Optimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model

Background: Malignant melanoma is the fifth most common cancer in the UK, with rates continuing to rise, resulting in considerable burden to patients and the NHS. Objectives: The objectives were to evaluate the effectiveness and cost-effectiveness of current and alternative follow-up strategies for...

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Autores principales:	Luke Vale, Patience Kunonga, Diarmuid Coughlan, Vasileios Kontogiannis, Margaret Astin, Fiona Beyer, Catherine Richmond, Dor Wilson, Dalvir Bajwa, Mehdi Javanbakht, Andrew Bryant, Wanwuri Akor, Dawn Craig, Penny Lovat, Marie Labus, Batoul Nasr, Timothy Cunliffe, Helena Hinde, Mohamed Shawgi, Daniel Saleh, Pam Royle, Paul Steward, Rachel Lucas, Robert Ellis
Formato:	article
Lenguaje:	EN
Publicado:	NIHR Journals Library 2021
Materias:	cutaneous melanoma surveillance systematic review evidence synthesis cost-effectiveness analysis Medical technology R855-855.5
Acceso en línea:	https://doaj.org/article/21247debab3e4d9bb4ce2c282c8aa36f
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id	oai:doaj.org-article:21247debab3e4d9bb4ce2c282c8aa36f
record_format	dspace
institution	DOAJ
collection	DOAJ
language	EN
topic	cutaneous melanoma surveillance systematic review evidence synthesis cost-effectiveness analysis Medical technology R855-855.5
spellingShingle	cutaneous melanoma surveillance systematic review evidence synthesis cost-effectiveness analysis Medical technology R855-855.5 Luke Vale Patience Kunonga Diarmuid Coughlan Vasileios Kontogiannis Margaret Astin Fiona Beyer Catherine Richmond Dor Wilson Dalvir Bajwa Mehdi Javanbakht Andrew Bryant Wanwuri Akor Dawn Craig Penny Lovat Marie Labus Batoul Nasr Timothy Cunliffe Helena Hinde Mohamed Shawgi Daniel Saleh Pam Royle Paul Steward Rachel Lucas Robert Ellis Optimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model
description	Background: Malignant melanoma is the fifth most common cancer in the UK, with rates continuing to rise, resulting in considerable burden to patients and the NHS. Objectives: The objectives were to evaluate the effectiveness and cost-effectiveness of current and alternative follow-up strategies for stage IA and IB melanoma. Review methods: Three systematic reviews were conducted. (1) The effectiveness of surveillance strategies. Outcomes were detection of new primaries, recurrences, metastases and survival. Risk of bias was assessed using the Cochrane Collaboration’s Risk-of-Bias 2.0 tool. (2) Prediction models to stratify by risk of recurrence, metastases and survival. Model performance was assessed by study-reported measures of discrimination (e.g. D-statistic, Harrel’s c-statistic), calibration (e.g. the Hosmer–Lemeshow ‘goodness-of-fit’ test) or overall performance (e.g. Brier score, R2). Risk of bias was assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). (3) Diagnostic test accuracy of fine-needle biopsy and ultrasonography. Outcomes were detection of new primaries, recurrences, metastases and overall survival. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies–2 (QUADAS–2) tool. Review data and data from elsewhere were used to model the cost-effectiveness of alternative surveillance strategies and the value of further research. Results: (1) The surveillance review included one randomised controlled trial. There was no evidence of a difference in new primary or recurrence detected (risk ratio 0.75, 95% confidence interval 0.43 to 1.31). Risk of bias was considered to be of some concern. Certainty of the evidence was low. (2) Eleven risk prediction models were identified. Discrimination measures were reported for six models, with the area under the operating curve ranging from 0.59 to 0.88. Three models reported calibration measures, with coefficients of ≥ 0.88. Overall performance was reported by two models. In one, the Brier score was slightly better than the American Joint Committee on Cancer scheme score. The other reported an R2 of 0.47 (95% confidence interval 0.45 to 0.49). All studies were judged to have a high risk of bias. (3) The diagnostic test accuracy review identified two studies. One study considered fine-needle biopsy and the other considered ultrasonography. The sensitivity and specificity for fine-needle biopsy were 0.94 (95% confidence interval 0.90 to 0.97) and 0.95 (95% confidence interval 0.90 to 0.97), respectively. For ultrasonography, sensitivity and specificity were 1.00 (95% confidence interval 0.03 to 1.00) and 0.99 (95% confidence interval 0.96 to 0.99), respectively. For the reference standards and flow and timing domains, the risk of bias was rated as being high for both studies. The cost-effectiveness results suggest that, over a lifetime, less intensive surveillance than recommended by the National Institute for Health and Care Excellence might be worthwhile. There was considerable uncertainty. Improving the diagnostic performance of cancer nurse specialists and introducing a risk prediction tool could be promising. Further research on transition probabilities between different stages of melanoma and on improving diagnostic accuracy would be of most value. Limitations: Overall, few data of limited quality were available, and these related to earlier versions of the American Joint Committee on Cancer staging. Consequently, there was considerable uncertainty in the economic evaluation. Conclusions: Despite adoption of rigorous methods, too few data are available to justify changes to the National Institute for Health and Care Excellence recommendations on surveillance. However, alternative strategies warrant further research, specifically on improving estimates of incidence, progression of recurrent disease; diagnostic accuracy and health-related quality of life; developing and evaluating risk stratification tools; and understanding patient preferences. Study registration: This study is registered as PROSPERO CRD42018086784. Funding: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol 25, No. 64. See the NIHR Journals Library website for further project information.
format	article
author	Luke Vale Patience Kunonga Diarmuid Coughlan Vasileios Kontogiannis Margaret Astin Fiona Beyer Catherine Richmond Dor Wilson Dalvir Bajwa Mehdi Javanbakht Andrew Bryant Wanwuri Akor Dawn Craig Penny Lovat Marie Labus Batoul Nasr Timothy Cunliffe Helena Hinde Mohamed Shawgi Daniel Saleh Pam Royle Paul Steward Rachel Lucas Robert Ellis
author_facet	Luke Vale Patience Kunonga Diarmuid Coughlan Vasileios Kontogiannis Margaret Astin Fiona Beyer Catherine Richmond Dor Wilson Dalvir Bajwa Mehdi Javanbakht Andrew Bryant Wanwuri Akor Dawn Craig Penny Lovat Marie Labus Batoul Nasr Timothy Cunliffe Helena Hinde Mohamed Shawgi Daniel Saleh Pam Royle Paul Steward Rachel Lucas Robert Ellis
author_sort	Luke Vale
title	Optimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model
title_short	Optimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model
title_full	Optimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model
title_fullStr	Optimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model
title_full_unstemmed	Optimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model
title_sort	optimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model
publisher	NIHR Journals Library
publishDate	2021
url	https://doaj.org/article/21247debab3e4d9bb4ce2c282c8aa36f
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spelling	oai:doaj.org-article:21247debab3e4d9bb4ce2c282c8aa36f2021-11-18T11:10:45ZOptimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model1366-52782046-492410.3310/hta25640https://doaj.org/article/21247debab3e4d9bb4ce2c282c8aa36f2021-11-01T00:00:00Zhttps://doi.org/10.3310/hta25640https://doaj.org/toc/1366-5278https://doaj.org/toc/2046-4924Background: Malignant melanoma is the fifth most common cancer in the UK, with rates continuing to rise, resulting in considerable burden to patients and the NHS. Objectives: The objectives were to evaluate the effectiveness and cost-effectiveness of current and alternative follow-up strategies for stage IA and IB melanoma. Review methods: Three systematic reviews were conducted. (1) The effectiveness of surveillance strategies. Outcomes were detection of new primaries, recurrences, metastases and survival. Risk of bias was assessed using the Cochrane Collaboration’s Risk-of-Bias 2.0 tool. (2) Prediction models to stratify by risk of recurrence, metastases and survival. Model performance was assessed by study-reported measures of discrimination (e.g. D-statistic, Harrel’s c-statistic), calibration (e.g. the Hosmer–Lemeshow ‘goodness-of-fit’ test) or overall performance (e.g. Brier score, R2). Risk of bias was assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). (3) Diagnostic test accuracy of fine-needle biopsy and ultrasonography. Outcomes were detection of new primaries, recurrences, metastases and overall survival. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies–2 (QUADAS–2) tool. Review data and data from elsewhere were used to model the cost-effectiveness of alternative surveillance strategies and the value of further research. Results: (1) The surveillance review included one randomised controlled trial. There was no evidence of a difference in new primary or recurrence detected (risk ratio 0.75, 95% confidence interval 0.43 to 1.31). Risk of bias was considered to be of some concern. Certainty of the evidence was low. (2) Eleven risk prediction models were identified. Discrimination measures were reported for six models, with the area under the operating curve ranging from 0.59 to 0.88. Three models reported calibration measures, with coefficients of ≥ 0.88. Overall performance was reported by two models. In one, the Brier score was slightly better than the American Joint Committee on Cancer scheme score. The other reported an R2 of 0.47 (95% confidence interval 0.45 to 0.49). All studies were judged to have a high risk of bias. (3) The diagnostic test accuracy review identified two studies. One study considered fine-needle biopsy and the other considered ultrasonography. The sensitivity and specificity for fine-needle biopsy were 0.94 (95% confidence interval 0.90 to 0.97) and 0.95 (95% confidence interval 0.90 to 0.97), respectively. For ultrasonography, sensitivity and specificity were 1.00 (95% confidence interval 0.03 to 1.00) and 0.99 (95% confidence interval 0.96 to 0.99), respectively. For the reference standards and flow and timing domains, the risk of bias was rated as being high for both studies. The cost-effectiveness results suggest that, over a lifetime, less intensive surveillance than recommended by the National Institute for Health and Care Excellence might be worthwhile. There was considerable uncertainty. Improving the diagnostic performance of cancer nurse specialists and introducing a risk prediction tool could be promising. Further research on transition probabilities between different stages of melanoma and on improving diagnostic accuracy would be of most value. Limitations: Overall, few data of limited quality were available, and these related to earlier versions of the American Joint Committee on Cancer staging. Consequently, there was considerable uncertainty in the economic evaluation. Conclusions: Despite adoption of rigorous methods, too few data are available to justify changes to the National Institute for Health and Care Excellence recommendations on surveillance. However, alternative strategies warrant further research, specifically on improving estimates of incidence, progression of recurrent disease; diagnostic accuracy and health-related quality of life; developing and evaluating risk stratification tools; and understanding patient preferences. Study registration: This study is registered as PROSPERO CRD42018086784. Funding: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol 25, No. 64. See the NIHR Journals Library website for further project information.Luke ValePatience KunongaDiarmuid CoughlanVasileios KontogiannisMargaret AstinFiona BeyerCatherine RichmondDor WilsonDalvir BajwaMehdi JavanbakhtAndrew BryantWanwuri AkorDawn CraigPenny LovatMarie LabusBatoul NasrTimothy CunliffeHelena HindeMohamed ShawgiDaniel SalehPam RoylePaul StewardRachel LucasRobert EllisNIHR Journals Libraryarticlecutaneous melanomasurveillancesystematic reviewevidence synthesiscost-effectiveness analysisMedical technologyR855-855.5ENHealth Technology Assessment, Vol 25, Iss 64 (2021)

Optimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model

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