American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Hospitals Show Wide Variability in Melanoma Care

New indicators developed by expert panel assembled by American College of Surgeons provide markers for improving care in areas where measures have been lacking.


CHICAGO (December 4, 2009): A host of quality indicators developed by an expert panel may help hospitals and physicians improve their care of patients with melanoma, the deadliest form of skin cancer, according to a study supported by the American College of Surgeons and published in the November 10, 2009, issue of the Journal of Clinical Oncology.

Although melanoma accounts for fewer than 5 percent of all skin cancers, it causes more deaths than any other form of skin cancer and it is the sixth most common malignancy in the United States, according to the American Cancer Society. Skin cancer is the most common of all cancers. If recognized and treated early, melanoma is nearly 100 percent curable, but in 2008 melanoma accounted for 8,400 deaths in the United States, according to the American Cancer Society. More than 62,000 new cases of invasive melanoma are diagnosed annually.

In the American College of Surgeons study, a panel of 13 physicians, including researchers in surgery, oncology, dermatology, and dermatopathology, identified 26 valid quality indicators for melanoma care. “Essentially we were able to develop quality indicators that hospitals can use to assess their own care and then help them focus on areas for improvement,” according to study coauthor Karl Y. Bilimoria, MD, MS, former research fellow at the American College of Surgeons and general surgery resident at Northwestern University, department of surgery, Chicago. “When hospitals are told that they have substandard outcomes in a particular area or if they’re just looking to improve, they’re often left without a lot of guidance,” Dr. Bilimoria explained. “Having validated measures developed by an expert panel allows hospitals to try to focus on these specific areas that are deemed important.”

The study authors then identified 47,643 patients from the National Cancer Data Base (NCDB) who underwent operations for melanoma in 2004 and 2005, and evaluated compliance with the quality indicators. The study involved 1,249 Commission on Cancer hospitals. “We found wide variability in hospital compliance with the measures,” Dr. Bilimoria said.

Among participating hospitals, adherence with the quality indicators ranged from 11.8 percent to 96.5 percent at the patient level, which determined the proportion of patients that received care in accordance with the quality measures; and from 3.7 percent to 83 percent at the hospital level. Institutions were considered adherent if 90 percent or more of patients received care compliant with the specific quality measure.

This study is unique in that it defines quality indicators for melanoma treatment. “This development really adds to the growing number of quality indicators available for cancer care in an area where there weren’t any measures at all,” according to Dr. Bilimoria “These indicators go beyond just guidelines. The quality indicators that the expert panel developed are considered near absolute; they should be adhered to almost all the time.”

Additionally, the indicators were created based on solid methodology and can have far-reaching impact. These newly developed quality indicators provide a meaningful metric for improving care for patients with melanoma. They were developed using the validated RAND-UCLA Appropriateness methodology, and with a multidisciplinary group of melanoma experts from around the world. The American College of Surgeons' Commission on Cancer has long helped to ensure important standards for cancer care are being met across the more than 1,400 accredited hospitals in the United States. With the formal development of cancer-specific quality indicators such as these, I am hopeful that the quality and outcomes of care for people with melanoma will be able to be improved even more,” according to study coauthor, Clifford Y. Ko, MD, FACS, Director, American College of Surgeons Division of Research and Optimal Patient Care, assistant professor of surgery, University of California (Los Angeles), and attending surgeon at the West Los Angeles VA Hospital.

The study authors concluded that hospitals can use the quality indicators to assess their adherence with existing guidelines on melanoma care by using feedback mechanisms through the NCDB to better direct their quality improvement efforts.

In addition to Doctors Ko and Bilimoria, the research team also included Mehal V. Raval, MD (American College of Surgeons Clinical Scholar in Residence and general surgery resident at Feinberg School of Medicine, Northwestern University) David J. Bentrem, MD, FACS (Northwestern University); Jeffrey D. Wayne, MD, FACS (Northwestern University); and Charles M. Balch, MD, FACS (Johns Hopkins School of Medicine).

The study was supported by the American College of Surgeons Clinical Scholars in Residence program and the Department of Surgery, Feinberg School of Medicine, Northwestern University.

The study can be viewed on the JCO Web site at:

CITATION: Bilimoria KY, Raval MV, Bentrem DJ, et al: National Assessment of Melanoma Care Using Formally Developed Quality Indicators. J Clin Oncol 27:5445-5451, 2009

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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 79,000 members and is the largest organization of surgeons in the world. For more information, visit

The NCDB is a joint program of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society that contains approximately 20 million records. The CoC, established in 1922 by the American College of Surgeons, is a consortium of 46 professional and related organizations that establish cancer care standards and monitor quality at hospitals it accredits. Approximately 1,400 hospitals in the United States and Puerto Rico are CoC-accredited, representing only 29 percent of all institutions but 70 percent of all new cancer cases.


Sally Garneski 

Cory Suzan Petty