Quality of Life Following Surgical Excision of Early-Stage Melanoma of the Head and Neck

To the Editor We read with great interest the recent article in JAMA Dermatology by Mori et al, in which patient quality of life following surgical excision of early-stage melanomas of the head and neck was assessed; we believe that their findings have important clinical implications. Of concern, however, was the misleading statement in the abstract that melanoma in situ (Tis) and T1a melanomas are "typically slowly progressive and nonfatal melanomas,"^(p85) and the introductory sentence of the article itself which stated "Tis and T1a melanomas of the head and neck have an excellent prognosis, with a more than 98% five-year disease-specific survival."^(p86) Although Tis melanoma typically has an excellent prognosis and is nonfatal, this is not the case for T1a melanomas. In a recent study undertaken at Melanoma Institute Australia, the 5-year melanoma-specific survival (MSS) for patients with T1a melanomas (as defined by the American Joint Committee on Cancer 8th Edition Cancer Staging Manual; ie, ≤0.8 mm in Breslow thickness without ulceration) was indeed good (96.7%; 95% CI, 95.5%-97.9%). However, the 10-year MSS was 94.2% (95% CI, 92.7%-95.8%); the 15-year MSS was 91.0% (95% CI, 88.8%-93.3%); and the 20-year MSS was 86.9% (95% CI, 83.3%-90.6%). Even beyond 20 years, deaths due to melanoma were still occurring, with no suggestion that the MSS curve had reached a plateau. Only 27.1% of the patients with T1a melanomas who died of melanoma did so within 5 years of their initial melanoma diagnosis; 49.1% died between 5 and 10 years after diagnosis; and 23.7% died more than 10 years after diagnosis. To quote excellent 5-year survival figures for T1a melanomas and imply that they are almost all nonfatal is therefore misleading. It is a surprising fact that more patients die of thin melanomas (≤1 mm) than die of thicker melanomas (>1 mm), which occurs because many more patients present with thin melanomas. With careful long-term follow-up (>20 years) our data indicated that approximately 15% of patients with T1a melanomas will ultimately die of melanoma.

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