Prediction is Difficult, Especially About the Future: Clinical Prognostic Tools in Melanoma

Excerpt

“What are my chances, doc?” No surgical oncologist who has been in practice more than a few months has escaped being asked this question by an anxious patient. Yet it is rare that the answer addresses the anxiety of the questioner, and rarer still that the answer accurately reflects the future course of the patient’s malignancy, especially when the patient has been diagnosed with cutaneous melanoma. Despite the progress recent years have seen in the understanding of melanoma biology and the consequent advances in therapy, our ability to assess the likelihood of recurrence and death for any individual patient remains conspicuously limited. Conventional staging systems such as the ubiquitous American Joint Committee on Cancer (AJCC) classification can subdivide patients with clinically localized (stage I through III) melanoma into those at relatively low, average, or high risk of recurrence and death, but, even then, at least 10–20 % of patients predicted to be at low or high risk of recurrence will defy the odds and their tumors will behave contrary to expectations. Moreover, as the incidence of melanoma continues to increase and more and more patients are diagnosed with early-stage disease, the absolute number of patients presenting with ‘low risk’ melanoma who ultimately relapse and die is growing.1,2 Sentinel lymph node biopsy (SLNB) clearly represented a major step forward in prognostication for patients with clinically localized cutaneous melanoma,3 but if we are ever to dramatically decrease the death toll from melanoma via adjuvant therapy strategies, then we must find ways to identify the ‘bad actors’ among the patients who the AJCC staging system would classify as at low to moderate risk for recurrence. …