Best of the Best Oral Presentation Clinical Oncology Society of Australia Annual Scientific Meeting 2020

The future of sentinel lymph node biopsy in the management of invasive melanoma in Australia: a mixed-methods study using a determinants of practice implementation science framework (#97)

Andrea L Smith 1 , Caroline Watts 2 , Frances Rapport 1 , Anne E Cust 2 , Australian Melanoma Centre of Research Excellence Study Group 3
  1. Australian Institute for Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
  2. Cancer Epidemiology and Prevention Research Group, School of Public Health, University of Sydney, Sydney, NSW, Australia
  3. University of Sydney, Sydney, NSW, Australia

Background

Sentinel node (SN) biopsy was introduced in the 1990s as a means of reducing morbidity from elective lymphadenectomy in patients with invasive melanoma.1 Since then, clinicians have debated the rationale for its use in melanoma mangement.2-4 Our objective was to understand perspectives on current and future use, including knowledge of and attitudes towards SN biopsy.

Methods

Mixed-methods study using questionnaires (n=319) and semi-structured interviews (n=66) with GPs, dermatologists and key informants including representatives from melanoma education, training and consumer organisations, professional associations and colleges. Qualitative data analysis was informed by a determinants of practice framework.5

Results

One-third (32%) of GPs and three-quarters (75%) of dermatologists described themselves as quite or very familiar with the national melanoma guidelines. Two-thirds (68%) of GPs and more than half (58%) of dermatologists thought SN biopsy had an important role in melanoma management. Almost all GPs and dermatologists (92% and 91%, respectively) reported Breslow thickness to be important in influencing referral for SN biopsy; however, only 39% of GPs and 66% of dermatologists correctly identified that SN biopsy is recommended for melanomas with a Breslow >1mm. Both GPs and dermatologists indicated SN biopsy was of value in assessing eligibility for adjuvant systemic therapies (67% and 79%, respectively), and in providing prognostic (71% and 60%, respectively) and staging information (71% and 53%, respectively). 

Interview data indicated attitudes towards SN biopsy are shifting among GPs and dermatologists, driven by data from landmark clinical trials and the influence of professional networks. Key informants indicate use of SN biopsy was continuing to be refined. Factors influencing use included lack of confidence in the evidence base and resulting guidelines, the influence of professional organisations and opinion leaders, prevailing norms among specialties, financial incentives driven by healthcare funding policies, and non-financial incentives such as professional identity and professional standing.

 

 

  1. Morton, D., et al. (1992). Technical details of intraoperative lymphatic mapping for early stage melanoma. Archives of Surgery. 127(4), 392-9.
  2. McGregor JM, Sasieni P. Sentinel node biopsy in cutaneous melanoma: time for consensus to better inform patient choice. British Journal of Dermatology 2015; 172:552–4.
  3. Bigby M., et al. Time to reconsider the role of sentinel lymph node biopsy in melanoma. Journal of the American Academy of Dermatology 2018.
  4. Morton D.L., et al. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. NEJM 2014; 370:599–609.
  5. Flottorp S.A., et al. A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation Science 2013; 8:35.