Recent declines in worldwide mortality from cutaneous melanoma in youth and middle age

Global trends in cutaneous malignant melanoma incidence and mortality

Mortality from cutaneous malignant melanoma (CMM) increased in the past, but trends have been favorable in more recent years in many high-income countries. However, incidence has been increasing in several countries. We provided an up-to-date overview of mortality trends from CMM. We analyzed death certification data from the WHO in selected countries worldwide from 1980 to the most recent available calendar years. We also reported incidence data derived from Cancer Incidence in Five Continents from 1990 to 2012. Separate analyses were performed for young adults aged 20-44 and middle-aged adults aged 45-64 years. Mortality from CMM in all age groups showed a favorable pattern in the majority of the countries considered. Mortality trends declined by 40 to 50% in Australia over the last decades, confirming the importance of prevention measures. Considering young adults aged 20-44, Australia, New Zealand and Northern Europe reported the highest death rates for both sexes (>0.90/100 000 in men and >0.60/100 000 in women) while Japan, the Philippines, and Latin America the lowest ones (<0.50/100 000 and <0.35/100 000 in men and women, respectively). Incidence trends were stable or upward in most countries, with higher rates among women. Our study highlights a global reduction of CMM mortality over the last three decades. The increasing awareness of risk factors, mainly related to UV exposure, along with early diagnosis and progress in treatment for advanced disease played pivotal roles in reducing CMM mortality, particularly in Australia.

Incidence, Mortality and Survival Trends of Cutaneous Melanoma in Umbria, Italy. 1978-82 and 1994-98

Many studies have reported increasing incidence rates of cutaneous melanoma during the last 30-40 years; the highest have been observed in Australia and New Zealand (27.9/100,000 among males and 25.0 among females) and in North America (10.9/100,000 among males and 7.7 among females). In Italy, from 1994-1998, in the areas covered by cancer registries (23% of Italian population), the incidence rate for males was 8.5 and for females, 1.9/100,000. The aim of the present study was to describe incidence, mortality and survival from cutaneous melanoma in the Umbrian population during the periods 1978-1982 and 1994-1998.

Cancer Mortality in Italy, 1997: Quantifying the Fall in Rates in Women and Men

Aims and Background

To update data and statistics on cancer death certification in Italy to 1997.

Methods

Data and statistics for 1997 subdivided into 31 cancer sites are presented. Trends in age-standardized rates for major cancer sites are plotted from 1955 to 1997. Results: The age-standardized (world standard) death certification rates from all neoplasms steadily declined from the peak of 199.2/100,000 males in 1988 to 174.7 in 1997 and for females from 102.5 to 93.0. The decline was larger in truncated rates, by about 26% for males since 1983 and by 24% for females since the top rate of the early 1960′s. A major component of the favorable trend in males was lung cancer, which showed a 16% decline from the peak of 1987-88, to reach 50.6/100,000 in 1997, corresponding to about 5,000 avoided deaths. The decline in lung cancer was about 34% at age 35 to 64. For females, in contrast, both the absolute number of lung cancer deaths and the age-standardized rate of 7.9/100,000 were among the highest values ever registered, reflecting the different pattern of spread of the tobacco-related lung cancer epidemic in the two sexes. Intestinal cancer rates were stable for males but declined by approximately 10% for females, mostly in middle age, as did breast cancer mortality. Among neoplasms showing favorable trends, there were other tobacco-related neoplasms in men, plus the continuing fall in stomach and cervix uteri. Upward trends were observed for non Hodgkin's lymphomas.

Conclusions

The fall in cancer mortality observed over the last decade in Italy is attributable to a decline in lung and other tobacco-related neoplasms in males, together with a persistent fall in stomach and uterine (cervical) cancer. In women, there were also recent falls in intestinal and breast cancer rates, and declines in both sexes in rarer neoplasms influenced by therapeutic advancements.

Trends in Skin Cancer Incidence in Neuchâtel, 1976-98

Aims and Background

Limited data are available on trends in skin cancer incidence. This paper examines trends of the three major histotypes of skin cancer in an environment favorable for skin cancer registration.

Methods

Trends of skin cancer incidence by histotype in the Swiss Canton of Neuchâtel (165,000 inhabitants) were analyzed on the basis of 4,455 incident cases of basal cell, squamous cell carcinoma, and malignant melanoma registered over the period 1976-1998.

Results

Trends over the last decade considered tended to be downwards for squamous cell carcinoma in both sexes, were still on the rise for basal cell carcinoma, and leveled off for malignant melanoma in both sexes.

Conclusions

Different trends were confirmed in this population between skin cancer histotypes related to cumulative intense sun exposure (squamous cell carcinoma) and those mainly related to more complex patterns of exposure to sunlight (basal cell carcinoma and malignant melanoma).

WITHDRAWN: Chemoimmunotherapy versus chemotherapy for metastatic malignant melanoma

BACKGROUND

Malignant melanoma, one of the most aggressive of all skin cancers, is increasing in incidence throughout the world. Surgery remains the cornerstone of curative treatment in earlier stages. Metastatic disease is incurable in most affected people, because melanoma does not respond to most systemic treatments. A number of novel approaches are under evaluation and have shown promising results, but they are usually associated with increased toxicity and cost. The combination of chemotherapy and immunotherapy has been reported to improve treatment results, but it is still unclear whether evidence exists to support this choice, compared with chemotherapy alone. No language restrictions were imposed.

OBJECTIVES

To compare the effects of therapy with chemotherapy and immunotherapy (chemoimmunotherapy) versus chemotherapy alone in people with metastatic malignant melanoma.

SEARCH METHODS

We searched the Cochrane Skin Group Specialised Register (14 February 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (2003 to 30 January 2006 ), EMBASE (2003 to 20 July 2005) and LILACS (1982 to 20 February 2006). References, conference proceedings, and databases of ongoing trials were also used to locate trials.

SELECTION CRITERIA

All randomised controlled trials that compared the use of chemotherapy versus chemoimmunotherapy on people of any age, diagnosed with metastatic melanoma.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each study to determine whether it met the pre-defined selection criteria, with differences being resolved through discussion with the review team. Two authors independently extracted the data from the articles using data extraction forms. Quality assessment included an evaluation of various components associated with biased estimates of treatment effect. Whenever possible, a meta-analysis was performed on the extracted data, in order to calculate a weighed treatment effect across trials.

MAIN RESULTS

Eighteen studies met our criteria and were included in the meta-analysis, with a total of 2625 participants. We found evidence of an increase of objective response rates in people treated with chemoimmunotherapy, in comparison with people treated with chemotherapy. Nevertheless, the impact of these increased response rates was not translated into a survival benefit. We found no difference in survival to support the addition of immunotherapy to chemotherapy in the systemic treatment of metastatic melanoma, with a hazard ratio of 0.89 (95% CI 0.72 to 1.11, P = 0.31). Additionally, we found increased hematological and non-hematological toxicities in people treated with chemoimmunotherapy.

AUTHORS' CONCLUSIONS

We failed to find any clear evidence that the addition of immunotherapy to chemotherapy increases survival of people with metastatic melanoma. Further use of combined immunotherapy and chemotherapy should only be done in the context of clinical trials.

Trends in Invasive Cutaneous Melanoma in Saskatchewan 1970–1999

Background:

Melanoma incidence rates have increased dramatically in white populations worldwide during the past several decades. A more modest increase has been observed for melanoma-related mortality. Cause-specific and disease-free survivals are related to tumor characteristics, gender, age, and possibly anatomic site. It is difficult to accurately assess these trends without information on tumor thickness that is often unavailable.

Objective:

This study determines trends in melanoma incidence, mortality, and survival in Saskatchewan for a 30-year period, incorporating analysis of tumor thickness.

Methods:

Information about cases of primary cutaneous melanoma for the 30-year period 1970–1999 was obtained from the population-based Saskatchewan Cancer Registry. A 50% random sample of charts was reviewed to collect information about Breslow depth, Clark level, and other demographic data not available from the Registry. Multivariate regression analysis was used to determine the significance of prognostic factors on incidence and five-year relative survival rates.

Results:

The number of patients registered increased dramatically during the study period. The increase was greatest for thin lesions in all age groups. Anatomic site varied by gender. Head and neck tumors showed continual increase in risk with increasing age. Mortality rates in females have been stable over time but increased for males in the 1990s. The prognostic factors that predicted excess mortality at five years were tumor thickness, Clark level, and gender.

Conclusion:

The observed increase in melanoma appears to be real and not the result of increased surveillance or screening. Tumor characteristics (Breslow depth, Clark level) and gender were significant prognostic indicators of five-year excess mortality.

Trends in incidence and predictions of cutaneous melanoma across Europe up to 2015

BACKGROUND

Melanoma is a significant health problem in Caucasian populations. The most recently available data from cancer registries often have a delay of several months up to a few years and they are generally not easily accessible.

OBJECTIVES

To assess recent age- and sex-specific trends in melanoma incidence and make predictions for 2010 and 2015.

METHODS

A retrospective registry-based analysis was performed with data from 29 European cancer registries. Most of them had data available from 1990 up to 2006/7. World-standardized incidence rates (WSR) and the estimated annual percentage change (EAPC) were computed. Predictions were based on linear projection models.

RESULTS

Overall the incidence of melanoma is rapidly rising and will continue to do so. The incidence among women in Europe was generally higher than in men. The highest incidence rates were seen for Northern and north-western countries like the UK, Ireland and the Netherlands. The lowest incidence rates were observed in Portugal and Spain. The incidence overall remained stable in Norway, where, amongst young (25-49 years) Norwegian males rates significantly decreased (EAPC -2.8, 95% CI -3.6; -2.0). Despite a low melanoma incidence among persons above the age of 70, this age group experienced the greatest increase in risk during the study period.

CONCLUSIONS

Incidence rates of melanoma are expected to continue rising. These trends are worrying in terms of disease burden, particularly in eastern European countries.

Incidence and mortality trends of melanoma in Croatia

Aim

To analyze melanoma incidence and mortality trends in Croatia 1988-2008, compare them with the trends in other populations, and identify possible changes in the trends.

Methods

Incidence data were obtained from the Croatian National Cancer Registry and the mortality data from the Croatian Bureau of Statistics. United Nations population estimates were used for calculating the age-specific rates. Age-standardized rates were calculated by the direct standardization method, using the world standard population as a reference. To estimate incidence and mortality trends, we performed joinpoint regression analysis.

Results

A significantly increasing incidence trend, with estimated annual percent change (EAPC) of 5.9% for men and 5.6% for women, was observed over the whole 21-year period and no additional joinpoints were identified. The overall incidence increase between the first and the last five-year period was 149% for men and 130% for women. Significant increase in the mortality trend was observed, with EAPC of 3.0% for men and 2.4% for women. No joinpoints were identified. The overall increase in mortality between the first and the last five-year period was 45% for men and 50% for women.

Conclusion

Melanoma rates in Croatia are steadily and markedly rising, with similar trends to those in the countries with lower/intermediate incidence. It is important to further investigate the more specific causes of the increasing trends, as well as to implement effective public policies targeting the melanoma burden.

The Euromelanoma skin cancer prevention campaign in Europe: characteristics and results of 2009 and 2010

BACKGROUND

Euromelanoma is a skin cancer education and prevention campaign that started in 1999 in Belgium as 'Melanoma day'. Since 2000, it is active in a large and growing number of European countries under the name Euromelanoma.

OBJECTIVE

To evaluate results of Euromelanoma in 2009 and 2010 in 20 countries, describing characteristics of screenees, rates of clinically suspicious lesions for skin cancer and detection rates of melanomas.

METHODS

Euromelanoma questionnaires were used by 20 countries providing their data in a standardized database (Belgium, Croatia, Cyprus, Czech Republic, FYRO Macedonia, Germany, Greece, Hungary, Italy, Lithuania, Luxembourg, Malta, Moldavia, Portugal, Serbia, Slovenia, Spain, Sweden, Switzerland and Ukraine).

RESULTS

In total, 59,858 subjects were screened in 20 countries. Most screenees were female (64%), median ages were 43 (female) and 46 (male) and 33% had phototype I or II. The suspicion rates ranged from 1.1% to 19.4% for melanoma (average 2.8%), from 0.0% to 10.7% for basal cell carcinoma (average 3.1%) and from 0.0% to 1.8% for squamous cell carcinoma (average 0.4%). The overall positive predictive value of countries where (estimation of) positive predictive value could be determined was 13.0%, melanoma detection rates varied from 0.1% to 1.9%. Dermoscopy was used in 78% of examinations with clinically suspected melanoma; full body skin examination was performed in 72% of the screenees.

CONCLUSION

Although the population screened during Euromelanoma was relatively young, high rates of clinically suspected melanoma were found. The efficacy of Euromelanoma could be improved by targeting high-risk populations and by better use of dermoscopy and full body skin examination.

The anatomic distribution of melanoma and relationships with childhood nevus distribution in Colorado

The nature of the relationship between nevus development in childhood and later development of melanoma is unclear. Data on melanoma diagnoses by histologic type and anatomic site were obtained for 2351 white, non-Hispanics in Colorado from the Colorado Central Cancer Registry between 2000 and 2004. Nevus size and body site were ascertained during skin exams conducted in the summer of 2007 on 717 white, non-Hispanic children aged 8-9 years. Chi-square goodness-of-fit analysis was used to assess the association between the anatomic site distributions of nevi versus melanoma. Superficial spreading melanoma was the most frequent histology, followed by lentigo maligna melanoma. Nodular melanoma was the least common histology. For males, there was no significant difference between the distribution of medium-sized (> or =2 mm) nevi and the distribution of both superficial spreading and nodular melanomas. For females, there was no significant difference between the anatomic distribution of small-sized (<2 mm) nevi and the distribution of nodular melanoma, and there was marginal evidence for a difference between the distribution of medium-sized (> or =2 mm) nevi and the distribution of nodular melanoma. There was evidence for a difference between all of the nevus distributions and the distributions of superficial spreading and lentigo maligna melanoma in females. The similarities between the nevus and melanoma distributions are interesting findings, but it is difficult to interpret the significance of these findings based on the current state of knowledge of melanoma etiology.

[Clinical-pathological features of cutaneous melanomas diagnosed in a Mediterranean tertiary hospital between 1990 and 2004: a comparison between sexes and age groups and analysis of longterm outcomes]

BACKGROUND

The incidence of malignant melanoma has increased over recent decades. Early diagnosis continues to be essential for effective treatment. Our objective was to analyze cutaneous malignant melanomas diagnosed over a 15-year period in a tertiary hospital for trends towards earlier diagnosis and to identify subgroups with poorer prognosis.

MATERIAL AND METHODS

Retrospective analysis of primary cutaneous melanomas analyzed in the pathology department of Hospital La Paz, Madrid, Spain, between 1990 and 2004.

RESULTS

In total, 526 melanomas were diagnosed. The mean (SD) Breslow thickness was 2.63 (4.84) mm and the median thickness was 0.98 mm (range, 0-65 mm). The mean size (widest point) was 16.59 (12.11) mm. The most common histological type was surface-spreading melanoma and the most common site was the trunk. Melanomas detected in men were generally larger and thicker than in women (P=0.05). Individuals aged over 60 years consulted for significantly thicker and larger tumors than younger individuals. The incidence of malignant melanomas has increased steadily over the years whereas the mean Breslow thickness and size have decreased.

CONCLUSIONS

Diagnosis of melanoma in Spain is made increasingly earlier, although locally advanced tumors are still sometimes seen in men and in individuals aged over 60 years.

Time trends in tumour thickness vary in subgroups: analysis of 6475 patients by age, tumour site and melanoma subtype

An elevated tumour thickness is strongly associated with an increased risk of mortality in melanoma patients. In the last few decades, an overall decrease of the tumour thickness to prognostically more favourable levels has been observed in several countries. Nevertheless, it is not clear whether this positive time trend occurred uniformly in specific subgroups of melanoma patients. Therefore, we aimed to assess time trends of tumour thickness by age group, tumour site and melanoma subtype. The study population consisted of 6475 patients with histologically proven primary invasive cutaneous melanomas seen at the Department of Dermatology and Allergology at the Ludwig-Maximilian-University Munich between 1977 and 2000. Age-adjusted time trends were assessed using linear and logistic regression analysis. Overall, a positive time trend with a decreasing tumour thickness was observed during the observation period in most subgroups. However, no significant time trend was observed in patients with a melanoma on the feet or with a nodular or acrolentiginous melanoma. The almost constant high tumour thickness of these patients might be caused by underaddressing the specific traits of these melanomas in earlier prevention campaigns. An important goal for the upcoming years should consist of a positive time trend with a decreasing tumour thickness in these subgroups.

Melanoma epidemic across the millennium: time trends of cutaneous melanoma in Emilia-Romagna (Italy) from 1997 to 2004

BACKGROUND

After a rapid increase in malignant melanoma (MM) incidence in the last decades, trends of the melanoma epidemic in the recent years seemed not homogeneous.

OBJECTIVE

This study aimed at the monitoring of some epidemiological data referring to melanoma in a region of the Northern Italy during the past 8-year period.

METHODS

All cases of melanoma, including also in situ lesions, diagnosed in Emilia-Romagna and San Marino State, with the exclusion of Cesena province, from 1997 to 2004 were recorded and the incidence of melanoma, adjusted for the European standard population by the direct method, was calculated.

RESULTS

Mean standardized incidence was 9.7 for invasive MMs and 11.9, considering also in situ ones, showing an ascending trend with an increment of 3.3 new incident cases in 2004 compared with 1997. No differences in age distribution, gender and site were reported. Concerning tumour thickness, although a general ascending trend in all subtypes, only thin melanoma incidence significantly increased over the study period.

CONCLUSIONS

Contrary to data from Northern European countries, melanoma incidence still showed an ascending trend in the Italian population of Emilia Romagna.

Proliferating endothelial cells, but not microvessel density, are a prognostic parameter in human cutaneous melanoma

The induction of angiogenesis is crucial in the development of most human tumors. Angiogenesis is routinely assessed by the density of tumor microvessels. This technique reveals controversial results on the clinical and prognostic value of angiogenesis in melanoma. We investigated angiogenesis in tumor tissues of 58 cutaneous melanoma patients, of which a clinical follow-up of over 10 years was available, through assessment of microvessel density and by enumeration of the number of proliferating endothelial cells. To that end, vessels were immunohistochemically detected by CD31/CD34 staining, and proliferating endothelial cells were enumerated in a double staining with the proliferation marker Ki67. We found that microvessel density did not correlate with tumor stage or survival, neither in intratumoral nor in peritumoral areas. In contrast, proliferating endothelial cells were only observed in intratumoral areas and were correlated positively with tumor stage and the presence of distant metastases. In addition, a strong positive correlation was found with the number of proliferating tumor cells. Finally, high numbers of growing endothelial cells predicted short survival. Our results show that angiogenesis could best be measured by enumeration of proliferating endothelial cells and that this parameter has prognostic value in patients with cutaneous melanoma.

Chemoimmunotherapy versus chemotherapy for metastatic malignant melanoma

BACKGROUND

Malignant melanoma, one of the most aggressive of all skin cancers, is increasing in incidence throughout the world. Surgery remains the cornerstone of curative treatment in earlier stages. Metastatic disease is incurable in most affected people, because melanoma does not respond to most systemic treatments. A number of novel approaches are under evaluation and have shown promising results, but they are usually associated with increased toxicity and cost. The combination of chemotherapy and immunotherapy has been reported to improve treatment results, but it is still unclear whether evidence exists to support this choice, compared with chemotherapy alone. No language restrictions were imposed.

OBJECTIVES

To compare the effects of therapy with chemotherapy and immunotherapy (chemoimmunotherapy) versus chemotherapy alone in people with metastatic malignant melanoma.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (14 February 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (2003 to 30 January 2006 ), EMBASE (2003 to 20 July 2005) and LILACS (1982 to 20 February 2006). References, conference proceedings, and databases of ongoing trials were also used to locate trials.

SELECTION CRITERIA

All randomised controlled trials that compared the use of chemotherapy versus chemoimmunotherapy on people of any age, diagnosed with metastatic melanoma.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each study to determine whether it met the pre-defined selection criteria, with differences being resolved through discussion with the review team. Two authors independently extracted the data from the articles using data extraction forms. Quality assessment included an evaluation of various components associated with biased estimates of treatment effect. Whenever possible, a meta-analysis was performed on the extracted data, in order to calculate a weighed treatment effect across trials.

MAIN RESULTS

Eighteen studies met our criteria and were included in the meta-analysis, with a total of 2625 participants. We found evidence of an increase of objective response rates in people treated with chemoimmunotherapy, in comparison with people treated with chemotherapy. Nevertheless, the impact of these increased response rates was not translated into a survival benefit. We found no difference in survival to support the addition of immunotherapy to chemotherapy in the systemic treatment of metastatic melanoma, with a hazard ratio of 0.89 (95% CI 0.72 to 1.11, p=0.31). Additionally, we found increased hematological and non-hematological toxicities in people treated with chemoimmunotherapy.

AUTHORS' CONCLUSIONS

We failed to find any clear evidence that the addition of immunotherapy to chemotherapy increases survival of people with metastatic melanoma. Further use of combined immunotherapy and chemotherapy should only be done in the context of clinical trials.

Quantitative discrimination of pigmented lesions using three-dimensional high-resolution ultrasound reflex transmission imaging

High-resolution ultrasound-reflex transmission imaging is a non-invasive method that can be performed in vivo. We have adapted and refined this technique for skin imaging. Scans can be analyzed to produce objective parameters. Previous work has highlighted sonographic differences between benign and malignant lesions. The aim of this study was to produce and test numerical parameters from ultrasound skin images that would quantify the acoustic differences between common pigmented lesions, which may aid their discrimination from melanoma. We report our findings for randomly selected patients referred from primary care with suspected melanoma. Those subsequently classified as malignant melanoma (MM), seborrheic keratosis (SK), and benign nevi by a consultant dermatologist (n=87) were imaged by high-resolution ultrasound-reflex transmission imaging. Using surrounding normal skin as a control, numerical sonographic parameters were derived for each lesion giving a relative measure of surface sound reflectance, intra-lesional sound reflection, total sound attenuation, and the relative uniformity of each parameter across the tumor. Significant quantitative differences existed between benign and malignant pigmented lesions studied. Sufficient discrimination was produced between MM (n=25), SKs (n=24) and other benign-pigmented lesions (n=38) to potentially reduce the referral of benign tumors by 65% without missing melanoma.

Melanoma cutâneo: estudo de base populacional em Goiânia, Brasil, de 1988 a 2000

FUNDAMENTOS: O Registro de Câncer de Base Populacional de Goiânia disponibiliza dados de melanoma de uma série temporal de 13 anos, com 96,6% de confirmação histopatológica. OBJETIVO: Comparar incidência, mortalidade e tendências mundiais com os dados do primeiro estudo de base populacional de melanoma cutâneo do Brasil. MÉTODOS: Foram analisados 290 casos novos diagnosticados em residentes do município (incidência) e 54 óbitos reportados ao Registro de Câncer de Goiânia (mortalidade), entre 1988 e 2000. Os coeficientes padronizados por idade e sexo foram calculados pela população mundial. Para análise das tendências, um modelo de regressão linear simples foi utilizado. RESULTADOS: Cento e quarenta e quatro casos de melanoma em mulheres e 146 em homens. Os coeficientes padronizados médios de incidência foram crescentes tanto para homens (r²=0,33; p=0,040) como para mulheres (r²=0,41; p=0,019), com tendência crescente nos homens acima de 60 anos e mulheres até 59 anos. Os coeficientes padronizados médios de mortalidade foram crescentes nos homens (r²=0,32; p=0,042) e estáveis nas mulheres, com tendência crescente para homens acima de 60 anos. CONCLUSÃO: Tanto em Goiânia como no mundo, a incidência de melanoma cutâneo é crescente para ambos os sexos. A mortalidade tende à estabilidade nas mulheres e é crescente para homens.

Epidemiología y supervivencia del melanoma cutáneo en España: estudio de 552 casos (1994-2003)

Studies on epidemiology and survival of patients diagnosed of cutaneous melanoma in our country are few. We described epidemiological, clinical, histopathologic and survival characteristics of patients diagnosed of cutaneous melanoma at Hospital Gregorio Marañón of Madrid during ten years (1994-2003). The incidence of melanoma has doubled in the last decade. An important proportion of melanomas continues to be diagnosed in advanced stages (III-IV; 14.5%). The following factors were associated with a poor global survival: Tumor thickness, ulceration, nodular type, masculine gender and age older than 65.

Slip! Slap! Slop! Cutaneous malignant melanoma incidence and social status in New Zealand, 1995-2000

Numerous studies have noted a strong social gradient in many types of ill health. In particular, people in more deprived areas tend to be less healthy than those in more affluent communities, even once the demographic and socio-economic differences of the people in those areas have been taken into account. The social gradient is evident for many types of health outcomes, including diseases such as cancer. However, this positive relationship is not evident for rates of melanoma incidence and mortality, with rates of the disease tending to decrease with measures of disadvantage. In this study, we assess the relationship between the incidence of melanoma and deprivation in New Zealand, a country with particularly high rates of the disease. In the light of greater public awareness of the risk factors associated with melanoma, through public awareness campaigns such as 'Slip! Slap! Slop' and 'No Suntan is Safe', we analyse small-area data on standardised rates of melanoma for the period 1995-2000. We found that melanoma rates increase with social status, even once other confounding factors are controlled for, but that the relationship is very small. Furthermore, the relationship between melanoma incidence and deprivation is context-dependent. Possible explanations for the relationship between melanoma and deprivation are discussed, including more frequent exposure to intermittent sunshine among less disadvantaged groups and the underreporting of melanoma incidence in the New Zealand cancer registry among individuals in lower social groups.

[Epidemiology of cutaneous melanoma: descriptive data in France and Europe]

INTRODUCTION

The incidence of melanoma and the resulting mortality have been the subject of many studies. However, controversy remains as to the interpretation of the number of cases observed and the existence of an actual "epidemic" of melanomas in fair-skinned populations.

OBJECTIVES

Analyze the descriptive epidemiological data available concerning cutaneous melanomas in France and in Europe.

METHODS

Data regarding incidence and mortality published in the literature and on the Internet were reviewed and analyzed.

RESULTS

In France, between 1980 and 2000, the standardized worldwide population incidence rate of melanoma increased from 2.4 to 7.6 per 100.000 inhabitants/years in men and from 3.9 to 9.5 in women. In the Haut-Rhin department in France, where Breslow indexes are registered, the increase in incidence was accompanied by an increase in the proportion of thin melanomas. In the year 2000, the estimated number of new cases of cutaneous melanomas was of 7231, with 58 p. 100 female and 42 p. 100 male cases. Great geographical disparity among the 9 departments in France equipped with registers was noted. This increase in incidence was accompanied by an increase in mortality. Between 1969 and 1997, mortality due to melanoma was multiplied by 2.7 in women and by 2.9 in men. In the year 2000, 1364 deaths were attributed to a melanoma. The standardized worldwide mortality rates were of 1.6/100000 inhabitants/years in men and 1.1/100000 inhabitants/years in women. In Europe, a great increase in the incidence and mortality has been registered in all countries since the nineteen fifties. It was earlier and greater in northern European countries, followed by western European countries, and finally by eastern and southern countries. There was great geographical disparity, with a double decreasing North-South East-West gradient. Analysis of the recent trends in development, in countries with high incidence such as those of northern Europe, showed a trend towards the stabilization in the incidence and decreased mortality in young adults.

DISCUSSION

In France, as in Europe, the extensive increase in incidence of melanoma and resulting mortality is a reality, reaching a peak in the northern European countries. The decrease in mortality observed recently in young cohorts in these countries and in Eastern Europe may announce an ultimate decrease in the older populations and the rest of Europe. Massive primary and secondary prevention campaigns seem effective and warrant reinforcement.

High-resolution ultrasound reflex transmission imaging and digital photography: potential tools for the quantitative assessment of pigmented lesions

BACKGROUND/AIMS

High-resolution ultrasound (HRU) is a relatively cheap imaging method that shows small quantitative differences between benign naevi and melanoma. Previous studies using B-mode display suggest that these arise from their differing attenuating properties. Attenuation characteristics, however, are better evaluated using reflex transmission imaging (RTI). White light clinical (WLC) photography is an even cheaper imaging method that is routinely used for monitoring but less frequently in everyday diagnosis. As features from each method may have an independent origin, two such modalities may be of greater diagnostic value than either method alone. However, although quantitative analysis of digital photographs is being developed to aid tumour diagnosis, in vivo RTI for the evaluation of pigmented skin lesions has not previously been described. This paper presents the feasibility of performing RTI in vivo and evaluates the reliability of the objective features used. The potential of the combination of quantitative RTI and white light (WL) digital photography data for the classification of pigmented lesions was assessed.

METHODS

Randomly selected patients were recruited via a skin cancer screening clinic. RTI data were acquired from each index lesion with a 20 MHz single-element scanner. WL images were taken using a high-resolution (2.8 Mpixels) digital camera. Quantitative features calculated from both images were used to derive a discriminant rule. This equation was then applied to reclassify each case based on its quantitative criteria. The resultant classification was compared with histological diagnosis.

RESULTS

Twenty-four lesions (10 melanoma and 14 naevi) were studied. On RTI, no subjective differences were observed between benign naevi and melanoma. Many lesions were either not visible on RTI or lacked clearly definable borders. Consequently, the WL photographs were used to draw lesion boundaries on RT images for feature calculation. Melanoma were less attenuating than naevi on RTI (P=0.026) and had greater red colour variegation on WL imaging (P=0.016). The combination of quantitative parameters (two from RTI and four from photographs) improved sensitivity for this sample without compromising the specificity of 100% compared with either modality alone. The procedure is highly reproducible (r=0.85 between two operators).

CONCLUSIONS

Pigmented skin lesions can be quantitatively defined from RTI data acquired in vivo and a significant difference in attenuation is shown. However, accurate registration of the RT image with a corresponding photograph was crucial for this purpose and only possible when corresponding points could be reliably identified on both images. Combination of features from ultrasound and optical images may synergistically improve diagnostic accuracy and a larger study is warranted to investigate this.

Epidemiología del melanoma en España

Spain has one of Europe's lowest melanoma incidence and mortality rates. Nevertheless, it is one of the fastest-growing pathologies in our country, with a 181.3% increase in the incidence rate in men and 205.3% increase in women. It represents 1.3% and 2.5% of malignant tumors in men and women, respectively, while the current standardized worldwide rate is respectively 2.4% and 4.9%. The highest incidence levels correspond to Tarragona for men (6.81%) and Gerona for women (8.24%), and lowest to the Canary Islands and Zaragoza (3.55% and 4.27% for women and men, respectively). This higher incidence among females differentiates Spain from the rest of Europe, where the opposite occurs. Mortality has also increased in Spain in the last few decades (1.76% in males and 1.26% in females), although this rising trend has stabilized in recent years. Spain's mortality rate is the lowest in Europe, as the EUROCARE-III study revealed. This study found an increase of 70.4% in the survival rate for men and 84.1% for women in the 1980s, while the figures for the 1990s were 73.9% for men and 89.8% for women. This low mortality rate in Spain may be due to the increase in thin melanomas, due to early diagnosis and surgical treatment.

Has mortality from malignant melanoma stopped rising in Spain? Analysis of trends between 1975 and 2001

BACKGROUND

There have been suggestions that mortality from cutaneous malignant melanoma (CMM) is starting to level off in the European Union.

OBJECTIVES

To analyse changes in CMM mortality trends in Spain during 1975-2001 using joinpoint regression models.

METHODS

Mortality data were obtained from the National Statistics Institute. For each gender, age group-specific and standardized (overall and truncated) rates were calculated by the direct method (using the world standard population). The joinpoint analysis was used to identify the best-fitting points where a statistically significant change in the trend occurred.

RESULTS

In women, there was a marked increase from 1975 to 1994 in age-adjusted (overall and truncated) CMM mortality rates [estimated annual percentage change (EAPC) 6.6% and 7.0%, respectively; P < 0.05], followed by a levelling off (EAPC - 0.3% and - 1.3%, respectively; not significant). In men, age-adjusted (35-64 years) mortality rates increased steadily from 1975 to 1991 (EAPC 9.1%, P < 0.05) and then levelled off.

CONCLUSIONS

We confirmed that CMM mortality rates in Spain rose dramatically from the mid-1970s to the beginning of the 1990s, but we also found that mortality rates are now levelling off in middle-aged adults (35-64 years), following a similar tendency to that observed in other countries.

Development of prognostic factors and survival in cutaneous melanoma over 25 years

BACKGROUND

Recent studies revealed that incidence rates of cutaneous melanoma (CM) were leveling off predominantly among younger people and patterns suggested birth-cohort effects. The current study analyzed the development of prognostic factors and survival in incident CM over 25 years.

METHODS

All 45,483 patients with incident CM diagnosed between 1976 and 2000 recorded by the German Central Malignant Melanoma Registry were considered. Linear and logistic regression analyses were used to judge time trends. Trends of survival rates were tested with the multivariate Cox model.

RESULTS

Median tumor thickness decreased from 1.81 mm in 1976 to 0.53 mm in 2000 (P < 0.0001). The percentages of in situ and level II CM increased, respectively (P < 0.0001). The percentage of ulcerated CM decreased (P < 0.0001). The percentage of superficial spreading melanoma increased, whereas the percentage of nodular melanoma decreased (P < 0.0001). These time trends were all significant in the strata of gender, however, male patients presented in general with more advanced disease. Between 1976 and 2000, the average patient got older (P < 0.0001). The percentage of patients diagnosed with the primary tumor alone increased (P < 0.0001). Across the 25 years of observation, adjusted survival rates did not increase for females (P = 0.1561) but they increased for males (P < 0.0001).

CONCLUSIONS

The data demonstrated a strong trend towards prognostically more favorable CM most likely due to earlier diagnosis. Men and older people should be the focus of health promotion activities as they presented with more advanced disease.

Patterns of detection of superficial spreading and nodular-type melanoma: a multicenter Italian study

BACKGROUND

Nodular histotype represents the condition that is mostly associated with diagnosis of thick melanoma.

OBJECTIVE

The objectives were to evaluate variables associated with and pattern of detection of nodular melanomas and to investigate variables associated with early diagnosis in accordance with histotype (nodular vs. superficial spreading melanomas).

METHODS

From the original data set of 816 melanomas, all the invasive lesions classified as superficial spreading (n=500) and nodular (n=93) melanomas were considered for the study. A multivariate logistic analysis was performed. Results. Nodular melanomas did not significantly differ from superficial spreading melanomas regarding sex, anatomic site, number of whole-body nevi, and the presence of atypical nevi. As expected, nodular melanomas were represented by a higher percentage of thick (>2 mm) lesions compared to superficial spreading melanomas (64.5% vs. 9.6%, p<0.001). The pattern of detection significantly differed between nodular and superficial spreading melanomas, the former being more frequently self-detected (44.1% vs. 38.0%) or detected by the family doctor (34.4% vs. 11.4%). Female sex, high level of education, and detection made by a dermatologist had an independent, protective effect against late (>1 mm in thickness) diagnosis in superficial spreading melanomas. No protective variable associated with nodular melanomas was found.

CONCLUSION

Patterns of detection for nodular melanomas significantly differ from those for superficial spreading melanomas. For superficial spreading, but not for nodular, melanomas, variables associated with protective effect against late diagnosis can be identified.

Cutaneous malignant melanoma in Europe

Cutaneous malignant melanoma is on the rise in fair skinned societies. Both its incidence and mortality rates have been increasing in Europe over the past decades, the latter seem to stabilise in Scandinavia. The main cause of melanoma is intermittent exposure to ultraviolet radiation, especially in combination with endogenous factors like skin type and genetic predisposition. Evidence on an association between sunbed use and melanoma is inconclusive, but seems to point to a slightly increased risk associated with sunbed use. Within Europe, considerably variation in patterns of melanoma incidence and mortality existed. In this paper, we discuss the possible explanations for the observed trends and options for primary and secondary prevention. Early detection seems the most promising way to combat the relatively poor survival rates in Southern and Eastern Europe.

Invasive cutaneous malignant melanoma in Sweden, 1990-1999

BACKGROUND

The objective of the current study was to compile prospective, population-based data on cutaneous invasive melanomas in Sweden during the period from 1990 to 1999, to describe and analyze survival data and prognostic factors, and to make comparisons with previously published Swedish and international data.

METHODS

Twelve thousand five hundred thirty-three patients, which included 97% of all registered melanomas in Sweden, were included and described. Among these, 9515 patients with clinical Stage I and II melanoma were included in an analysis of survival and in a univariate analysis, and 6191 patients were included in a multivariate analysis of prognostic factors.

RESULTS

There was no significant change in melanoma incidence during 1990-1999. Favorable prognostic factors were found, especially in younger and female patients, resulting in a relative 5-year survival rate of 91.5%. In the multivariate analysis, significant factors that had a negative effect on survival were Clark level of invasion, Breslow thickness, ulceration, older patient age, trunk location, greatest tumor dimension, nodular histogenetic type, and male gender.

CONCLUSIONS

During the period from 1990 to 1999, the 5-year survival of patients with malignant melanoma in Sweden was better compared with the previously reported rates in published, population-based studies from Sweden, probably as a result of better secondary prevention due to better knowledge and awareness by both patients and the medical profession. The more favorable prognostic factors and the change in melanoma location found in younger patients, compared with earlier reports, may reflect changes in clothing as well as tanning habits; however, a decrease also was found in Clark Level II and thin melanomas for the same patient group. The authors concluded that further improvements can be achieved with better access to health care and with the use of early melanoma detection campaigns.

Mortality from cutaneous malignant melanoma in Europe. Has the epidemic levelled off?

Trends of mortality from cutaneous malignant melanoma (CMM) between 1960 and 1999 in several European countries and the European Union (EU) as a whole have been reviewed, using death certification data for skin cancer available from the World Health Organization. Separate analyses were performed for young (i.e., age 20-44 years) and middle-aged (i.e., age 45-64 years) adults, among whom around 80-90% of skin cancer deaths are attributable to CMM. After steady rises between 1960 and 1990, skin cancer rates among young adults have tended to decline since the mid-1990s in several European countries, with a fall of 14% in men and of 11% in women in the EU as a whole. In middle-aged adults, the trends were less favourable, although mortality started to level off since the mid-1990s. Thus, our data provide further evidence of an improvement of CMM mortality trends in recent years in several European countries. The particularly favourable trends in young people suggest that a further decline in mortality from CMM in Europe is likely to occur within the next few years.

Cancer mortality in Europe, 1995-1999, and an overview of trends since 1960

Mortality data, abstracted from the World Health Organization database, are presented in tabular form for 26 cancer sites or groups of sites, plus total cancer mortality, in 36 European countries during the period 1995-1999. Trends in mortality are also given in graphic form for 23 major countries plus the European Union as a whole over the period 1960-1999. In the European Union, total cancer mortality declined by 7% for both sexes over the last 5 years considered. The fall since the late 1980s was 10% in both sexes, corresponding to the avoidance of over 90000 deaths per year, as compared to the rates of the late 1980s. For the first time, over the last few years, some leveling of mortality was reported also in the Russian Federation, the Czech Republic, Poland, Hungary and other Eastern European countries, although cancer rates in those areas remain exceedingly high. The overall favorable pattern of cancer mortality over recent years is largely driven by the decline of tobacco-related cancer mortality in men. However, important components of the trends are also the persistence of substantial falls in gastric cancer, mainly in Russia and Eastern Europe, the recent decline in intestinal cancer in both sexes and of breast cancer in women, together with the long-term falls in uterine (cervical) cancer, leukemias, Hodgkin's disease and other neoplasms amenable to advancements in diagnosis and treatment. Female lung cancer mortality has been declining in the Russian Federation, but is still rising in other areas of the continent. Thus, urgent intervention is needed to bring under control the tobacco-related lung cancer epidemic in European women before it reaches the high level observed in North America. Supplementary material for this article can be found on the International Journal of Cancer website at http://www.interscience.wiley.com/jpages/0020-7136/suppmat/index.html

Melanoma epidemic: True or false?

Melanoma incidence has increased dramatically over the last decades in most industrial countries, mainly as a result of the large numbers of early melanomas being diagnosed. Simultaneously, a lack of commensurate change in mortality has been reported, raising the possibility that skin melanoma may have modified its aggressiveness as a result of the increased diagnosis of biologically benign lesions. The main data and controversies arising from the melanoma epidemic are reviewed.

Use of an early-detection strategy to improve disease control in melanoma patients

In order to assess whether early detection might lead to improvement in disease control for patients with melanoma, a rapid access pigmented lesion clinic (PLC) was set up at Mount Vernon Hospital, UK in 1993. Previously we have shown that thinner melanomas were detected via the PLC compared with those presenting prior to its establishment and with those referred via existing routes of referral. The aim of this study was to investigate whether both rates of disease recurrence and disease-free interval were improved via a rapid access PLC. A retrospective case notes audit was performed on three patient groups: those diagnosed with melanoma 1991-1992, those diagnosed via the PLC (1993-1996) and those diagnosed with melanoma through existing routes of referral after establishment of the PLC (1993-1996). There was a significantly improved disease-free interval for patients with regional recurrences diagnosed via the pigmented lesion clinic (PLC) when compared with pre-PLC, non-PLC groups (chi2=13.8487, p=0.0002; chi2=17.0164, p<0.0001, respectively), and when compared with all melanoma patients diagnosed after the establishment of the PLC, irrespective of route of referral (chi2=5.2773, p=0.0216). Local recurrences developed later in patients in the PLC group compared with the pre-PLC group (chi2=6.4883, p=0.0109), and the non-PLC group (chi2=18.49, p<0.0001). In addition there was a reduction in the proportion of regional and local recurrences in the PLC group when compared with the pre-PLC group (chi2=13.92, P<0.001; chi2=2.85, P=0.09 respectively) and non-PLC group (chi2=17.15, P<0.001; chi2=7.73, P=0.005, respectively). These results support the use of rapid access PLCs as a means of improving disease control for melanoma patients.

Lower incidence rates but thicker melanomas in Eastern Europe before 1992

The objective of this study was to investigate the epidemiology of melanoma across Europe with regard to Breslow thickness and body-site distribution. Incidence data from Cancer Incidence in 5 Continents and the EUROCARE-melanoma database were used: 28?117 melanoma cases from 20 cancer registries in 12 European countries, diagnosed between 1978 and 1992. Regression analysis and general linear modelling were used to analyse the data. Melanomas in Eastern Europe were on average 1.4 mm thicker (P<0.05) than in Western Europe and appeared more often on the trunk. From 1978 to 1992, their Breslow thickness had decreased in Western but not Eastern Europe. There was a latitude gradient in incidence, with highest rates in southern regions in Eastern Europe and an inverse gradient in Western Europe, with highest rates in the North. Mortality:incidence ratios were less favourable in southern parts across Europe, especially in Eastern Europe. If Eastern European populations copy the sunbathing behaviour of the West it is likely that in the near future a higher melanoma incidence can be expected there.

Global perspectives of contemporary epidemiological trends of cutaneous malignant melanoma

During the past several decades, there has been a substantial increase in the incidence of cutaneous melanoma among all caucasian populations. The number of deaths due to cutaneous malignant melanoma has also increased in most fair-skinned populations throughout the world in the past few decades. Trends in melanoma incidence worldwide are examined. The most recent data on the mortality from cutaneous melanoma are reported. The role of different environmental, genetic and host factors in the aetiology of melanoma is discussed.

Monitoring of nevus density in children as a method to detect shifts in melanoma risk in the population

BACKGROUND

Nevus density in children, a well-known risk factor for malignant melanoma, depends both on constitutional factors and on previous ultraviolet (UV) exposure. Secular trends of childhood UV exposure could thus be indirectly monitored by repeated standardized surveys assessing nevus density in children, such as the "childhood monitoring of nevus density (CMONDE-Study)".

METHODS

Two complete surveys comprising all children at the time of school enrolment were performed in the city and county of Göttingen, Germany, during the years 1999 and 2000. A total of 4252 children with a median age of 6.25 years were examined as part of the mandatory school enrolment health assessment, and complete data were available for 3881 children.

RESULTS

Median nevus density was 5.8/m(2) in the entire study group. The subgroup-specific median increased from "Fitzpatrick skin type" IV to II, but the density was not increased for the type I subgroup. Similarly, nevus density rose with increasing lightness of hair color, but was very low in red-haired individuals. While the number of freckles was also strongly associated with nevus density, the association between iris color and skin reflectance, respectively, was weak. The duration of the additional examination for CMONDE was on average 3-5 min per child.

CONCLUSION

We regard CMONDE as a highly feasible surveillance instrument, which should be implemented as an important addition to regular regional or national health reporting.

Changing epidemiology of malignant cutaneous melanoma in Europe 1953-1997: rising trends in incidence and mortality but recent stabilizations in western Europe and decreases in Scandinavia

We analyzed time trends in incidence of and mortality from malignant cutaneous melanoma in European populations since 1953. Data were extracted from the EUROCIM database of incidence data from 165 cancer registries. Mortality data were derived from the WHO database. During the 1990s, incidence rates were by far highest in northern and western Europe, whereas mortality was higher in males in eastern and southern Europe. Melanoma rates have been rising steadily, albeit with substantial geographic variation. In northern Europe, a deceleration in these trends occurred recently in persons aged under 70. Joinpoint analyses indicated that changes in these trends took place in the early 1980s. In western Europe, mortality rates have also recently leveled off [estimated annual percentage change (EAPC) from -13.6% (n.s.) to 3.3%], whereas in eastern and southern Europe both incidence and mortality rates are still increasing [incidence EAPCs 2.3-8.9%, mortality EAPCs -1.8% (n.s.) to 7.2%]. Models including the effects of age, period and birth cohort were required to adequately describe the rising incidence trends in most European populations, with a few exceptions. Time trends in mortality were adequately summarized on fitting either an age-cohort model (with the leveling off of rates starting in birth cohorts between 1930 and 1940) or an age-period-cohort model. The most plausible explanations for the deceleration or decline in the incidence and mortality trends in recent years in northern (and to a lesser extent western) Europe are earlier detection and more frequent excision of pigmented lesions and a growing public awareness of the dangers of excessive sunbathing.

Effect of lesion size on the diagnostic performance of dermoscopy in melanoma detection

BACKGROUND

Dermoscopy is able to correctly classify a higher number of melanomas than naked-eye examination. Little is known however about factors which may influence the diagnostic performance during practice. The aim of the study was to analyze the effect of size of the lesion on diagnostic performance of dermoscopy in melanoma detection.

METHODS

Eight dermatologists examined clinical and, separately, clinical and dermoscopic (combined examination) images of 200 melanocytic lesions previously excised [64 melanomas, 24 in situ and 40 invasive (median thickness 0.30 mm) and 136 melanocytic nevi]. After examination, diagnostic performance was analyzed in accordance with the major diameter of the lesions divided into 3 groups, i.e. small (less than 6 mm), intermediate (between 6 and 9 mm) and large (10 mm or more) lesions. These groups were shown to be highly comparable concerning the microstaging of melanomas (median thickness value 0.30, 0.22 and 0.32 mm, respectively).

RESULTS

Dermoscopy increased the diagnostic performance of naked-eye examination of both intermediate and large lesions [sensitivity value: +19.3 (p = 0.002) and +10.3 (p = 0.007); diagnostic accuracy value: +7.4 (p = 0.004) and +6.1 (p = 0.07)]. On the contrary, no statistically significant increase was found dealing with small lesions (sensitivity +3.7, p = 0.66; diagnostic accuracy -1.7, p = 0.55).

CONCLUSIONS

The diagnostic improvement associated with the addition of dermoscopy to naked-eye examination is influenced by the size of the lesion, i.e. it is lacking with lesions up to 6 mm in diameter. The optimized use of dermoscopy in melanoma detection is obtained dealing with melanocytic lesions 6 mm in diameter or larger.

Relationship between cause of referral and diagnostic outcome in pigmented lesion clinics: a multicentre survey of the Italian Multidisciplinary Group on Melanoma (GIPMe)

Pigmented lesion clinics (PLCs) are permanent units to which subjects presenting with suspicious pigmented skin lesions can be rapidly referred and which can provide a prompt response to an individual's concern about melanoma. However, little is known about the melanoma detection rate in these clinics, in particular with regard to intermediate risk populations. We report a survey involving more than 1000 subjects consecutively referred by family doctors to six Italian PLCs. Using a histological diagnosis of melanoma as the endpoint, the pooled melanoma detection rate at these PLCs was 1.5% (one melanoma for diagnosed every 64 subjects examined), and the ratio between the number of melanomas and benign lesions excised for diagnostic verification was 1: 5.8 (16 melanomas and 93 benign lesions). Almost all the melanomas (15 out of 16) were detected in subjects who had requested referral for a specific doubtful lesion (group A) or for the presence of melanoma risk factors (previous melanoma, large number of common and atypical naevi, family history of melanoma) (group B). Only one melanoma was detected amongst the 418 subjects seeking consultation for concern about their moles (group C) (P = 0.004). The positive and negative predictive values of the referral groups A and B combined were 2.5% and 99.7%, respectively. Since the probability of detecting a melanoma in subjects referred only for reassurance about their moles, which nevertheless represented 43% of the subjects examined, is very low, an optimized role for PLCs in melanoma prevention would be to limit consultation to subjects who present for examination of a specific lesion or who have one or more risk factors for melanoma.

Chemotherapy and bio-chemotherapy in patients with advanced melanoma: combination therapy with a nitrosourea

The treatment of advanced melanoma is still disappointing. In a multicenter randomized clinical trial to compare a chemotherapy (CT) with or without low doses of IL-2 and IFN (Bio-CT), the participating centers chose whether or not to add a nitrosourea, carmustine (BCNU) to the therapy. The aim of the present paper is to report the clinical results of the patients (pts) treated in both arms with BCNU. One hundred and seventy-six pts with advanced melanoma were enrolled in the study from 27 centers and a total of 18 pts also received BCNU in 3 centers. No further changes to the protocol criteria were allowed. One patient refused the treatment. No complete responses were observed. Irrespectively of the treatment arm, 9/17 pts showed a partial response to therapy (53%) (5/9 in the CT and 4/8 in the BioCT arm). The most important adverse events observed were hematological: 12 pts presented grade 3 (6 pts) or grade 4 (6 pts) leukocytopenia and 9 pts had grade 4 thrombocytopenia, all of which resolved spontaneously. The addition of a nitrosourea to CT or Bio-CT appears to improve response rates compared to the same regimens without nitrosourea. Patient tolerability is acceptable. Further studies using this combination are warranted.

Unexpected reduction of mortality rates from melanoma in males living in central Italy

A registry-based study has been carried out in central Italy to investigate cutaneous melanoma incidence and mortality trends. The incidence of invasive (1492 cases analysed) and in situ (224 cases) cutaneous melanomas increased significantly from 1985 to 1997, in both genders. The increase of invasive tumours was mainly due to 'thin' (<or=1.00 mm) lesions, while thick ones showed stable rates. From 1985 to 1999, we evidenced a statistically significant decrease in mortality among males, the estimated annual percent change (EAPC) was -3.3%/year (P<=0.012), but this was not observed among females (EAPC=0.2, P=0.896). The stage at diagnosis was worse for males than females at the beginning of the analysed period, therefore the former had more possibilities for improvement than females. This may partially explain this finding since mortality rates among females were also quite low during the late 1980s. However, the stable incidence rates of the thick forms of melanoma make this finding largely unexpected, and difficult to understand assuming that in the last decade no 'clear-cut' improvements in survival have been documented as a result of new treatments in advanced melanomas.

Epidemiological research on cancer with a focus on Europe

Cancer has been a growing public health problem throughout the last century. Cancer mortality rates in both sexes combined in the European Union (EU) reached a peak in 1988. Thereafter, they declined by 9.4% in 1998. Likewise, lung cancer rates in the EU for both sexes combined increased by 58% between 1960 and 1988, but declined by 14% in 1998. Over a third of the decline was accounted for by lung cancer alone and approximately half by the combination of tobacco-related neoplasms. About half of the decline in total cancer mortality not attributable to tobacco derived from the steady fall in mortality from gastric cancer. The remaining half, including favourable trends in colorectal, breast, testis and lymphoid neoplasms, can be at least in part attributed to advancements in cancer diagnosis and treatment. The major causes of cancer and hence the most important priorities for research will be reviewed, with a specific focus on European priorities for research.

Cutaneous melanoma in the Florentine area, Italy: incidence, survival and mortality between 1985 and 1994

In recent decades, the increase in incidence of melanoma (MM) and the consequent mortality pointed to the concept of a 'melanoma epidemic'. More recently, the mortality has been slowly declining in many countries. This study is aimed at evaluating the incidence, mortality and survival in the Florentine area of Italy, using registry-based information. Between 1985 and 1994, 997 cases were notified with a survival of 713 patients (1985-92) and 316 deaths. Age-adjusted incidence, mortality rates and 95% confidence interval were calculated by period, gender and Breslow thickness. The relative survival rates were calculated and the effects of prognostic factors were evaluated using multivariate analysis. The incidence of MM increased during this period. This result referred only to 'thin melanomas', while the incidence rate for melanomas thicker than 1.00 mm remained unchanged both in young and old individuals. The mortality rate remained stable. The 5-year survival rate increased between 1985 and 1992. The inclusion of Breslow thickness in the multivariate model caused a reduction of the period effect. In conclusion, a changing pattern of MM epidemiology is being observed, with increase of 'thin' forms and a tendency for mortality to decline. The increasing awareness of population about MM prevention may partially explain these findings.

Gender differences in rising trends in cutaneous malignant melanoma in Spain, 1975-98

BACKGROUND

Cutaneous malignant melanoma (CMM) morbidity and mortality rates have increased over the past several decades all around the world, but some developed countries have experienced recent declines in mortality from CMM among the young and middle-aged and even a reversal in the long-term increase in deaths attributable to CMM.

OBJECTIVES

To describe CMM mortality trends, by age and gender, in Spain between 1975 and 1998.

METHODS

Crude, age-adjusted, truncated, cumulative, age-specific and potential years of life lost rates of CMM mortality were calculated by gender. Age and period Poisson regression models were fitted to gender- and age-specific CMM mortality rates.

RESULTS

In males there were marked increases in all CMM mortality rates between 1975 and 1994, followed by their decrease during 1995-98. In contrast, rates rose in females between 1975 and 1998. There were annual increases of 13% in the risk of dying among males and 33% among females. Relative risks of CMM mortality increased with age in both genders: (i) 21.75 (95% confidence interval, CI 17.32-27.30) in males, and (ii) 28.27 (95% CI 24.99-31.97) in females in the > or = 70-year-old group, when compared with those < 35 years.

CONCLUSIONS

CMM mortality rates continue to rise in females while males have experienced a recent reversal of this trend in Spain. Emphasizing the danger of overexposure to ultraviolet radiation may be especially important in females.

Current concepts in the management of patients with melanoma

Melanoma is a significant health problem. Despite public education and free cancer screenings, the incidence and mortality of melanoma continues to rise; however, many currently diagnosed melanomas are thin lesions, suggesting that education and awareness is having an impact. In addition, there are still subsets of patients who need increased surveillance in order to increase their survival. Although large congenital nevi may be precursors of melanoma, small and medium congenital nevi have an insignificant risk for melanoma development. Large congenital nevi, which are axial in location, appear to be more likely to develop melanoma and are associated with melanocytosis and melanoma of the CNS, both of which portend a poor prognosis. Recently, the recommended margins of excision have become more conservative so that many of the surgical defects can be closed primarily. Lymphoscintigraphy and sentinel node biopsy have replaced elective node dissections, thus decreasing the morbidity associated with the surgical management of melanoma. Although controversy still exists as to whether or not sentinel lymph node biopsy alters a patient's prognosis, it has been shown to be a powerful prognostic indicator. Although most melanomas are managed by routine surgical excision, other modalities are sometimes employed. For example, cryosurgery or radiation therapy may be indicated in the frail, elderly individual with a large facial lentigo maligna. Mohs surgery is the treatment of choice for head and neck melanomas and those located in areas where maximum preservation of tissue is required and for desmoplastic and acral lentiginous melanomas. Much more work remains in the area of adjuvant therapy, chemotherapy, and immunotherapy. Dacarbazine remains the drug of choice in disseminated melanoma, but remissions are usually short lived. Interleukin and biochemotherapy has yielded good results but the percentage benefiting is small. Although high dose interferon increases disease-free and overall survival in some patients, it remains a controversial drug which is not easily tolerated. In the new staging system for melanoma, ulceration is second only to Breslow's thickness. In transit (satellite) lesions have also been included in this new system. The new system also recognizes that patients with only microscopic metastatic nodal disease fare better than patients with clinically enlarged metastatic nodes and that it is the number of nodes involved with metastases, not their size, that determines the patient's prognosis. Except for lesions <1mm thick, the Clark's level of invasion has been de-emphasized.