Are Medicare Patients Waiting Too Long for Melanoma Removal?

Melanoma is a dangerous, rapidly progressive cancer. While delays in tumor excision have not been linked to survival in melanoma patients specifically, it does appear to increase morbidity and mortality in patients with cancers of the lung, bladder, and breast. Most oncologists recommend removing melanomas within 4 to 6 weeks of diagnostic biopsy.

Researchers from Yale Medical School in New Haven, Connecticut, have analyzed Medicare’s database to determine how quickly our highest risk population—elderly people—have melanomas removed. Their findings indicate 20 percent wait more than 1.5 months to have the malignancy removed, and roughly 8 percent wait longer than 3 months.

These researchers looked at data from 32,501 Medicare patients who were diagnosed with melanoma between January 2000 and December 2009. The patient demographics were expected in keeping with melanoma’s usual presentation—white race and increasing age are risk factors, and sun-exposed skin is most likely to be affected.

Almost all patients were white and presenting with a first melanoma, and more than 60 percent were male and 75 years or older. Forty percent of tumors occurred on the head, and half were in situ disease.

Although more than three-quarters of Medicare beneficiaries had their tumors removed within the 6 weeks that oncologists informally recognize as acceptable, 22.3 percent did not. They waited more than 6 weeks for an appointment and 8.1 percent waited more than 3 months.

Patients aged 85 years or older were more likely to have treatment delays than younger patients. Having a prior melanoma and having one or more Elixhauser comorbidities (specific acute and chronic conditions significantly associated with in-hospital mortality) were also associated with delayed excision.

Having a dermatologist perform the biopsy and provide surgical care reduced risk of a delay. Having a primary care physician perform the biopsy doubled the risk of delay.

The researchers note that their findings represent opportunities for quality improvement in dermatologic care. Enhancing care coordination could reduce delays, and could better interdisciplinary education and improved handoff communication between specialists. This study appears in the online version of JAMA Dermatology.