Health Care System and Socioeconomic Factors Associated With Variance in Use of Sentinel Lymph Node Biopsy for Melanoma in the United States Karl Y. Bilimoria, Charles M. Balch, Jeffrey D. Wayne, David C. Chang, Bryan E. Palis, Sydney M. Dy, and Julie R. Lange From the Cancer Programs, American College of Surgeons; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Departments of Surgery and Oncology, Johns Hopkins School of Medicine; Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins, Balti- more, MD. Submitted June 27, 2008; accepted December 1, 2008; published online ahead of print at www.jco.org on March 9, 2009. Supported in part by the American College of Surgeons Clinical Scholars in Residence Program (K.Y.B.). The National Cancer Data Base is supported by the American College of Surgeons, the Commission on Cancer, and the American Cancer Society. Authors’ disclosures of potential con- flicts of interest and author contribu- tions are found at the end of this article. Corresponding author: Julie R. Lange, MD, ScM, Department of Surgery, Johns Hopkins School of Medicine, 600 N Wolfe St, Carnegie 681, Baltimore, MD 21287; e-mail: jlange@jhmi.edu. © 2009 by American Society of Clinical Oncology 0732-183X/09/2711-1857/$20.00 DOI: 10.1200/JCO.2008.18.7567 A B S T R A C T Purpose Guidelines recommend sentinel lymph node biopsy (SLNB) for patients with clinical stage IB/II melanomas, but not clinical stage IA melanoma. This study examines factors associated with SLNB use for clinically node-negative melanoma. Methods Patients diagnosed with clinically node-negative invasive melanoma in 2004 and 2005 were identified from the National Cancer Data Base. Regression models were developed to assess the association of clinicopathologic (sex, age, race/ethnicity, comorbidities, T stage), socioeconomic (insurance status, educational level, income), and hospital (hospital type, geographic area) factors with SLNB use. Results A total of 16,598 patients were identified: 8,073 patients with clinical stage IA and 8,525 patients with clinical stage IB/II melanoma. For clinical stage IB/II melanoma, SLNB use was reported in 48.7% of patients. Patients with clinical stage IB/II melanoma were less likely to undergo SLNB if they were older than 75 years; had T1b tumors, no tumor ulceration, or head/neck or truncal lesions; were covered by Medicaid or Medicare; or lived in the Northeast, South, or West census regions. SLNB use was reported in 13.3% of patients with clinical stage IA melanoma and was more likely in patients who were younger than 56 years or lived in the Mountain or Pacific census regions. Patients treated at National Comprehensive Cancer Network– or National Cancer Institute– designated hospitals were most likely to undergo SLNB in adherence with national consensus guidelines. Conclusion SLNB use was associated with clinicopathologic factors but also with health system factors, including type of insurance, geographic area, and hospital type. These findings have implications for provider education and health policy. J Clin Oncol 27:1857-1863. © 2009 by American Society of Clinical Oncology INTRODUCTION Sentinel lymph node biopsy (SLNB) for the staging of melanoma was first described in detail in 1992. 1 Numerous studies have subsequently documented the prognostic and staging value of sentinel node status in patients with melanoma. 2-8 Moreover, SLNB is associated with improved regional disease control and improved disease-free survival. 7,9,10 SLNB has been integrated into practice guidelines for regional lymph node staging in patients with newly diagnosed melanoma more than 1 mm in thickness. The procedure was included in the Na- tional Comprehensive Cancer Network (NCCN) melanoma guidelines in 1998 and the American Joint Committee on Cancer’s (AJCC’s) 6th edition Cancer Staging Manual in 2002. 11-13 By 2004, there was considerable evidence of the value of SLNB in providing prognostic and staging information in ad- dition to regional disease control. Variance in cancer management related to so- cioeconomic and geographic factors has been shown in breast, colon, and prostate cancer, as well as other common malignancies. 14-18 A report using the Sur- veillance, Epidemiology, and End Results data set showed that the use of SLNB in patients with mela- noma increased from 1998 to 2001, with variability in adherence to treatment guidelines associated with age, race, primary tumor location, and registry site. 19 The socioeconomically disadvantaged have been JOURNAL OF CLINICAL ONCOLOGY O R I G I N A L R E P O R T VOLUME 27  NUMBER 11  APRIL 10 2009 © 2009 by American Society of Clinical Oncology 1857 Downloaded from jco.ascopubs.org on July 27, 2016. For personal use only. No other uses without permission. Copyright © 2009 American Society of Clinical Oncology. All rights reserved.