University of Twente Student Theses


Systemic therapy and imaging surveillance in high-stage melanoma patients during the end of life : a retrospective cohort study

Lith, Pieter van (2020) Systemic therapy and imaging surveillance in high-stage melanoma patients during the end of life : a retrospective cohort study.

[img] PDF
Abstract:Introduction Melanoma is the most aggressive form of skin cancer and is the cause for 11% of all skin cancers. The incidence increased significantly in the period 1990-2019. In recent years, new systemic therapies have been developed that improve the survival of high-stage melanoma patients, but these systemic therapies are associated with high costs and potentially severe side effects. Therefore, it is very important to carefully consider its use towards the end of life in high-stage melanoma patients. Currently, very little is known about which factors are related to the use of systemic therapy and of diagnostic interventions for melanoma patients in the months before death. The aim of the current study is to examine which patient and tumor characteristics are associated with the use and timing of systemic therapies, and which imaging techniques are performed in high-stage melanoma patients during the end of life. Methods A retrospective cohort study was performed analyzing patients with high-stage melanoma from the Netherlands Cancer Registry (NCR). From the 1st of July 2017 a melanoma high stage registration (MelaHS) was incorporated in the NCR. The study contained 476 patients with high-stage melanoma who were deceased between July 2017 till the end of 2019. Patient and tumor characteristics were summarized using descriptive statistics for types of systemic therapy (immune, targeted-, both or no therapy), also patients who started and ended with systemic therapy and types of imaging interventions were stratified according to certain time frames before death occurred. Significance was tested by using chi-square tests (p < 0.05). Results Patients who received systemic therapy (N = 314; 66%) were younger (69 vs. 75,5 years), lived longer after diagnosis high-stage (5,9 vs. 2 months), were diagnosed with more metastases (5,3 vs. 2,8) had a ‘good’ performance status (ECOG 0 – 1; 70% vs. 24,1%) and had a BRAF mutation (56,7% vs. 21,6%) compared to non-systemic patients. Most patients who were treated systemically had received immune therapy (46,8%). Patients who were treated with both therapies (immune- and targeted therapy) were younger, had a ‘good’ performance status, lived longer since the primary high-stage diagnosis, irradiated and screened most often with mainly CT & MRI-scan compared to patients who received only immune- or targeted therapy. Patients who started with only immune therapy within 30 days before death had more elevated LDH levels (76,2% vs. 58,8%), compared to patients who started within 90 days before death, the same applies to only targeted treated patients but the difference was smaller. A ‘good’ performance status and a longer lifespan (0 – 30 = 1,9 months & 31 – 90 = 3,4 months) since the MelaHS inclusion was seen more in only immune treated patients, compared to patients who were treated with only targeted therapy with a shorter lifespan (0 – 30 = 0,8 months & 31 – 90 = 3 months) since the MelaHS inclusion and with mainly a ‘poorer’ performance status shortly before death. Most imaging surveillance was used on patients receiving both therapies. Conclusion This study showed that age, performance status (ECOG), elevated LDH levels and a BRAF mutation were possible factors associated with the use and timing of systemic therapy in the period before death and which imaging techniques were used. A start with targeted therapy was used for potentially weaker and older patients, where immune treated patients (and combination of both) were younger and potentially stronger shortly before death. To start or end a systemic therapy is a complicated and often emotionally charged decision, where a well-informed assessment of both the harm and benefit of systemic therapy should be comprehensively considered, especially when the patient is nearing the end of life.
Item Type:Essay (Master)
Faculty:TNW: Science and Technology
Subject:44 medicine
Programme:Health Sciences MSc (66851)
Link to this item:
Export this item as:BibTeX
HTML Citation
Reference Manager


Repository Staff Only: item control page