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Developing Indications for the Use of Sentinel Lymph Node Biopsy and Adjuvant High-Dose Interferon Alfa-2b in Melanoma
Robert W. Dubois, MD, PhD;
Susan M. Swetter, MD;
Michael Atkins, MD;
Kelly McMasters, MD;
Ron Halbert, MD, MPH;
Stanley J. Miller, MD;
Ronald Shiell, MD;
John Kirkwood, MD
Arch Dermatol. 2001;137:1217-1224.
Objectives To convene a multidisciplinary panel of dermatologists, surgical oncologists, and medical oncologists to formally review available data on the sentinel lymph node (SLN) biopsy procedure and high-dose adjuvant interferon alfa-2b therapy for patients with melanoma and to rate the "appropriateness," "inappropriateness," or "uncertainty" of the procedure and therapy to guide clinical decision making in practice.
Participants The panel comprised 13 specialists (4 dermatologists, 4 oncologists, and 5 surgeons) from geographically diverse areas who practiced in community-based settings (n = 8) and academic institutions (n = 5). Participants were chosen based on recommendations from the relevant specialty organizations.
Evidence A formal literature review was conducted by investigators at Protocare Sciences Inc, Santa Monica, Calif, on the risks and benefits of performing an SLN biopsy in patients with stage I or II melanoma and adjuvant interferon alfa-2b therapy in patients with stage II or III disease. The MEDLINE database was searched from 1966 through July 2000, and supplemental information was obtained from various cancer societies and cancer research groups. Panel participants were queried on additional sources of relevant information. Unpublished, presented data were included in abstract form on 1 recently closed clinical trial.
Consensus Process The RAND/UCLA Appropriateness Method was used to review and rate multiple clinical scenarios for the use of SLN biopsy and interferon alfa-2b therapy. The consensus method did not force agreement.
Conclusions The panel rated 104 clinical scenarios and concluded that the SLN biopsy procedure was appropriate for primary melanomas deeper than 1.0 mm and for tumors 1 mm or less when histologic ulceration was present and/or classified as Clark level 4 or higher. The SLN biopsy was deemed inappropriate for nonulcerated Clark level 2 or 3 melanomas 0.75 mm or less in depth and uncertain in tumors 0.76 to 1.0 mm deep unless they were ulcerated or Clark level 4 or higher. Interferon alfa-2b therapy was deemed appropriate for patients with regional nodal and/or in-transit metastasis and for node-negative patients with primary melanomas deeper than 4 mm. The panel considered the use of interferon alfa-2b therapy uncertain in patients with ulcerated intermediate primary tumors (2.01-4.0 mm in depth) and inappropriate for node-negative patients with nonulcerated tumors less than 4.0 mm deep. Specialty-specific ratings were conducted as well.
From Protocare Sciences Inc, Santa Monica, Calif (Drs Dubois and Halbert); the Department of Dermatology, Stanford University Medical Center, Stanford, Calif, and VA Palo Alto Health Care System, Palo Alto, Calif (Dr Swetter); Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Mass (Dr Atkins); the Division of Medical Oncology, University of Louisville Cancer Center, Louisville, Ky (Dr McMasters); John Hopkins Medical Center, Baltimore, Md (Dr Miller); State University of New York, Upstate Medical University, Syracuse (Dr Shiell); and the Division of Medical Oncology, University of Pittsburgh Cancer Center, Pittsburgh, Pa (Dr Kirkwood). Dr Dubois is employed by and has stock ownership in Protocare Sciences Inc.
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