are using inappropriately narrow excision margins in localized invasive melanoma. This practice may account for one-fourth of all melanoma-related deaths, according to a new study. Increasing the percentage of optimal excision margins (for example, 1.5 cm for melanoma between 1 and 2 mm depth, wider for deeper melanoma) might substantially reduce mortality, concludes Case Western Reserve University researchers, David A. Barzilai and Mendel E. Singer, Ph.D.

In a study supported in part by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00059), the researchers used a computer simulated model to follow until death a hypothetical group of 55-year-old people (all of whom were white) newly diagnosed with localized invasive melanoma. They compared outcomes (melanoma-related death and life expectancy) for two scenarios: usual care and intervention with 100 percent optimal excision margins.

Based on real community data for usual care (which showed only 38 percent use of optimal excision margins), the model estimated 8.17 percent melanoma-related mortality following localized melanoma. Modeling intervention with 100 percent of recommended excision margins reduced this rate to 6.15 percent, a 25 percent relative reduction in deaths.

Using recommended excision margins also increased average life expectancy by 0.437 years, which equates to about 11 additional years in the 4 percent of individuals who would not experience a local recurrence due to improved excision margins. Increasing the percentage of optimal excision margins to 80 percent would still yield substantial improvement, with 6.83 percent melanoma-related deaths, saving 0.29 life-years compared with community rates.

See "The potential impact on melanoma mortality of reducing rates of suboptimal excision margins," by David A. Barzilai and Dr. Singer, in the June 2003 Journal of Investigative Dermatology 120(6), pp. 1067-1072.

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