Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Department of Dermatology and Huntsman Cancer Institute, Salt Lake City, UT, USA.
Ann Surg Oncol. 2022 Sep;29(9):5948-5956. doi: 10.1245/s10434-022-11869-7. Epub 2022 May 18.
Risk-based thresholds to guide management are undefined in the treatment of primary cutaneous melanoma but are essential to advance the field from traditional stage-based treatment to more individualized care.
To estimate treatment risk thresholds, hypothetical clinical melanoma scenarios were developed and a stratified random sample was distributed to expert melanoma clinicians via an anonymous web-based survey. Scenarios provided a defined 5-year risk of recurrence and asked for recommendations regarding clinical follow-up, imaging, and adjuvant therapy. Marginal probability of response across the spectrum of 5-year recurrence risk was estimated. The risk at which 50% of respondents recommended a treatment was defined as the risk threshold.
The overall response rate was 56% (89/159). Three separate multivariable models were constructed to estimate the recommendations for clinical follow-up more than twice/year, for surveillance cross-sectional imaging at least once/year, and for adjuvant therapy. A 36% 5-year risk of recurrence was identified as the threshold for recommending clinical follow-up more than twice/year. The thresholds for recommending cross-sectional imaging and adjuvant therapy were 30 and 59%, respectively. Thresholds varied with the age of the hypothetical patient: at younger ages they were constant but increased rapidly at ages 60 years and above.
To our knowledge, these data provide the first estimates of clinically significant treatment thresholds for patients with cutaneous melanoma based on risk of recurrence. Future refinement and adoption of thresholds would permit assessment of the clinical utility of novel prognostic tools and represents an early step toward individualizing treatment recommendations.
在治疗原发性皮肤黑色素瘤时，尚未定义基于风险的阈值来指导治疗，但这对于将传统的基于分期的治疗方法推进到更个体化的治疗至关重要。
为了估计治疗风险阈值，我们开发了假设的临床黑色素瘤病例，并通过匿名在线调查向专家黑色素瘤临床医生分发了分层随机样本。这些病例提供了明确的 5 年复发风险，并要求对临床随访、影像学检查和辅助治疗提出建议。估计了在整个 5 年复发风险范围内的边际反应概率。将建议进行治疗的 50%受访者所面临的风险定义为风险阈值。
总应答率为 56%（89/159）。构建了三个独立的多变量模型来估计每年两次以上的临床随访、每年至少一次的横断面影像学监测以及辅助治疗的建议。36%的 5 年复发风险被确定为建议每年两次以上临床随访的阈值。推荐横断面成像和辅助治疗的阈值分别为 30%和 59%。阈值随假设患者年龄的变化而变化：在较年轻的年龄组中，它们是恒定的，但在 60 岁及以上的年龄组中迅速增加。
据我们所知，这些数据首次根据复发风险为皮肤黑色素瘤患者提供了临床上有意义的治疗阈值的估计值。未来对阈值的进一步细化和采用将允许评估新型预后工具的临床实用性，并代表朝着个体化治疗建议迈出的早期一步。
