Who discovers melanoma? Patterns from a population-based survey

Participation of older males in a study on photography as an aid to early detection of melanoma

OBJECTIVE

To examine the acceptability of photography as an aid to skin examinations in men over 50 years of age.

METHODS

A randomised trial of men selected from the electoral roll. All participants were photographed, but only half received their photographs. Skin examinations by GPs at years one and two.

RESULTS

55% of men consented to have photographs taken and 51% did so. 86% of respondents had risk factors for melanoma (compared to 68% of non-responders) and 47% had two or more risk factors (compared to 23% of non-responders). At year one, 91% of participants remaining in study regions had been examined. Photographs were lost by only six participants.

CONCLUSIONS

Men over 50 years of age respond to personalised health messages about melanoma and respondents include a high proportion of males with risk factors for melanoma.

IMPLICATIONS

These initial results suggest that photography may be a logistically acceptable approach for assisting in the early detection of melanoma.

Time trends of cutaneous melanoma in Queensland, Australia and Central Europe

BACKGROUND

The objective of this study was to describe recent developments in cutaneous melanoma from the German speaking countries in Europe (Germany, Austria, and Switzerland) and from Queensland, Australia.

METHODS

All incident invasive cutaneous melanoma cases recorded between 1986 and 1996 by the Queensland Melanoma Register and by the Central Malignant Melanoma Registry of the German Dermatological Society were included in the analysis. Weighted linear trend analyses were performed to assess significant changes over the years using yearly sample sizes as weights.

RESULTS

In Central Europe, the median tumor thickness decreased from 1.2 mm in 1986 to 0.8 mm in 1996 (P < 0.001), whereas it varied insignificantly between 0.5 mm and 0.6 mm in Queensland. The percentage of patients with Clark Level II invasion increased significantly in Queensland (P < 0.001; 1996, 61.1%) and in Central Europe (P = 0.041; 1996, 24.5%). The percentage of superficial spreading melanomas rose in Central Europe (P = 0.043; 1996, 64.4%), whereas it decreased slightly in Queensland (P = 0.032; 1996, 75%). In Queensland and in Central Europe, younger people and women presented more frequently with thinner melanomas (</= 0.75 mm).

CONCLUSIONS

In both Central Europe and Queensland, trends toward thinner and less invasive melanomas were observed between 1986 and 1996, although the median tumor thickness decreased significantly only for Central European data. Men and elderly individuals should be the focus of health-promotion activities, because they tended to present on average with thicker and prognostically poorer melanomas.

Increasing supplies of dermatologists and family physicians are associated with earlier stage of melanoma detection

BACKGROUND

Physicians are important in the early detection of melanoma. We investigated whether primary care physician supply and the supply of dermatologists were related to stage at diagnosis for malignant melanoma.

METHODS

From the state tumor registry in Florida in 1994, we identified incident cases of malignant melanoma for which stage at diagnosis was available (N = 1884). Data on physician supply was obtained from the 1994 American Medical Association Physician Masterfile. Logistic regression determined the effects of physician supply (at the ZIP code level) on the odds of early-stage diagnosis controlling for patients' age, gender, race/ethnicity, marital status, education level, income level, comorbidity, and type of health insurance.

RESULTS

Each additional dermatologist per 10,000 population was associated with a 39% increased odds of early diagnosis (odds ratio = 1.39, 95% confidence interval [CI] 1.09-1.70, P =.010). For each additional family physician per 10,000 population, the odds of early diagnosis increased 21% (odds ratio = 1.21, 95% CI 1.09-1.33, P <.001). Each additional general internist per 10,000 population was associated with a 10% decrease in the odds of early-stage diagnosis (odds ratio = 0.90, 95% CI 0.83-0.98, P =.009). The supplies of general practitioners, obstetrician/gynecologists, and other nonprimary care specialists were not associated with stage at diagnosis.

CONCLUSIONS

Increasing supplies of dermatologists and family physicians were associated with earlier detection of melanoma. In contrast, increasing supplies of general internists were associated with reduced odds of early detection. Our findings suggest that the composition of the physician work force may affect important health outcomes and needs further study.

Patterns of detection in patients with cutaneous melanoma

BACKGROUND

Despite the importance of early detection in preventing mortality from melanoma, little is known regarding how patients with the disease come to diagnosis.

METHODS

The authors prospectively evaluated 471 newly diagnosed melanoma patients between 1995 and 1998. Patients completed a questionnaire that included 1) identification of the person who detected the lesion, 2) the anatomic location of the lesion, and 3) family history of melanoma. Logistic regression analysis was performed to examine the relation between detection patterns and lesion thickness, adjusting for age, gender, anatomic site of the primary lesion, and family history of melanoma.

RESULTS

The majority of patients detected their own melanoma (n = 270; 57%). Females were more likely to self-detect than males (69% vs. 47%; P < 0.0001). Physicians detected the melanoma in 16% of patients (n = 74), followed by "spouse" in 11% of patients (n = 51). Within this group, detection by wives was 7.5 times more common than detection by husbands (P < 0.0001). Logistic regression analysis revealed that physicians were 3.6 times more likely to detect thin lesions (</=0.75 mm) compared with nonphysician detectors (95% confidence interval [95% CI], 2.1, 6.5; P = 0.0001). In addition, patients who reported a family history of melanoma had a 2.7-fold increased likelihood of presenting with a thin lesion (95% CI, 1.6, 4.7; P = 0.0003).

CONCLUSIONS

Physician detection and a report of a family history of melanoma are associated with the presentation of patients with early melanoma, suggesting that awareness of the disease among physicians and the public is critical for preventing mortality from melanoma. Increasing melanoma awareness in males may be a particularly effective means of secondary prevention.

Delays in diagnosis and melanoma prognosis (II): the role of doctors

A prospective survey was conducted to assess physician responsibility in melanoma prognosis. Consecutive patients with primary melanoma were interviewed and examined using a standardized questionnaire. Main outcome measures were medical components of the delay before tumor resection and tumor thickness. Of 590 melanomas, 29.1% were coincidentally detected by physicians and their tumor depth was lower than in melanomas detected by patients (p < 0.001). Physician sensitivity for melanoma diagnosis was evaluated at 86%. Median time intervals to propose resection and to perform removal of melanoma were short: 0 (mean 103) and 7 (mean 68) days, respectively. Melanomas were managed in an inappropriate way in 14.2% of cases. Location on acral areas and absence of pigmentation were associated with longer medical delays and more frequent inappropriate medical attitudes. Melanomas located on hardly visible areas were less frequently detected by physicians than those on visible areas. Medical delays were shorter, doctor's attitude was more frequently appropriate, and melanoma thickness was lower (p < 0.001) when the patient visited a dermatologist (54.7%) than when he or she visited a general practitioner (33.4%). Our study shows that doctor responsibility accounts for only a small part of the total delay before melanoma removal. However, systematic total examination and better training of doctors, especially about unusual forms of melanoma, could still improve melanoma detection.

Detection of artificial changes in mole size by skin self-examination

BACKGROUND

The efficacy of the skin self-examination (SSE) to detect artificial changes in the size of nevi has not been evaluated in a controlled setting.

OBJECTIVE

Our purpose was to determine the sensitivity and specificity of the SSE in detecting artificial changes in mole size in patients at high risk for melanoma.

METHODS

In a single-center, single-blinded cross-over study, patients who had been performing the SSE confidently for at least 1 year examined their backs after the diameter of an existing mole was increased artificially in random order by 0, 2, or 4 mm.

RESULTS

The specificity of the SSE was 62% (95% confidence interval [CI], 53%-72%) (N = 103). The sensitivity of the 2 mm change was 58% (95% CI, 49%-68%) and that of the 4 mm change was 75% (95% CI, 66%-83%). SSE performance was not related to perceived risk, number of moles, gender, age, or frequency of self-examination.

CONCLUSION

Even in our highly motivated and selected group of high-risk patients, 25% could not detect an obvious increase in the diameter of an existing nevus, whereas 38% incorrectly identified a change when none was made. The SSE is only a moderately effective tool for the detection of acute, large, changes in mole size. The usefulness of the SSE in detection of new lesions or changes in existing lesions is likely due to a combination of factors or due to factors other than size, such as color, border irregularity, and texture, among others.

Issues in the delivery of dermatologic surgery for skin cancer

Significant financial resources need to be dedicated to treating the large numbers of skin cancers in the United States. The goal of the surgical treatment of skin cancer is to provide a high cure rate in a manner that is minimally morbid, convenient, and inherently of high value. Cost-effective delivery of this skin cancer care is critical given the prevalence of cutaneous neoplasia. Dermatologists are the best-trained physicians in the identification and management of melanoma and NMSCs. They are the most highly skilled judges of when intervention is indicated, of which lesions warrant biopsy, and of which treatment techniques are applicable for each individual tumor. These skills take years to develop and are necessary to provide the highest standard of medical and surgical management of skin cancer. As dermatologic surgery continues to evolve and dermatologists in residency receive even more surgical training, the dermatologist will prove to be the surgical skin cancer specialist well into the new millennium.

Awareness and early detection of cutaneous melanoma: an analysis of factors related to delay in treatment

Factors associated with the detection of cutaneous melanomas and reasons for delay in diagnosis were investigated in 429 patients with histologically proven melanoma operated on between January 1993 and June 1996. Patients were interviewed using a standardized questionnaire. In 25% of patients, treatment was delayed for more than 1 year from the time they first noticed a suspicious pigmented lesion. Melanoma was detected by the patients themselves in 67% of women and 45% of men. The three predominant clinical symptoms of melanoma were change in colour (darker), increase in size and increase in elevation of a pigmented lesion. The role of sun exposure and of naevi as risk factors for melanoma, as well as the potential benefit of early treatment, were known by 87%, 66% and 82% of the patients, respectively. However, melanoma awareness had no impact on the time period between first observation of skin changes and treatment. Among the factors associated with delay in melanoma diagnosis, an initial incorrect diagnosis as a benign lesion by the physician first visited (in 18% of all cases) had the highest significance. Patients detecting their lesions themselves were treated significantly later than patients in whom others had remarked on changes in a naevus. Furthermore, melanomas of the head and neck were treated later than melanomas at other body sites. Further efforts to educate both the public and the medical profession are essential to ensure earlier treatment for cutaneous melanomas.

Thorough skin examination for the early detection of melanoma

BACKGROUND

Melanoma is a major public health problem for which early detection may reduce mortality. Since melanoma is generally asymptomatic, this requires skin examination. We sought to evaluate the extent to which the general public has their skin examined by themselves, their partners, or health care providers and the frequency of these examinations.

METHODS

Random-digit-dial survey of adult Rhode Islanders.

RESULTS

Only 9% performed a thorough skin examination (TSE) at least once every few months, although over half of the sample reported conducting skin self-examination "deliberately and systematically." Participants were more likely to perform TSE if they were women and if their health care provider had asked them to examine their skin. Most participants reported that their health care provider never or rarely looked at the areas of their skin in which melanoma is most likely to arise.

CONCLUSIONS

The reported frequency of skin self-examination depends critically on the manner of inquiry. TSE by self or a partner is uncommon, and health care providers do not routinely examine the areas of the skin on which melanomas commonly arise.

Participant satisfaction and value in American Academy of Dermatology and American Cancer Society skin cancer screening programs in Massachusetts

BACKGROUND

More than 1 million Americans have attended the American Academy of Dermatology's Melanoma/Skin Cancer Screening Programs since 1985. However, there have been no reports of the participants' perceived value, satisfaction, and benefits of skin cancer screening.

OBJECTIVE

We attempted to measure the benefits and subsequent screening practices of persons with presumptive positive screening diagnoses.

METHODS

A self-administered questionnaire was sent to participants with positive screening diagnoses in Massachusetts.

RESULTS

Of the 643 respondents, 81% rated their satisfaction as high and 84% had similar ratings for the value of the screening. Screenings apparently led to an increase in self-screening (60% before screening compared with 84% after screening).

CONCLUSION

Although screening appears to have relatively strong benefits, further studies should be conducted nationally.

The role of screening in the management of skin cancer

The incidence of skin cancer has been rising at an alarming rate for the past several years. This poses a significant public health problem in the United States. Detection and treatment of melanoma early in its course is critical for improved outcome. Of the approaches to cancer control that can reduce mortality from melanoma and nonmelanoma skin cancer, screening holds the greatest promise for a rapid and major impact. Prevention and early detection are crucial in reducing morbidity and mortality from skin cancer. For a number of reasons, however, the full effect of screening for both melanoma and nonmelanoma skin cancers has not been achieved. Controversy exists regarding who should perform screening, who should be screened, and whether screening should be performed at all. It is clear that melanoma and nonmelanoma skin cancer control programs combining primary prevention, education, and screening are in developmental stages. This review will discuss the advantages and disadvantages of screening for skin cancer.

Factors involved in presentation of older people with thick melanoma

OBJECTIVE

To examine whether presentation of older people with thick melanoma is a result of the site and histological type or of their reduced ability to identify melanoma.

DESIGN AND SETTING

Retrospective analysis of the Newcastle Melanoma Unit patient database.

PATIENTS

2154 patients with melanoma for whom complete data (histological type, thickness and site of melanoma) were available and who presented from February 1981 to April 1997.

MAIN OUTCOME MEASURES

Histological type and site of melanoma in older (> or = 50 years) versus younger men and women; frequency with which these groups identified melanoma and the first changes of melanoma that were noticed.

RESULTS

Patients aged > or = 50 years, particularly men, were more likely to present with thicker lesions. Older men and, to a lesser extent, older women were more likely to present with nodular melanoma, which were more frequent on the scalp and face in older, compared with younger, men, and scalp and back in older men compared with older women. Failure to identify melanoma was associated with older age, sites on the scalp and back and histological type of the lesion, but was independent of sex once histological type, age, site and thickness were taken into account. Multivariate analysis indicated that the association of older age of patients with failure to identify melanoma applied irrespective of the site, type and thickness of their melanoma.

CONCLUSION

The higher frequency of thick melanoma in older people is accounted for by an increased proportion of nodular melanoma and decreased ability to recognise the changes of melanoma. These findings have important implications for examination of older patients by doctors and for design of strategies for early detection of melanoma in this age group.

Cutaneous melanoma: patient surveillance and tumor progression

BACKGROUND

The goal of surveillance examinations (SVE) in patients at high risk for cutaneous melanoma (CM) is to diagnose premetastatic tumors.

OBJECTIVE

We attempted to determine whether SVE before CM diagnosis influences the histopathologic features of tumor progression.

METHODS

A retrospective review was conducted of consecutive patients who presented with an intact primary CM during a 36 month period (1991 to 1994) in a university dermatology ambulatory setting.

RESULTS

Thirty-nine intact CMs were diagnosed in 34 patients. Compared with 23 CMs in as many patients presenting at the first encounter, 16 CMs diagnosed in 11 patients during SVE had a smaller mean tumor diameter (P = .007) and tumor thickness (P = .002) and were more likely anatomic level I or II (P = .003) with microscopic thickness less than 0.76 mm (P = .01) and less than 0.50 mm (P = .002).

CONCLUSION

Primary CMs are more likely to be smaller and thinner when diagnosed during SVE than at first encounter, features that are likely to have a positive impact on CM mortality.

Public health interventions for melanoma. Prevention, early detection, and education

Worldwide melanoma control programs that include some combination of primary prevention, education, and screening activities have only recently begun to undergo an evaluation process. More studies with rigorous design and evaluation are needed. Until then, the proper public health policy guidelines for melanoma control, especially screening, are open to debate. Future studies must determine how screening, early detection, case finding, and education can best be used to reduce mortality and achieve optimal melanoma control.

Family physicians' knowledge of malignant melanoma

BACKGROUND

The incidence and mortality of melanoma have been increasing during the past two decades. Melanoma is relatively easy to detect and, when diagnosed early, is curable.

OBJECTIVE

Our purpose was to assess the baseline knowledge of malignant melanoma among family practitioners and to identify their preferred method of learning new information about the skin.

METHODS

The design was a randomized survey by mailed questionnaire.

RESULTS

More than 50% of physicians stated they lacked confidence in being able to recognize melanoma. Family physicians were well informed on factors affecting prognosis, but knowledge deficits were identified on history, physical examination, and risk factors. The most effective method of learning new information about the skin was hands-on teaching demonstration.

CONCLUSION

Many family physicians are not confident in their ability to recognize melanoma, and knowledge deficits were identified. In addition, some important risk factors were not well recognized. Thus, those at highest risk may not be receiving education on early detection that may help decrease the incidence and mortality of melanoma.

The melanoma epidemic: more apparent than real?

To examine inconsistencies between the growth in incidence of melanoma and more modest changes in melanoma-related mortality, we reviewed the medical literature on the incidence of melanoma diagnosis and associated mortality and on the changes in diagnosis and mortality over time. Increases in melanoma surveillance activity have been associated with increases in the diagnosis of thin melanomas, but the incidence of advanced tumors has changed minimally. The large increases in diagnosis of melanoma without commensurate increases in advanced tumors and mortality are not compatible with presumed malignant behavior of thin melanomas. Increased intensity of melanoma surveillance may artificially increase the incidence of melanoma by harvesting histologically "malignant" but biologically benign tumors. Little available evidence suggests the presence of an actual increase in the frequency of biologically malignant tumors. Attempts to increase screening intensity for melanoma may result in further increases in diagnosis of melanomas. Nevertheless, limitations in histopathologic diagnostic techniques will continue to hinder efforts at early identification of those at risk for death from melanoma without diagnosing melanoma in large numbers of patients with biologically benign pigmented skin tumors.

Effect of a public awareness campaign on the appropriateness of patient-initiated skin examination in general practice

The aim of the study was to describe the appropriateness of patient-initiated skin examinations, and assess whether an awareness program leads to a greater proportion of inappropriate patient-initiated skin examinations. General practitioners (n = 27, response rate 71 per cent) from a regional town in Queensland recorded details of consultations involving a skin examination over a five-week period straddling the 1991 National Skin Cancer Awareness Week. The outcome measure was the clinical impression (benign, suspicious or malignant) of the most serious skin lesion presented by each general practice patient (n = 1183). Thirty-six per cent of patient-presented lesions were clinically suspicious or malignant. Lesions were more likely to be clinically suspicious or malignant if they were presented as the primary reason for the consultation (odds ratio OR = 1,219.95 per cent confidence interval (CI) 1.01 to 1.48); if the patient was aged over 35 years (OR = 5.594, CI 1.08 to 7.66); or male (OR = 1.634, CI 1.35 to 2.00). Following a public skin cancer awareness campaign, there was a slight nonsignificant decrease (OR 0.938, CI 0.91 or 1.25) in the proportion of clinically suspicious and malignant lesions detected. An increase in the number of skin examinations following an awareness campaign did not result in an increase in the proportion of inappropriate skin examinations. Patient-initiated skin examinations have an important role to play in the early detection of skin cancer.

The incidence of malignant melanoma in the United States: issues as we approach the 21st century

The risk of malignant melanoma developing in an American in the United States has now reached 1 in 87 (up more than 1800% since the 1930s). This rising incidence of malignant melanoma is, in fact, real because (1) it is not due to increased surveillance; (2) it is not due to better cancer-counting methods in general; (3) it is not due to changes in histologic diagnostic criteria; (4) it is being noted worldwide; and (5) most importantly, despite rising survival percentages, the mortality rate from malignant melanoma also continues to rise. On the basis of these trends, incidence rates for malignant melanoma will continue to rise for at least the next 10 to 20 years, although the demographics of those affected may change. Effective programs to improve public and professional education must be developed to enhance early clinical detection and behavioral changes. An establishment of a National Melanoma Registry is needed to more effectively assess the magnitude and impact of future incidence and the success of prevention program efforts into the next century.

Skin cancer diagnosis in a primary care setting

BACKGROUND

Primary care providers are in a good position to detect sk in cancers early, but their current involvement in diagnosis and referral of patients with skin cancer is unknown. Some managed care settings utilize a primary care case manager approach to health care.

OBJECTIVE

The purpose of this study was to assess the incidence and demographic associations of skin cancer in a managed care population served by primary care providers.

METHODS

this study analyzed 1215 skin biopsy specimens obtained by family physicians, internists, and supervised certified physician assistants within an eastern Washington health maintenance organization and the 69 biopsy specimens obtained by referral specialists and confirmed by pathologic consultation.

RESULTS

Internists, family physicians, and their physician assistants performed 94.7% of the biopsies on 87% of all malignancies. Dermatologists and surgeons performed the rest. Primary care providers and dermatologists detected malignant melanomas at a rate comparable to a similar study from British Columbia but lower than other previous investigations.

CONCLUSION

Melanomas were diagnosed in this managed care system at a rate comparable to a similar system in Canada. Lower rates for other skin cancers are probably because of methodologic differences from other studies, but variation in histologic diagnoses between pathologists and differences in skin cancer detection cannot be excluded.

Skin cancer screening

The key to reducing morbidity and mortality from skin cancer is early detection. Prevention through education is, of course, ultimately the best outcome of collective human efforts. Many questions are still unresolved, but skin cancer screening by general internists, family practitioners, dermatologists, and other health professionals could prove cost-effective and reliable. As more knowledge becomes available, clinicians will have the resources to improve skills in prevention and early detection.

Melanoma and Skin Cancer Control: An International Perspective

Approximately one million Americans are diagnosed with skin cancer each year. Since melanoma and skin cancer are amenable to prevention, education, and early detection, efforts to reduce the incidence of and death from melanoma have developed in many countries. Programs promoting behavioral changes and the incorporation of skin cancer control into national health care agendas have begun in a number of countries. Additional programs for the at-risk and general populations require further development and evaluation.

The effect of an educational brochure on knowledge and early detection of melanoma

Men over the age of 45 present with thicker, more advanced melanomas than younger people. A randomised trial was conducted in this group to evaluate whether an educational brochure would increase knowledge about melanoma and the ability to recognise and discriminate between pigmented skin lesions. Men in an industrial complex were allocated to an intervention group (n = 110) and two control groups (n = 96 and n = 108). The intervention group was given two educational brochures about melanoma. Their effect on knowledge and ability to detect pigmented lesions was assessed by a questionnaire and a self-examination body chart given before the brochure, and at four weeks and three months after return of the brochure. The control groups did not receive any educational material, but control group 2 received the questionnaire and chart. At the end of the study all participants were examined for pigmented lesions by doctors, whose counts were compared with those of the participants. There was a significant (19.8 per cent) increase in knowledge about melanoma in the intervention group (but not in the control groups), except for discrimination of photos of benign and malignant lesions. The educational material did not improve the ability of those in the intervention group to recognise and count their pigmented lesions nor to discriminate between benign and malignant pigmented lesions. The increased knowledge about melanoma was retained for at least three months.

Public education and cancer of the skin. What do people need to know about melanoma and nonmelanoma skin cancer?

Cutaneous melanoma (CM) and nonmelanoma skin cancer (NMSC) have a high chance for cure if detected in an early phase of development. Patients who have these tumors may now be treated in the outpatient setting with a minimum of discomfort, inconvenience, and cost. Most skin cancer deaths are caused by CM. Until recently, CM incidence in the United States has been increasing faster than any other potentially lethal cancer, attributable at least in part to aggressive case detection and greater public awareness about the significance of risk factors and early warning signs of evolving tumors, resulting in increased numbers of curable tumors. Most CMs are discovered by patients or close acquaintances. Most CM deaths are related to patient delay in seeking medical care. Patient delay is attributed mostly to lack of knowledge rather than to fear and denial. In the United States, primary prevention of CM and NMSC has focused on encouraging sensible sun-exposure behaviors, while secondary prevention consists of a yearly national campaign that promotes skin awareness and self-examination and free examinations to detect evolving tumors, sponsored by the American Academy of Dermatology and the American Cancer Society. More attention is needed to encourage timely consultation for evolving tumors and predisposing risk factors and to focus screening and surveillance efforts of those people at greatest risk. Public education must continue to promote personal responsibility in the intervention process to reduce the morbidity and mortality associated with CM and NMSC.

The early detection of and screening for melanoma. International status

Cutaneous melanoma is an increasingly common public health problem in industrialized nations. In theory, education and early detection should decrease melanoma morbidity and mortality, because the lesion is external and visible, risk factors are known, and thin tumors are associated with a high 5-year survival rate. The efficacy of early detection and screening programs, however, remains untested by randomized trials. Some early data are available from melanoma prevention and control efforts that have begun in many nations over the past decade. Textbook definitions of cancer screening are particularly challenging when applied to skin cancer control. Although some propose that there are rigid differences among screening, education, and early detection of skin cancer, the visible nature of this cancer makes early detection through education and screening inextricably intertwined. This article discusses the intermediate measures of education and screening within the context of the American Academy of Dermatology programs. Over the next few decades, screening and education for melanoma and other skin cancer will receive increasing worldwide attention. Multiple strategies will be required to combat increasing incidence and mortality rates. Screening and educational programs have been implemented worldwide, but data on their effects are only just being collected. Future collaborative work in melanoma/skin cancer prevention, education, and early detection holds promise as a way to decrease mortality and save lives.

Basal cell and squamous cell carcinomas are important risk factors for cutaneous malignant melanoma. Screening implications

BACKGROUND

This study was designed to determine the risk of developing malignant melanoma (MM) in patients with a history of basal cell and/or squamous cell skin cancer (BCC/SCC) and to determine whether surveillance efforts can be directed toward these patients for the detection of early MMs.

METHODS

The study cohort was followed by annual total cutaneous examination (TCE). Controls consisted of individuals from the United States population matched for age, sex, and length of follow-up. The anatomic locations of the study cohorts' newly diagnosed MMs were plotted on an anatomic chart. The setting was a private dermatology practice. Two hundred, ninety consecutive white patients with a history of BCC/SCC but with no personal or family history of MM were followed by annual TCEs. The main outcome measures were the relative risk of developing MM and their prognosis.

RESULTS

Ten of the 290 patients developed an MM within an average of 109 months of follow-up (range, 3-17 years). All MMs were less than 0.70 mm in Breslow thickness and 80% occurred on usually clothed cutaneous sites. The expected number of MMs in the control population was 0.59 (P = 0.006), resulting in a relative risk of 17.

CONCLUSION

Patients with BCC/SCC skin cancer are at substantial increased risk for developing MM. Regular and life-long surveillance TCE is an inexpensive and effective method for detecting curable MMs in such patients.

Melanoma control in the United States: current status

Screening and education for melanoma/skin cancer are receiving increasing worldwide attention. In an attempt to improve melanoma control in the United States, where incidence and mortality rates continue to increase, the American Academy of Dermatology (AAD) has provided free skin cancer screenings to more than 600,000 Americans and prevention messages to millions more. This chapter reviews and summarizes ongoing melanoma control activities in the United States, including prevention, education, and early detection/screening. We also address outcome measures in melanoma control and suggest that the unique external and visible nature of skin cancer blurs the distinction between screening and education. Measuring and evaluating the benefits of international melanoma control activities presents many challenging tasks. Future collaborative work must include complementary strategies in melanoma/skin cancer prevention, education, and screening to combat the worldwide increase in melanoma incidence and mortality.

Skin cancer prevention: a link between primary prevention and early detection?

The aim of this paper was to determine if there is any link between primary prevention and early detection for skin cancer. Results from a study of a large random sample of Gold Coast residents (N = 995) identified an association (P < 0.01) between individual primary prevention and early detection activities. People were also more likely to use both prevention methods if they had personal experience with skin cancer (P = 0.01) or if they were male (P = 0.05). Future primary prevention and early detection skin cancer programs might be most effective if they are combined.

Nevus counting as a risk factor for melanoma: comparison of self-count with count by physician

BACKGROUND

The number of total body nevi is a major risk marker for malignant melanoma. No previous study has evaluated the accuracy of whole body large nevus (> or = 5 mm) self-counts.

OBJECTIVE

Our purpose was to evaluate the accuracy of large nevus self-counts by sex, age, educational level, body site, family history of skin cancer, and nevus characteristics.

METHODS

Self-counting of large nevi by 125 patients was compared with physician counting, with attention to nevus characteristics.

RESULTS

Overall, 79% of the self-counts agreed to within +/- 3 nevi of the physician's count. Analysis of variance revealed that the presence of nonpigmented or flat nevi significantly increased the chance of subject undercount, as did male sex.

CONCLUSION

Self-counts of large nevi are comparable to physician's counts and may be useful for melanoma screening.

Accuracy in the clinical diagnosis and pattern of malignant melanoma at a dermatological clinic

The diagnostic pattern of malignant melanoma and clinical suspicion rate has been investigated at a dermatological university clinic. Of 174 histologically proven malignant melanomas, 60 (34%) were not clinically suspected as melanomas. The accuracy of clinical diagnosis increased with level of experience. Physicians with < 1 year experience in dermatology were able to detect malignant melanoma as the first diagnosis in 31% of the cases in contrast to 63% for those with > 10 years experience. Of 50 patients immediately referred from the dermatologic clinic to surgery departments, 12 did not have melanoma.

Screening for melanoma and options for its evaluation [see comment]

A review of the published evidence presented here argues that screening for melanoma is recommended and practised at present, but with wide diversity of opinions about its value; there is evidence that screening has considerable potential for benefit, but the evidence of actual benefit is limited; and there are substantial costs and potential hazards from screening. On this basis the evaluation of screening procedures for melanoma is important, and options for this are discussed. The ideal study design to assess the efficacy of melanoma screening in reducing mortality is a large scale randomised trial. This may need a well coordinated proposal involving several centres in one or more countries, and the cost would be substantial. Without such a trial, however, it is most likely that increasing resources will be put into poorly designed screening programmes of unknown value. The simplest and strongest designs use individual randomisation, but group randomisation designs may have practical advantages, though they require a greater sample size. Designs based on general population screening, and on screening only high risk groups, are both considered. They answer different questions. In countries with high incidence the value of general population screening is probably the more critical. Not enough is known to specify the type and frequency of screening precisely; both screening by doctors and self screening require evaluation, and annual screening should probably be tested. The age range at risk will depend on the local incidence, but is likely to be quite wide-for example, 45-69, and both sexes need inclusion. Thus a suggested design for a moderate to high incidence area would be a trial, randomised by individual or group, assessing at least two annual rounds of both screening by doctor and self screening (ideally by a factorial design), for adults aged 45-69, with mortality over several years' follow up as the critical outcome. In an area with good data systems such a study could compare screening offered to some 260,000 subjects with 10 times that number of controls passively followed up, with 90% power to detect a one third reduction in mortality. A general assessment of costs over five years gave estimates of $8.3 million for the screening programme and $2.4 million for the evaluation. The much weaker designs, area based cohort studies using individual data or a simpler ecological comparison, and case-control studies, are also considered. If well designed with attention to their methodological limitations they may be valuable but are unlikely to be as definitive as a randomised trial.

Use of health services before the diagnosis of melanoma: implications for early detection and screening

OBJECTIVE

To determine whether persons with melanoma were integrated into the health care system prior to diagnosis.

DESIGN

Population-based survey by mailed questionnaire.

PATIENTS/PARTICIPANTS

216 persons with malignant melanoma diagnosed in Massachusetts in 1986.

MAIN RESULTS

Of the 216 cases, 87% stated that they had regular physicians, 63% had seen those physicians in the year prior to diagnosis, but only 20% had regular dermatologists. Overall, only 24% had examined their own skin prior to diagnosis and 20% reported physician skin examinations.

CONCLUSIONS

Persons diagnosed with melanoma reported extensive contact with regular physicians in the year prior to diagnosis. However, most of these persons neither received skin examinations nor examined their own skin during that time. While additional study is necessary to confirm these findings, the authors suggest that physicians caring for patients at risk for melanoma integrate melanoma screening into routine care.