Management Decisions Made by Physician Assistants and Nurse Practitioners in Cutaneous Malignant Melanoma Patients: Impact of a 31-Gene Expression Profile Test
November 2018 | Volume 17 | Issue 11 | Original Article | 1220 | Copyright © 2018
Rachel S. Mirsky BA,a Giselle Prado MD,b Ryan M. Svoboda MD MS,c Alex M. Glazer MD,d Darrell S. Rigel MD MSe
aMedical Student, Albert Einstein College of Medicine, Bronx, NY bClinical Research Fellow, National Society for Cutaneous Medicine, New York, NY cClinical Research Fellow, Department of Dermatology, Duke University School of Medicine, Durham, NC dResident, Division of Dermatology, University of Arizona, Tucson, AZ eClinical Professor, Department of Dermatology, NYU School of Medicine, New York, NY
IMPORTANCE: The 31 gene-expression profiling test (31-GEP) has been shown to provide useful prognostic information in patients with cutaneous melanoma. The test dichotomizes patients into lower risk (Class 1) or higher risk (Class 2) for melanoma metastasis. Previous studies have demonstrated the clinical utility of the test in impacting dermatologists’ management decisions. Physician assistants and nurse practitioners (PA/NPs) account for a significant portion of dermatologic providers. The impact of a 31-GEP assay on clinical management has not been evaluated in this group. OBJECTIVE: To determine the impact of 31-GEP test results on management decisions made by dermatology PA/NPs for cutaneous melanoma patients. Design, Setting, and Participants: 164 PA/NPs attending a national dermatology conference completed an online survey designed to determine the impact of 31-GEP test results on management decisions in a variety of clinical situations. Participants answered a series of questions related to six melanoma patient vignettes, each featuring different patient and lesion characteristics. MAIN OUTCOMES AND MEASURES: Proportion of PA/NPs who would recommend sentinel lymph node biopsy (SLNBx) or further imaging for each patient vignette (without 31-GEP results, with a lower risk result, or with a higher risk result). The effect of the test results on the follow-up intervals recommended by PA/NPs was also examined. RESULTS: In the majority of cases, a lower risk 31-GEP test result led to a statistically significant decrease in the proportion of PA/NPs who would recommend SLNBx, imaging, or quarterly follow-up. Conversely, a higher risk 31-GEP result significantly altered management toward increased intensity (more recommendations for SLNBx, imaging, or quarterly follow-up) in all cases. CONCLUSIONS AND RELEVANCE: The results of a 31-GEP test appear to significantly impact management decisions made by dermatology PA/NPs regarding SLNBx, acquisition of imaging, and follow-up for patients with cutaneous melanoma. J Drugs Dermatol. 2018;17(11):1220-1223.
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Individuals with early-stage melanoma experience lower melanoma-specific mortality rates compared to those with more advanced (Stage III or IV) disease. However, despite this lower mortality rate, the highest absolute number of melanoma-related deaths occur in patients initially diagnosed with Stage I or II disease.1 This is partially explained by the greater number of early-stage lesions that are diagnosed compared to more advanced cases. Recommendations for clinical management of early-stage melanoma are directed from population based risk of recurrence estimates.2,3 Patients with Stage I-IIA disease receive fewer interventions (eg, sentinel lymph node biopsy (SLNBx), use of imaging, frequency of visits) than those with Stage IIB-IIC disease. Given the magnitude of patients diagnosed with early-stage disease who develop metastases, there is a need for additional stratification tools (beyond conventional methods such as AJCC staging) that can augment identification of Stage I and II patients who are at higher risk for subsequent metastasis. A commercially available 31 gene-expression profiling (31-GEP) test (Decision Dx-Melanoma, Castle Biosciences Inc., Friendswood, TX) has been shown to be an accurate tool in identifying early-stage melanoma patients who are at higher risk for subsequent local recurrence, metastasis, or death.4-9 This validated test dichotomizes patients into lower risk (Class 1) and higher risk (Class 2) groups based on differences in recurrence and surviv