Collaborative Ocular Melanoma Study (COMS)

Purpose | Background | Description | Patient Eligibility | Recruitment Status | Current Status | Results | Publications | Clinical Centers | Resource Centers | NEI Representative

Purpose

• To evaluate therapeutic interventions for patients who have choroidal melanoma, the most common primary eye cancer affecting adults, and to assess the potential life-preserving as well as sight-preserving role of radiation therapy.
• To determine which of two standard treatments, removal of the eye or brachytherapy, is more likely to prolong survival of eligible patients with medium-sized choroidal melanoma.
• To determine whether preoperative radiation prolongs life for patients whose eyes with large choroidal melanoma are enucleated.

Background

For more than 100 years, removal of the eye (enucleation) has been the standard treatment for choroidal melanoma. Before the COMS was initiated in 1986, interest in radiation therapy had increased because of the potential for saving the eye and perhaps some vision. However, the merits of radiation with respect to prolonging patient survival were unknown. The best data from nonrandomized studies suggested that there was no difference in length of remaining life between patients treated with radiation and those whose eyes were enucleated. Thus, it was appropriate and necessary to conduct a randomized, controlled clinical trial in which a large number of patients would be followed for many years in order to compare enucleation and radiation with respect to relative success in prolonging survival of choroidal melanoma patients.

Description

The Collaborative Ocular Melanoma Study (COMS) is a set of long-term, multicenter, randomized controlled trials. In the trial for patients with tumors of medium size, enucleation and irradiation with an iodine-125 episcleral plaque are compared on the basis of length of remaining life. All randomized patients will be followed for 5 to 15 years or until death. For patients randomly assigned to enucleation, the eye was removed following a standard procedure. For patients assigned to plaque irradiation, the margins of the tumor were located and the dimensions of the tumor were measured by the ophthalmic surgeon. A gold plaque with a plastic seed carrier that contained the proper dosage and configuration of radioactive iodine seeds was sutured to the outside (sclera) of the eye over the base of the tumor. This procedure made possible the delivery of a high dose of radiation to a very localized area (85 Gy [TG-43] to the tumor apex). The plaque typically was removed from the eye after three to seven days. Enrollment was completed in this trial in July 1998 with 1,317 patients enrolled. Clinical follow-up of patients will end in July 2003.

In the COMS trial of preoperative radiation, patients with large tumors were randomized to enucleation alone or to enucleation preceded by 20 Gy of external beam radiation. The two randomly assigned groups of patients were followed for at least five years or until death and have been compared on the basis of length of remaining life and other outcomes. Enrollment in this trial was completed in December 1994, with 1,003 patients enrolled. Clinical follow-up of all patients in this trial ended in July 2000.

Accrual to a nonrandomized pilot study to assess the feasibility of a randomized trial for small tumors was halted in 1989. Additional followup of those 204 patients was carried out from 1994 to 1996.

The COMS is conducted in 43 clinical centers located in major population areas of the United States and Canada. Six resource centers participate and have major roles in quality assurance for the study. Information gathered and analyzed includes time to death from all causes, time to death from cancer (whether metastatic choroidal melanoma or not), diagnosis of other tumors, complications of radiation, and changes in visual acuity. A parallel study of quality of life for patients enrolled in the trial of radioactive plaque was initiated in January 1995. From November 1986 through July 1998, 8,712 patients with choroidal melanoma of all sizes were screened for eligibility for a COMS clinical trial.

Patient Eligibility

Men and women eligible for the study had to be age 21 or older, have primary choroidal melanoma in only one eye, and have no evidence of metastatic disease. Accurate estimation of tumor thickness by echography also was required.

Patient Recruitment Status

Recruitment began in November 1986. Accrual to the trial of pre-enucleation radiation (large tumor trial) was completed on December 15, 1994, when the sample size goal was met; 1,003 patients enrolled. Accrual to the trial of radioactive plaque (medium tumor trial) was completed on July 31, 1998, when 1,317 patients had enrolled.

Current Status of Study

Patient follow-up ongoing in the trial of radioactive plaque.

Results

Nonrandomized Small Tumor Pilot Study
The treatment and mortality results of the COMS nonrandomized small tumor pilot study were reported in 1997. From December 1986 to August 1989, 204 patients with small choroidal melanoma, defined as 1.0 to 3.0 mm in apical height and at least 5.0 mm in basal diameter, were enrolled in a prospective followup study. The median length of followup was 92 months. Eight percent of patients were treated at the time of study enrollment and an additional 33 percent were treated during followup. Based on 27 deaths, the Kaplan-Meier estimate of five-year all-cause mortality was 6.0 percent (95 percent confidence interval, 2.7 percent - 9.3 percent) and eight-year all-cause mortality was 14.9 percent (95 percent confidence interval, 9.6 percent - 20.2 percent). Mortality findings and analysis of predictors of growth have been published (COMS Reports Nos. 4 and 5).

The Randomized Trial of Pre-Enucleation Radiation for Large Choroidal Melanoma
Initial mortality findings published in 1998 (COMS Report No. 10) showed that patients with large choroidal melanoma had similar survival rates regardless of whether they were treated with radiation prior to removal of the eye or had their eye removed without prior radiation therapy. Five-year survival rates were approximately 60 percent in both treatment arms. The COMS large tumor trial found neither benefit nor harm from treating ocular melanoma patients with radiation before removal of the eye. However, patients who had pre-enucleation radiation had fewer local complications (COMS Report No. 11).

The Randomized Trial of I-125 Brachytherapy for Medium Choroidal Melanoma
Initial mortality findings published in 2001 (COMS Report No. 18) showed that survival rates for radiation therapy (I-125 brachytherapy) and enucleation (removal of the eye) are about the same. The five-year survival rate of patients who were treated with either radiation therapy or eye removal was 82 percent, considerably better than the 70 percent five-year survival rate that had been projected when the study was designed in 1985. Compared to immediate loss of vision when the eye is removed, eyes treated with radiation steadily lost vision gradually, with 63 percent having visual acuity of 20/200 or worse by three years after treatment (COMS Report No. 16).

Publications

Collaborative Ocular Melanoma Study Group: The COMS randomized trial of Iodine 125 brachytherapy for choroidal melanoma, III: Initial mortality findings. COMS Report No. 18. Arch Ophthalmol 119: 969-982, 2001.

Collaborative Ocular Melanoma Study Group: The COMS randomized trial of Iodine 125 brachytherapy for choroidal melanoma, II: Characteristics of patients enrolled and not enrolled. COMS Report No. 17. Arch Ophthalmol 119: 951-965, 2001.

Collaborative Ocular Melanoma Study Group: Collaborative Ocular Melanoma Study (COMS) randomized trial of I-125 brachytherapy for medium choroidal melanoma, I: Visual acuity after 3 years. COMS Report No. 16. Ophthalmology 108 (2): 348-366, 2001.

Collaborative Ocular Melanoma Study Group: Assessment of metastatic disease status at death in 435 patients with large choroidal melanoma in the Collaborative Ocular Melanoma Study. COMS Report No. 15. Arch Ophthalmol 119: 670-676, 2001.

Collaborative Ocular Melanoma Study Group: Cause-specific mortality coding: Methods in the Collaborative Ocular Melanoma Study. COMS Report No. 14. Controlled Clinical Trials 22: 248-262, 2001.

Collaborative Ocular Melanoma Study Group: Consistency of observations from echograms made centrally in the Collaborative Ocular Melanoma Study. COMS Report No. 13. In press,. Ophthalmic Epidemiol.

Collaborative Ocular Melanoma Study Group: Echography (ultrasound) procedures for the Collaborative Ocular Melanoma Study. COMS Report No. 12, Part I. J Ophth Nurs Technol 18(4): 143-149, 1999.

Collaborative Ocular Melanoma Study Group: Echography (ultrasound) procedures for the Collaborative Ocular Melanoma Study. COMS Report No. 12, Part II. J Ophth Nurs Technol 18(5): 219-232, 1999.

Collaborative Ocular Melanoma Study Group: The Collaborative Ocular Melanoma Study (COMS) randomized trial of pre-enucleation radiation of large choroidal melanoma, III: Local complications and observations following enucleation. COMS Report No. 11. Am J Ophthalmol 126: 362-372, 1998.

Collaborative Ocular Melanoma Study Group: The Collaborative Ocular Melanoma Study (COMS) randomized trial of pre-enucleation radiation of large choroidal melanoma, II: Initial mortality findings. COMS Report No. 10. Am J Ophthalmol 125: 779-796, 1998.

Collaborative Ocular Melanoma Study Group: The Collaborative Ocular Melanoma Study (COMS) randomized trail of pre-enucleation radiation of large choroidal melanoma, I: Characteristics of patients enrolled and not enrolled. COMS Report No. 9. Am J Ophthalmol 125: 767-778, 1998.

Grossnicklaus HE, Albert DM, Green WR, Conway BP, Hovland KR, for the Collaborative Ocular Melanoma Study Group: Clear cell differentiation in choroidal melanoma. COMS Report No. 8. Arch Ophthalmol 115: 894-898, 1997.

Collaborative Ocular Melanoma Study Group: Sociodemographic and clinical predictors of participation in two randomized trials: Findings from the Collaborative Ocular Melanoma Study. COMS Report No. 7. Controlled Clinical Trials 22: 526-537, 2001.

Collaborative Ocular Melanoma Study Group: Histopathologic characteristics of uveal melanomas in eyes enucleated from the Collaborative Ocular Melanoma Study. COMS Report No. 6. Am J Ophthalmol 125: 745-766, 1998.

Collaborative Ocular Melanoma Study Group: Factors predictive of growth and treatment of small choroidal melanoma. COMS Report No. 5. Arch Ophthalmol 115: 1537-1544, 1997.

Collaborative Ocular Melanoma Study Group: Mortality in patients with small choroidal melanoma. COMS Report No. 4. Arch Ophthalmol 115: 886-893, 1997.

Collaborative Ocular Melanoma Study Group: Design and methods of a clinical trial for a rare condition: The Collaborative Ocular Melanoma Study. COMS Report No. 3. Controlled Clinical Trials 14: 362-391, 1993.

Collaborative Ocular Melanoma Study Group: Complications of enucleation surgery. COMS Report No. 2. In: Proceedings of the Symposium on Retina and Vitreous (Rudolph M. Franklin, ed.). New Orleans Academy of Ophthalmology. Kugler Publications, New York. 181-190, 1993.

Collaborative Ocular Melanoma Study Group: Accuracy of diagnosis of choroidal melanomas in the Collaborative Ocular Melanoma Study. COMS Report No. 1. Arch Ophthalmol 108: 1268-1273, 1990.

COMS Quality of Life Study Group: Quality of life assessment in the Collaborative Ocular Melanoma Study: Design and methods. COMS-QOL Report No. 1. Ophthalmic Epidemiol 6: 5-17, 1999.

Melia BM, Moy CS, McCaffrey L: Quality of life in patients with choroidal melanoma: A pilot study. Ophthalmic Epidemiol 6: 19-28, 1999.

Wells C, Bradford RH, Fish GE, Straatsma BR, Hawkins BS, for the COMS Group: Choroidal melanoma in American Indians. Arch Ophthalmol 114: 1017-1018, 1996.

Straatsma BR, Fine SL, Earle JD, et al., for the Collaborative Ocular Melanoma Study Research Group: Enucleation versus plaque irradiation for choroidal melanoma. Ophthalmology 95: 1000-1004, 1988.

Earle J, Kline RW, Robertson DM: Selection of iodine 125 for the Collaborative Ocular Melanoma Study. Arch Ophthalmol 105: 763-764, 1987.

* See the COMS website for additional publications from the COMS Group and publicly available documents: http://www.med.jhu.edu/wctb/coms/. .

Clinical Centers

Arizona
Leonard Joffe, M.D.
Retina Associates Southwest
Tucson, AZ

California
Bradley R. Straatsma, M.D.
Jules Stein Eye Institute
University of California at Los Angeles
Los Angeles, CA

A. Linn Murphree, M.D.
Estelle Doheny Eye Institute
The University of Southern California
Los Angeles, CA

Man M. Singh Hayreh, M.D.
Southern California Permanente Group
Panorama City, CA

Robert N. Johnson, M.D.
Private Practice
Schatz, McDonald and Johnson
San Francisco, CA

Colorado
Kenneth R. Hovland, M.D.
Adventist Hospital
Denver, CO

Florida
Timothy G. Murray, M.D.
Bascom Palmer Eye Institute
University of Miami School of Medicine
Miami, FL

W. Sanderson Grizzard, M.D.
Retina Associates of Florida, P.A.
South Tampa Medical Center
Tampa, FL

Georgia
Paul Sternberg, Jr., M.D.
Emory Eye Center
Emory University
Atlanta, GA

James H. Frank, M.D.
Piedmont Hospital
Eye Consultants of Atlanta, P.C.
Atlanta, GA

Illinois
Lee M. Jampol, M.D.
Northwestern University Medical School
Retina Study Center
Chicago, IL

Norman P. Blair, M.D.
The University of Illinois
Chicago, IL

Indiana
John T. Minturn, M.D.
Midwest Eye Institute
Indianapolis, IN

Iowa
Thomas A. Weingeist, M.D., Ph.D.
University of Iowa Hospitals and Clinics
Iowa City, IA

Louisiana
Gerald Cohen, M.D.
Touto Infirmary
New Orleans, LA

Maryland
Andrew P. Schachat, M.D.
Wilmer Ophthalmological Institute
The Johns Hopkins Medical Institutions
Baltimore, MD

Massachusetts
Clement L. Trempe, M.D.
Schepens Retina Associates
Boston, MA

Michigan
Andrew K. Vine, M.D.
The W. K. Kellogg Eye Center
University of Michigan
Ann Arbor, MI

Antonio Capone, M.D.
Associated Retinal Consultants, P.C.
Royal Oak, MI

Minnesota
Dennis M. Robertson, M.D.
Mayo Foundation
Rochester, MN

Missouri
J. William Harbour, M.D.
Washington University School of Medicine
St. Louis, MO

New York
David H. Abramson, M.D.
Cornell University Medical Center
New York/Brooklyn, NY

Paul T. Finger, M.D.
New York Eye and Ear Infirmary
New York, NY

North Carolina
Jonathan J. Dutton, M.D., Ph.D.
Atlantic Eye and Face Center
Cary, NC

Ohio
Z. Nicholas Zakov, M.D.
Retina Associates of Cleveland/Case Western Reserve University
Beachwood, OH

Froncie A. Gutman, M.D.
The Cleveland Clinic Foundation
Cleveland, OH

Frederick H. Davidorf, M.D.
Ohio State University College of Medicine
Columbus, OH

Oklahoma
Reagan H. Bradford, Jr., M.D.
Dean A. McGee Eye Institute
Oklahoma City, OK

Oregon
David J. Wilson, M.D.
Casey Eye Institute
Oregon Health Sciences University
Portland, OR

Pennsylvania
Karl R. Olsen, M.D.
Retina-Vitreous Consultants
Pittsburgh, PA

Texas
Dwain G. Fuller, M.D.
Texas Retina Associates
Dallas, TX

Richard S. Ruiz, M.D.
Hermann Eye Center
Houston, TX

Wichard A. Van Heuven, M.D.
The University of Texas
Health Science Center
San Antonio, TX

J. Paul Dieckert, M.D.
Scott and White Memorial Hospital
Temple, TX

Virginia
Brian P. Conway, M.D.
University of Virginia
Health Sciences Center
Charlottesville, VA

Washington
Craig G. Wells, M.D.
The University of Washington
School of Medicine
Seattle, WA

Wisconsin
Suresh R. Chandra, M.D.
The University of Wisconsin Eye Clinic
Madison, WI

Judith E. Kim, M.D.
Medical College of Wisconsin Eye Institute
Milwaukee, WI

Canada
E. Rand Simpson, M.D.
The Ontario Cancer Institute/Princess
Margaret Hospital
Toronto, Ontario Canada

Christina Corriveau, M.D.
Notre Dame Hospital
Montreal, Quebec Canada

Resource Centers

Chairman's Office
Stuart L. Fine, M.D.
Scheie Eye Institute
University of Pennsylvania
51 North 39th Street
Philadelphia, PA 19104
Telephone: (215) 662-9679

Coordinating Center
Barbara S. Hawkins, Ph.D.
Clinical Trials and Biometry Division
Wilmer Ophthalmological Institute
The Johns Hopkins Medical Institutions
Baltimore, MD 21205-2010
Telephone: (410) 955-8943

COMS Website
http://www.med.jhu.edu/wctb/coms/

NEI Representative

Natalie Kurinij, Ph.D.
National Eye Institute
National Institutes of Health
Executive Plaza South, Suite 350
6120 Executive Boulevard, MSC 7164
Rockville, MD 20892-7164
Telephone: (301) 496-5983
Fax: (301) 402-0528

Last Updated: 11/15/01