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 © November 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
The results of this study indicate that the additional information provided by a 31-GEP test alters the management decisions made by dermatology PA/NPs in a variety of clinical situations. In most situations, a lower risk 31-GEP result was associated with a significant reduction in recommendations for SLNBx and further imaging, as well as a propensity to lengthen the recommended follow-up interval. This has the potential to reduce costs and patient burden. It also offers the potential to avoid complications related to SLNBx in a population with a very low rate of SLNBx positivity.14,15 Compared to baseline, a higher risk result was associated with a significant increase in recommendation for SLNBx, further imaging, and a shorter follow-up interval in all cases. These patients are at the highest risk for development of subsequent metastases and might benefit from closer monitoring than would typically be recommended for patients with Stage I or II disease. The results from this study suggests that 31-GEP test results could lead to targeted redistribution of resources to those patients at highest risk for recurrence.When the results of this study are considered in the context of prior studies demonstrating similar changes in management among dermatologists and dermatology residents,11,12 it is clear that a 31-GEP test can be appropriately applied by all dermatology professionals. These findings indicate that changes in real-world management due to 31-GEP test results have the potential to benefit both lower risk patients who could undergo fewer unnecessary tests and higher risk patients who could receive closer follow-up. In the current age of accountable care, where providers are increasingly assessed on the value of care provided, these findings are particularly meaningful.Limitations to this study include the possibility that the clinical vignettes used are not comprehensive representations of real-world patient cases. Additionally, the sample of PA/NPs attending the national conference may not accurately represent the larger population of dermatology PA/NPs practicing in the United States.
The results of this study demonstrate that the availability of 31-GEP test results significantly influenced the decisions of dermatology PA/NPs to recommend SLNBx, radiologic imaging, and follow-up interval. Furthermore, in the majority of cases, respondents utilized the information to alter management in the appropriate direction (eg, decreased SLNBx and imaging with a lower risk result and increased SLNBx and imaging with a higher risk result), while remaining in the context of existing guidelines. This indicates that the assay has clinical utility among PA/NPs and suggests that the improved prognostic information provided by the test would have an appropriate impact on patient management, potentially leading to more efficient resource allocation.
Dr. Rigel served as a consultant to Castle Biosciences Inc. Drs. Glazer, Svoboda, and Prado participated in a research fellowship which was partially funded by Castle Biosciences Inc.
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