Clinical Audit: Follow-up and surveillance of patients post-treatment for melanoma

Audit focus

This audit focusses on follow-up and surveillance for patients who have been diagnosed with melanoma and completed curative-intent treatment.

Background

Post-treatment follow-up and long-term surveillance of people with a history of melanoma improves the likelihood that recurrence (or a new primary melanoma) will be identified early. In most cases, melanoma recurrence is self-detected. However, ongoing primary care follow-up is still essential to provide a more comprehensive assessment for recurrence, lymphoedema and surveillance of new lesions of concern, and to deliver ongoing education and support.

There is limited evidence to guide the ideal follow-up schedule for patients with a history of melanoma, however, the frequency and duration of clinical follow-up is generally based on the patients staging at diagnosis and may need to be individualised depending on the patient’s needs, objectives or other circumstances, e.g. the presence of many melanocytic or atypical naevi.

Routine laboratory monitoring is not recommended for detecting recurrence in asymptomatic patients as abnormal blood findings are rarely the first sign of metastases and laboratory tests have a low level of specificity for melanoma recurrence. General laboratory testing may become relevant for monitoring the effects of known recurrence, e.g. liver function testing in patients with liver metastases.

Ultrasound assessment of draining nodal basins may be appropriate for some patients, in addition to clinical examination, e.g. patients with sentinel node biopsy-positive stage III melanoma where lymphadenectomy has not been performed. Nodal size alone cannot be used to accurately distinguish between benign and malignant nodes as small nodes can have malignant features and benign reactive nodes can be enlarged.

Routine follow-up with cross-sectional imaging e.g. CT and MRI, is generally only indicated for patients with stage II-C melanoma onwards or when recurrence or metastatic disease is suspected based on clinical presentation, history or findings on ultrasound examination.

As with any cancer diagnosis, a diagnosis of melanoma and the ensuing treatment required, can have a significant impact on a patient’s quality of life, as well as their mental health and emotional wellbeing. Evidence suggests that emotional support from a general practitioner can have a positive effect on a patient’s follow-up experience.

For further information, see: “Melanoma: post-treatment follow-up and surveillance”

The objectives of follow-up are to:

• Detect any potential recurrence or new melanoma that may not have been identified by the patient during self-checks and to detect lymphoedema. The physical evaluation should include a review of the primary melanoma excision site, potential in-transit pathways towards the lymph nodes and palpation for lymph node enlargement. A full body skin examination, including the scalp, should be performed at least annually in primary care; any new or suspicious lesions should be examined using dermatoscopy.
• Identify other features that may indicate distant metastases; particular attention should be given to any symptom(s) that have increased in intensity or frequency over time, or other unexplained systemic features
• Deliver ongoing education, including reinforcing the importance of sun smart principles and skin self-checks
• Assess the patient’s mental health and emotional wellbeing

N.B. It is not intended that all aspects of follow-up are covered in the same appointment. These checks may take place in dedicated follow-up appointments, opportunistically during appointments for other reasons and over time.

Audit Plan

Summary

This audit identifies whether a follow-up and surveillance plan was established for patients who have completed curative-intent treatment for melanoma.

Recommended audit standards

Ideally, all patients affected by melanoma should undergo long-term follow-up and surveillance with the findings from each appointment clearly documented in their notes. This may not be achieved on the first cycle of the audit but should be the aim for the second cycle.

Audit data

Eligible people

Any patient who has been diagnosed with melanoma and has transitioned from active treatment to post-treatment follow-up and surveillance is eligible for this audit.

Identifying patients

You will need to have a system in place that allows you to identify eligible patients who have been diagnosed and treated for melanoma and audit their clinical notes. Many practices will be able to identify patients by running a “query” through their PMS system, initially searching for all patients with melanoma as a diagnosis. The clinical notes will need to be checked to identify those patients who have completed curative-intent treatment.

Sample size

For the purposes of this audit, all eligible patients should be included.

Criteria for a positive result

You will need to access and review the patients’ clinical notes to complete this audit. For a positive result, there should be documentation of:

• The patient’s stage at diagnosis and the recommended frequency of follow-up
• Regular examination of the primary melanoma excision site, lymph nodes and potential in-transit pathway towards the lymph nodes and examination of the skin; if a suspicious lesion is identified, there should be evidence of the use of dermatoscopy or referral if dermatoscopy is not available in the practice
• Assessment of overall health including any symptoms or systemic features that may have increased in intensity or frequency over time
• Discussion around methods for self-skin checks and sun smart principles
• Consideration of the patient’s mental health and emotional wellbeing

Any patient whose notes do not contain the information described above should be flagged for review. Aim for a higher number of positive results in Cycle 2.

Data analysis

Use the sheet provided to record your data. A positive result is any patient post-melanoma treatment who has evidence in their clinical notes of appropriate follow-up and surveillance, as demonstrated by a “YES” in column F (which encompasses the criteria detailed in columns A – E). The percentage achievement can be calculated by dividing the number of patients with a positive result by the total number of patients audited.

Identifying opportunities for Audit of Medical Practice

The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.

Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.

Taking action

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

Problem solving process

• What is the problem or underlying problem(s)?
• Change it to an aim
• What are the solutions or options?
• What are the barriers?
• How can you overcome them?

Overcoming barriers to promote change

• Identifying barriers can provide a basis for change
• What is achievable – find out what the external pressures on the practice are and discuss ways of wdealing with them in the practice setting
• Identify the barriers
• Develop a priority list
• Choose one or two achievable goals

Effective interventions

• No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
• Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Review

Monitoring change and progress

It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:

• Is the process working?
• Are the goals for improvement being achieved?
• Are the goals still appropriate?
• Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that practitioners complete the first part of the CQI activity summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices complete the remainder of the Audit of Medical Practice summary sheet.