LAUSR

Patients with resected stage III melanoma are at high risk for recurrence. Clinical trials primarily including stage IIIB or higher patients have demonstrated a 2-year relapsefree survival rate of less than 50% without adjuvant therapy. With the advent of effective immunotherapy and targeted therapy for melanoma, there has been an increased interest in early detection of recurrent disease with hopes of improving survival through earlier treatment. However, there is still much that needs to be studied to determine whether more frequent surveillance imaging actually helps achieve that goal. Current National Comprehensive Cancer Network (NCCN) guidelines state that one should consider imaging every 3–12 months for 2 years, then every 6–12 months for another 3 years, for all stage IIB–IV patients in whom there has been no evidence of disease. The wide range of imaging frequency and the lack of distinction between different stages and substages leave a lot to be determined by individual physicians and create great variability in how we follow patients. Decisions about surveillance strategies need to be thought of in terms of balancing risk and benefit, similar to how we think of treatment strategies. One potential risk of increased surveillance imaging is the increased anxiety around the time of surveillance imaging, often termed ‘‘scanxiety,’’ which can impact a patient’s quality-of-life measures. A second potential risk is cumulative radiation exposure over time. Although there has not been a clear causative effect of computed tomography (CT) scans and radiation-associated cancers, data regarding radiation doses suggest that the risk after multiple CT scans is not negligible. Additionally, one needs to consider the cost of more frequent surveillance imaging. This includes not only the actual cost of the test itself but also the cost of false positive results that require additional workup and likely contribute further to the fear of cancer recurrence that patients experience. Identifying cost-effective strategies is particularly important when patients are being treated in lower-resource settings. Insurance companies and hospitals with fewer resources will need to choose which tests to advocate for covering, and patients with fewer resources will need to decide how much time and money they can or should sacrifice for additional visits and tests. On the other hand, patients are likely willing to undergo surveillance imaging if catching and treating recurrences earlier will improve their overall survival, as well as for the piece of mind provided by a test that shows no evidence of disease. The burden of proof is on us to determine what types of surveillance strategies have the potential to benefit patients by improving survival rates and/or quality of life. One example of a prospective study for melanoma surveillance strategies is the MELFO Study, a multicenter, prospective, randomized clinical trial on the effects of a reduced stage-adjusted follow-up schedule for stage IB–IIC cutaneous melanoma patients. This study included four different questionnaires and scales to assess patient-reported outcome measures including anxiety, worry about cancer recurrence, and overall quality of life. The 3-year follow-up results of this study found that a reduced followup schedule did not impact recurrence-free or disease-free survival, but did lower stress response symptom scores on the Impact of Event Scale. It is natural to next ask whether these findings will be replicated in patients with a baseline higher risk of recurrence. In Dieng et al.’s study entitled ‘‘The impact of surveillance imaging frequency on detection of distant disease for patients with resected stage III melanoma,’’ the authors performed a retrospective study of a large prospective melanoma database (2000–2017) and grouped Society of Surgical Oncology 2022