Quality measurements for the Melanoma Register
The primary purpose of the Melanoma Registry is to help ensure that patients receive the same and correct treatment that follows the National Action Programme with guidelines for diagnosis, treatment and follow-up of malignant melanoma.
The recommendations in the Action Programme for Diagnosis, Treatment and Follow-up of Malignant Melanoma form the basis for variables and quality measures in the Melanoma Registry. In cooperation with the Cancer Registry, the Advisory Council has defined quality objectives to be evaluated in the annual report (Norwegian only).
Quality indicators
Tumor thickness, ulceration and mitotic rate are very important prognostic variables that the pathologists must describe in the response reports. We see that there is some variation between the various laboratories as to whether tumor thickness and ulceration are stated explicitly in the responses, but virtually all laboratories stay within what is defined as a high target attainment for this quality indicator. It is very important that the pathologists use the recommendations for standardized setup and reporting published by the Norwegian Association of Pathologists.
It is beneficial for the patient to have the diagnosis made as early as possible - preferably in stage T1 - as these normally have very good survival after surgery alone. T1 is characterized by the melanoma being 1 mm or thinner. The specialist group has set as a quality target that at least 60% of the melanomas that are removed must be in stage T1. The results show that in Norway the proportion is 58.1%.
Read more about quality objectives in the Annual Report 2023 Melanoma (Norwegian only)
Quality improvements
One of the Melanoma Registry's most important tasks has been, and still is, to ensure high reporting of clinical information so that the data can be used for quality-improving work in hospitals. The registry's data basis can then be used to assess whether all patients receive the best possible treatment, and whether the entire health service complies with the guidelines. Changes in treatment guidelines will also be considered if the measures implemented do not have sufficient effect.
Information from the Cancer Registry of Norway is important for influencing guidelines and for ensuring that they are followed throughout the country. In 2020, the guidelines for when to perform sentinel lymph node surgery were changed based on figures from the Melanoma Registry. This is precisely how we want data from the register to help to continuously improve the guidelines.
The Melanoma Registry contacts individual health enterprises/clinics/departments during the work on the annual reports if there are results that stand out from the rest of the country. This makes it possible for the relevant units to assess what may be the reasons for the results and, if necessary, rectify this or include it as comments in the reports.
The Norwegian Melanoma Group encourages the academic communities to use the report and assess their own results to see to what extent the recommendations in the action programme are complied with.
See results in annual report 2023 Melanoma (Norwegian only)
Areas for improvement
Ulceration (ulcer formation) and morphological type
Results show that there is ulceration in 14% of melanomas nationally, and there is less variation between hospitals than in previous years. It is important that the pathologists follow structured templates to answer melanomas, so that important factors for staging, prognosis and recommended treatment regimens are in place. For ulceration, it is important that this is explicitly reported, even in cases where there is no ulceration, and we follow this further. Melanoma with unknown morphology where no specific tumor type is described in the pathology report (melanoma UNS) accounts for approximately 15% of melanoma cases. Since the various morphological tumor types grow differently and have different prognoses, it is very important that the pathologists describe the type of melanoma in question in the histology response.
Free margin after primary excision performed in primary care and in hospital
Results show that only 70% of melanomas are removed with a pathologically free margin, among GPs. This is worrying because it is in primary care that most primary excisions are performed. It is therefore important to provide training so that GPs have the knowledge and competence to make correct assessments and examinations of suspicious lesions so that these are removed and sent for examination at an early stage. They must also know how to remove the lesions and focus on removing them with a free margin. It is difficult to reach out with information to a collective group of GPs, but we hope that the various health organizations focus on their GPs. In comparison, 85% of melanomas in hospitals are removed with a pathologically free margin.
Adequate margin with extended excision
We see that there is a large variation between the hospitals in terms of sufficient free margin after the extension excision. Results below 80% are cause for concern and we see that there are significant differences in the treatment of melanoma in Norway. Furthermore, we know that in some cases you can choose to compromise with the recommendations, in consultation with the patient.
Time from primary excision to extended excision
The time from when the patient sees a doctor until the lesion is removed, examined and an extended excision is performed must be within 35 days, according to the package procedure for melanoma. Results show that only 59% are treated within the deadline, and all healthcare facilities have potential for improvement. Even so, there are several healthcare companies that have improved their results from 2022. It will be important to follow developments further in order to be able to identify unnecessary delays.
Early diagnostics
The registry focuses on early diagnosis, which hopefully means that more patients can be cured. This includes both diagnosing melanoma cases early, while they are still thin (T1 tumors), and diagnosing any recurrences as early as possible. Here, of course, it is important to inform both the general population and melanoma patients about symptoms and signs that should prompt them to see a doctor as early as possible. The specialist group has set as a quality target that at least 60% of the melanomas that are removed must be in stage T1. The focus must therefore be directed at certain hospitals that stand out significantly, with too low a proportion in stage T1. Here it is necessary to collaborate with the Norwegian Cancer Society, with its contact with the population, and the Norwegian Association for General Medicine with its contact with GPs.
Medical treatment
Several drugs and forms of treatment are at full speed in the treatment of melanoma patients with spread. In this year's report, we show the proportion of patients with spread who receive neoadjuvant treatment, the proportion of patients who receive adjuvant treatment, and how long it takes from metastasis surgery to the start of adjuvant treatment. We see that the vast majority of patients start adjuvant treatment within 12 weeks after surgery. We look forward to following the effect of neoadjuvant treatment. We see that there is great variation between the health institutions, so it will be necessary to ensure the quality of the results at hospitals that only provide neoadjuvant treatment to a small extent. In addition, we will continue to monitor the effect of adjuvant treatment in the coming years.
Read about information about drug cancer treatment
See results in Annual Report 2023 Melanoma (Norwegian only)
Proms
In order to further strengthen the quality of health care, the Cancer Registry of Norway has in 2019 and 2020 worked on planning and building infrastructure for collecting PROMs (Patient-reported outcome and experience goals), including integration with ePROM, which is the national solution for collecting PROMs.
The Melanoma Registry has been allocated funding from the Professional Centre for Patient-Reported Data to use ePROM. In order to distinguish between common ailments in the population and ailments related to melanoma, a random sample of people without melanoma will also be invited to submit a questionnaire.
The National Quality Registry for Melanoma started with routine collection of PROMs/PREMs in April 2021 and selected results are presented for the third time in this year's report.
See results of PROMs/PREMs in Annual Report 2023 Melanoma (Norwegian only)
