Mode of presentation and time to treatment of uveal melanoma in Finland

Abstract

Aims: To investigate the current referral pattern and delays in treatment of patients with primary uveal melanoma.

Methods: 184 consecutive Finnish patients with uveal melanoma diagnosed between July 1994 and June 1999 were eligible, and 159 were enrolled (inclusion rate, 86%). Their mean age was 60 years (range 14-87). The dates of visits to dispensing optician, physician, ophthalmologist and ocular oncologist, the presence of symptoms, and reason for consultation were determined by structured telephone interview. Time intervals to treatment planning and treatment were calculated.

Results: 139 patients (87%) had symptoms at presentation and 44 patients (28%) had been seen by an ophthalmologist less than 2 years previously. The median height of the tumour was 6 mm (range, 1.0-17.0) and its largest basal diameter 11 mm (range 2.5-22.0) at diagnosis. Melanoma developed from a previously detected presumed naevus in 13 patients (8%). When the first contact was a dispensing optician (15%) the median time to treatment planning was 22 days (range 1-1156). When a physician other than an ophthalmologist (19%) was contacted the delay was 68 days (range 0-1283) and when an ophthalmologist (65%) was seen it was 34 days (range 1-1426). These differences were not significant (p=0.32). The chance of being referred at first visit was 89%. Median time to treatment was not associated with symptoms (p=0.16) and tumour volume (p=0.29), but it was significantly different between patients who were and were not referred at first visit (140 days v 34 days; p<0.001) and between those treated by ruthenium and iodine brachytherapy (59 days v 33 days; p=0.009).

Conclusions: Analysis of delays in management indicates that earlier treatment could be achieved if dilated fundus examinations were performed without exceptions, all suspicious naevi were referred for a second opinion, and if the patients with melanoma were referred to the ocular oncology service concurrently with staging examinations done at the regional hospital.

Figure 1

Cumulative frequency plot of the time span between the last visit (unrelated to the tumour) to an ophthalmologist and to a dispensing optician and initial presentation with the tumour.

Figure 2

Cumulative frequency plots of time from the initial presentation to treatment planning in the national ocular oncology service according to (A) (Mann-Whitney U test) the healthcare professional seen (one patient referred by a school nurse is omitted), (B) whether or not the tumour was suspected at first visit, (C) whether or not misdiagnoses or administrative problems occurred in the referral process. Cumulative frequency plot of time from the initial presentation to treatment (D). Cumulative frequency plots of time from the initial presentation to treatment planning according to categorised tumour size (E) (Kruskal-Wallis test), and the type of brachytherapy (F) (Mann-Whitney U test).