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Prognosis of Metastatic Melanoma: Where Are the Details?

Akdeniz University Faculty of Medicine, Antalya, Turkey

To the Editor: I read with great interest the article by Butow et al entitled "Psychosocial Predictors of Survival in Metastatic Melanoma."¹ They claim that psychosocial factors predict survival in metastatic melanoma and "perception of treatment goal" was found to be a "strong predictor of outcome."¹ A few points need to be clarified in this article.

First, there is a discordance in the percentage of patients who received no treatment. In Table 2, it is reported that 26% of all participants received no treatment, but in Table 6, 73% and 78% of the patients who received no treatment perceived the aim of the treatment to be cure/long-term survival or short-term survival/palliative, respectively.

Second, other than the site of metastasis, number of metastases and the duration of remission are well-known independent prognostic factors in metastatic melanoma.²³ In Butow et al's study, those two factors were not included in univariate analysis. The oncologist's goal may be to achieve long-term survival for a patient with a limited number of resectable metastases, as the patient may perceive. Also, patients who relapse after a long remission again may expect to "live long-term." So in fact, the patient's perception would fit with a nonpsychosocial prognostic factor. Butow et al's article does not provide those important details about nonpsychosocial prognostic factors.

Third, Butow et al criticize their study by saying that one of the explanations for these findings may be patients' responses reflected what their oncologist had told them, but these data were not collected. This statement is ultimately correct, but there is more. Patients' responses might reflect how their oncologists tend to treat metastatic melanoma. The goal of some oncologists may be palliation, and they may treat their patients with palliative radiotherapy or surgery for symptomatic disease sites only. Others may choose a more aggressive approach, using systemic combined chemoimmunotherapy for patients they find suitable for such treatment. Because we do not know the details of treatment in Butow et al's study population (type of surgery, chemotherapy regimen, use of combined therapies), we cannot be sure that better prognosis was not related to better treatment but was a consequence of psychosocial factors. More aggressively treated patients (those who have good performance status) would probably be the ones perceiving the aim of the treatment to be long-term survival.

The trial has an intelligent way of thinking about the detailed psychosocial status of patients, but it lacks details of biologic aspects of melanoma that can definitely affect survival.

REFERENCES

1. Butow PN, Coates AS, Dunn SM: Psychosocial predictors of survival in metastatic melanoma. J Clin Oncol17:2256-2263, 1999[Abstract/Free Full Text]

2. Balch CM, Soong SJ, Murad TM, et al: A multifactorial analysis of melanoma: IV. Prognostic factors in 200 melanoma patients with distant metastases (stage III). J Clin Oncol1:126-134, 1983[Abstract]

3. Barth A, Wanek LA, Morton D: Prognostic factors in 1,521 melanoma patients with distant metastasis. J Am Coll Surg181:193-201, 1995[Medline]

Response

The University of Sydney, Sydney, Australia

In Reply: Dr Samur has raised some important issues regarding our article. The disparity between the total and subset percentages of patients who received no treatment is due to a clerical error in Table 6, where the percentages should have been reversed. We are grateful to Dr Samur for pointing out this error.

We agree that it is extremely important to explore all possible explanations for the finding that psychosocial factors predicted survival in our cohort, and in particular to control for disease variables that may be potential confounders. We measured all variables known to be predictors of outcome, which were readily accessible from hospital records. Details of specific treatments and treatment intent were not routinely recorded; however, we did control for time since both the primary and metastatic diagnoses, as proxy measures of the remission duration. Recording of the more fine-grained details of disease and treatment, as well as typical approach by the doctors to this disease, would be a useful addition to the analyses.

We are now conducting a randomized controlled trial of an individual psychologic intervention, designed to increase realistic optimism and minimize the impact of cancer on patients' lives, with patients with metastatic melanoma and breast cancer. We are seeking to establish, first, whether optimism and coping are malleable and, second, whether increasing optimism will lead to a survival advantage. The randomized control design will make the results of this study clearer and provide a higher order of evidence for or against a role for psychosocial factors in the outcome of metastatic cancer.

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Samur, M. Articles by Butow, P. Search for Related Content PubMed PubMed Citation Articles by Samur, M. Articles by Butow, P. Social Bookmarking                            What's this?