Earlier diagnosis of second primary melanoma confirms the benefits of patient education and routine postoperative follow-up

Full-body skin examination in screening for cutaneous malignancy: a focus on concealed sites and the practices of Australian dermatologists

BACKGROUND

Full-body skin examination (FSE) is a vital practice in the diagnosis of cutaneous malignancy. Precisely how FSE should be conducted with respect to concealed site inclusion remains poorly elucidated.

OBJECTIVE

To establish the approach of Australian dermatologists to concealed site examination (CSE).

METHODS

A cross-sectional study was performed consisting of an online self-administered 11-question survey delivered to fellows of the Australasian College of Dermatologists.

RESULTS

There were 237 respondents. Anogenitalia was the least often examined concealed site (4.6%), and 59.9, 32.9, and 14.3% reported always examining the scalp, breasts, and oral mucosa, respectively. Patient concern was the most frequently cited factor prompting examination, while many cited low incidence of pathology and limited chaperone availability as the main barriers to routine examination of these sites.

CONCLUSION

Most Australian dermatologists do not routinely examine breasts, oral mucosal, or anogenital sites as part of an FSE. Emphasis should be made on identifying individual patient risk factors and education regarding self-examination of sensitive sites. A consensus approach to the conduct of the FSE, including concealed sites, is needed to better delineate clinician responsibilities and address medicolegal implications.

Prognostic significance of time trends in treatment of head and neck squamous cell carcinoma

PURPOSE

To analyze the impact of demographic, clinical, and management variables on time to treatment initiation (TTI) and overall survival (OS).

STUDY DESIGN

Retrospective chart review.

MATERIALS AND METHODS

Medical records of patients diagnosed with head and neck cancer from 2018 to 2020 were reviewed. Univariate linear and Cox-regressions identified predictors of TTI and OS. Kaplan Meier (KM) curves assessed the difference in survival by diagnostic year and TTI.

RESULTS

381 patients met eligibility criteria. Median TTI was 35.0 days (IQR: 25.0-49.0). Only 10.8 % of all patients reported any treatment delay, with TTI exceeding 90 days found in 3.7 % of patients. TTI increased with African American race (p = 0.02), ED referrals (p = 0.02), and direct admission status (p = 0.01). When compared to treatment with surgery alone, TTI was shorter in patients undergoing surgery with adjuvant radiation (p = 0.02), adjuvant chemoradiation (p = 0.04), and salvage surgery (p = 0.04). Univariate Cox-regressions found smoking (p = 0.01), direct admission status (p = 0.02), increased duration of symptoms (p = 0.02), placement of PEG tubes (p < 0.01) and tracheostomies (p < 0.01), combination treatment (p < 0.01), and surgery with adjuvant chemoradiation treatment (p = 0.01) to increase mortality risk. Disease characteristics, including tumor size (p < 0.01), presence of nodal disease (p = 0.02), and late-stage disease (p < 0.01), increased mortality risk. TTI and diagnostic year did not impact survival.

CONCLUSIONS

Our analysis determined several demographic, referral, and treatment factors impacted TTI. However, increased TTI did not impact survival. Characteristics consistent with advanced disease worsened OS. Despite the pandemic burden, patients diagnosed in 2020 showed no difference in short-term survival compared to prior years.

Potential risk factors, clinicopathological features and determinants of survival for multiple primary melanoma patients compared to single primary melanoma: a large single-center Italian study

Melanoma patients have a high risk of developing subsequent primary melanomas, a condition known as multiple primary melanoma (MPM). We aimed to compare risk factors of patients with MPM and single primary melanoma (SPM). Primary MPM and SPM consecutively treated at the National Cancer Institute in Milan, Italy, from 1978 to 2021 were retrospectively investigated. Demographic and clinicopathological characteristics were analyzed. Multivariate hazard ratios and mortality were estimated using Cox proportional hazards regression models. Overall, 9122 patients with SPM and 944 with MPM were included. A total of 1437 and 85 deaths occurred in SPM and MPM group, respectively. Of these, 1315 (14.4%) within SPM patients and 60 (6.4%) in MPM group were melanoma-specific deaths (MSDs). Males had a higher risk for MPM (hazard ratio = 1.29), while age was not associated with MPM (hazard ratio = 0.98). The risk of MPM decreased by about 50% for Breslow thickness >1 mm, and by about 45 and 75% in presence of mitoses and ulceration, respectively. The multivariate hazard ratio of death for MPM compared to SPM patients was 0.85 (95% confidence interval, CI: 0.67-1.06), while considering MSD the corresponding hazard ratio was 0.93 (95% CI: 0.71-1.22). Melanoma patients should receive regular follow-up with complete skin examination to detect early subsequent primary melanoma. Patients with more advanced primary have decreased risk of MPM, while males have higher risk. Our study reported no significant difference in mortality between SPM and MPM, but the issue is still open for discussion and further studies.

Adherence with surveillance schedule in patients with invasive melanoma

BACKGROUND

Seven percent of patients develop melanoma recurrence after successful treatment, and 4-8% develop a second primary melanoma. This study aimed to assess how providing Survivorship Care Plans (SCPs) to patients may improve adherence to surveillance visits.

METHODS

All patients treated for invasive melanoma at our institution between 8/1/2018-2/29/2020 were included in this retrospective chart review. SCPs were delivered in-person to patients and sent to primary care providers and dermatologists. Logistic regression was performed to assess influences on adherence.

RESULTS

Of 142 patients, 73 (51.4%) received SCP regarding their follow-up care. Reception of SCP (p = 0.044) and shorter distance from clinic (p = 0.018) significantly improved rates of adherence. Seven patients developed melanoma recurrences, five were physician-detected. Three patients had primary site recurrence, six had lymph node recurrences, and three had distant recurrences. There were 5 second primaries, all physician-detected.

CONCLUSION

Our study is the first to investigate the impact of SCPs on patient adherence in melanoma survivors and the first to reveal a positive correlation between SCPs and adherence in any type of cancer. Melanoma survivors require close clinical follow-up, as demonstrated by our study finding that even with SCPs, most recurrences and all new primary melanomas were physician-detected.

Risk Factors Associated With First and Second Primary Melanomas in a High-Incidence Population

Importance

An increasing number of people develop more than 1 primary melanoma, yet to date, no population-based prospective cohort studies have reported on risk factors for developing first vs second primary melanomas.

Objective

To compare the clinical characteristics of first and second melanomas and then to estimate the relative risks of developing 1 vs multiple melanomas associated with demographic, phenotypic, sun exposure, and genetic factors.

Design, Setting, and Participants

This population-based prospective cohort study included men and women aged 40 to 69 years recruited in 2011 and followed up until December 2018 in Queensland, Australia. Data analysis was performed from February to July 2022.

Exposures

Self-reported information about demographic, phenotypic, and sun exposure measures captured using a survey completed at baseline, and polygenic risk score for melanoma.

Main Outcomes and Measures

Incident first or second primary melanoma diagnosis, and histologic and clinical characteristics thereof. The Wei-Lin-Weissfeld model for recurrent events was used to estimate the association of each factor with the risks of first and second primary melanoma.

Results

A total of 38 845 patients (mean [SD] age at baseline, 56.1 [8.2] years; 17 775 men and 21 070 women) were included in the study. During a median follow-up period of 7.4 years, 1212 (3.1%) participants had a single primary melanoma diagnosis, and 245 (0.6%) had a second primary melanoma diagnosis. Second melanomas were more likely than first melanomas to be in situ; for invasive tumors, second melanomas were more likely to be thin (ie, ≤1 mm) than first melanomas. Having many moles at age 21 years (self-reported using visual scoring tool) was more strongly associated with second (hazard ratio [HR], 6.36; 95% CI, 3.77-10.75) than first primary melanoma (HR, 3.46; 95% CI, 2.72-4.40) (P value for difference between the HRs = .01). A high genetic predisposition (ie, polygenic risk score in tertile 3) was also more strongly associated with second (HR, 3.28; 95% CI, 2.06-5.23) than first melanoma (HR, 2.06; 95% CI, 1.71-2.49; P = .03). Second melanomas were more strongly associated with a history of multiple skin cancer excisions (HR, 2.63; 95% CI, 1.80-3.83) than first melanomas (HR, 1.86; 95% CI, 1.61-2.16; P = .05). For all other phenotypic characteristics and sun exposure measures, similarly elevated associations with first vs second melanomas were observed.

Conclusions and Relevance

Findings of this cohort study suggest that within the general population, the presence of many nevi and having a high genetic predisposition to melanoma were associated with the highest risks of developing second primary melanomas.

Predictors of subsequent primary melanoma: a case-control study

Patients with history of malignant melanoma (MM) are at risk of developing subsequent primary MM (SPM). Predictors of SPM may be helpful to identify patients at higher risk. The objective of the study is to investigate the phenotypic traits, indirect actinic exposure features and pathological variables associated with the risk of development of SPM. A ten-year retrospective case-control study was undertaken involving patients following MM excision who underwent regular video-dermoscopic examination at 4-6-month intervals for the first 5 years, followed by annual dermoscopic examination for the following five years. Patients with only one primary cutaneous MM were compared with those who developed at least one SPM. A total of 577 patients were included, 309 (53.6%) men and 268 (46.5%) women (mean age, 55 ± 15 years), comprising 450 patients with single melanoma and 127 with at least one SPM. The median time span to the SPM was 30 (IQR 12-53) months. Compared to the first melanoma, SPM were thinner, mean Breslow 0.56 ± 0.64 mm vs 1.37 ± 1.83 mm (p < 0.001); in situ MM prevalence 12% vs 36% (p < 0.001). 36 % of the patients with SPM developed it in the anatomical site of the previous melanoma. At multivariate analysis, having numerous naevi (i.e. 10-50 nevi) OR = 2.88 (95% CI 1.32-6.28, previous dysplastic naevi excisions OR = 2.51 (95% CI 1.53-4.12), solar lentigo OR = 2.68 (95% CI 1.67-4.31) and actinic keratosis OR = 3.09 (95% CI 1.64-4.31) were associated with an increased risk of SPM. These features may identify persons at increased risk of developing SPM.

Multiple Primary Melanomas: Retrospective Review in a Tertiary Care Hospital

Multiple primary melanomas (MPM) refer to the occurrence of more than one synchronous or metachronous melanoma in the same individual. The aim of this study was to identify the frequency of MPM and describe the clinical and histopathologic characteristics of patients with MPM. An observational single-center retrospective study was designed based on a cohort of melanoma patients followed in a tertiary care hospital. Fifty-eight (8.9%) patients developed MPM. Most patients were men (65.5%) and the median age at the time of diagnosis of the first melanoma was 71 years old. The median time of diagnosis of the second melanoma from the first melanoma was 10.9 months, and 77.6% of second melanomas were diagnosed within the first 5 years. In total, 29 (50%) and 28 (48.3%) first and second melanomas were located in the trunk, respectively. Concordance of anatomic site between primary and subsequent melanoma was found in 46.6% of the patients. Proportion of in situ melanomas was increasingly higher in subsequent melanomas (from 36.21% of first melanomas to 100% of fifth melanomas). An increasing rate of melanomas with histological regression was observed within subsequent melanomas (from 60.3% of first melanomas to 80% of third melanomas). Our results support the importance of careful long-term follow-up with total body examination in melanoma patients.

Multiple primary melanomas: Our experience

Patients with melanoma have an increased risk of having other neoplasms, and particularly other melanomas and non-melanoma skin cancers. The study aimed to describe multiple primary melanomas in a large medical university centre from Romania (Cluj-Napoca) from 2004 to 2020. Out of 699 patients with melanoma included in the study, 26 (3.71%) developed multiple tumours. The 26 patients developed a total of 59 melanomas, corresponding to a mean of 2.3 melanomas per patient. The site and histological subtype of the first and second melanomas were not consistent. The proportion of subsequent melanomas that were in situ (51.5%) or thin melanomas (<1 mm, 24.2%) was higher compared with first melanomas (7.7%, respectively 11.5%). The median and mean time to diagnosis was 2.75 months, respectively, 28.09 months. In total, 76.92% of second melanomas were detected within three years, but we were able to document a subsequent melanoma more than ten years after the first diagnosis. The study highlights the importance of follow-up in patients diagnosed with melanoma, not only in the first years after the primary diagnoses but for the entire life.

Differences in Risk Factors for Melanoma in Young and Middle-aged Higher-risk Patients

BACKGROUND/AIM

Differences in risk factors for melanoma between young adults (18-39 years) and middle-aged (40-60 years) are not well documented. In this study, we aimed to determine differences in risk factors and characteristics of melanoma between these groups.

PATIENTS AND METHODS

This retrospective study is a review on 330 patients, including 250 middle-aged and 80 young adults, during the period 2006-2016 in the Tampere university hospital, in Finland.

RESULTS

Forty-one per cent of middle-aged and 47% of young adults were defined as higher-risk patients. High nevus count was the most common host risk factor in both groups. Young were more likely to have a family history of melanoma. Middle-aged had more often excessive intermittent sun exposure and a history of sunburn. Host risk characteristics were less commonly associated with thicker melanomas.

CONCLUSION

A high number of patients have host risk factors for melanoma. Several differences exist in risk factors and characteristics of melanomas between young adults and middle-aged patients.

Prevalence and correlates of skin self-examination behaviors among melanoma survivors: a systematic review

Melanoma is the most common cause of skin cancer deaths, and individuals who have had melanoma have an increased risk of developing new melanomas. Doing regular self-examinations of skin enables one to detect thinner melanomas earlier when the disease is more treatable. The aim of this systematic review is to characterize and evaluate the existing literature on the prevalence and correlates of skin self-examination (SSE) behaviors among adult melanoma survivors in the USA and Canada. A computerized literature search was performed using PubMed, Google Scholar, and ScienceDirect. The inclusion criteria for the studies were: (a) reported results for adult melanoma survivors in the USA or Canada, (b) papers described empirical research, (c) assessed SSE and related behaviors, and (d) papers were published in a peer-reviewed journal in the past 20 years. Key phrases such as "skin self-examination/SSE in melanoma survivors in the United States" and "correlates of skin self-examination/SSE" were used. Based on the inclusion criteria, 30 studies were included in the systematic review. SSE prevalence varied depending on how SSE was defined. Demographics and factors (gender, education level, patient characteristics, partner assistance, and physician support) associated with SSE were identified. Findings of this review show evidence for the need to have a consistent way to assess SSE and suggest different types of correlates on which to focus in order to promote SSE and reduce the risk of melanoma recurrence in survivors. This systematic review and its protocol have been registered in the international database of prospectively registered systematic reviews in health and social care (PROSPERO; ID: 148878).

Clinical and Histologic Features of Multiple Primary Melanoma in a Series of 31 Patients

BACKGROUND

We reviewed all cases of multiple primary melanoma diagnosed at our department over a 32-year period (1987-2019) to better characterize this subgroup of patients and develop a tailored protocol to offer them closer follow-up.

METHODS

Retrospective, observational, descriptive study of patients diagnosed with multiple primary melanoma at a tertiary care hospital between January 1987 and March 2019. We collected clinical, epidemiologic, and histologic characteristics of primary and subsequent melanomas and performed a descriptive analysis.

RESULTS

Thirty-one patients (15 men and 16 women) with a median age of 67years (range, 36-85years) were included. Second primary melanomas were diagnosed after a median of 2years (range, 0-4years). The median number of melanomas per patient was 2 (range, 2-6). Twenty-three of the 31 patients, 25 had 2 primary melanomas (80%), 4 had 3 melanomas (13%), and 2 patients each had 5 and 6 primary melanomas. Subsequent melanomas were less invasive than the initial primary melanomas. Median Breslow thickness was 1mm (range, 0.67-4mm) for the first primary melanoma and 0.5mm (range, 0.32-2.42mm) for subsequent melanomas.

CONCLUSIONS

Subsequent melanomas are thinner than primary melanomas. We observed an increase in the number of cases of multiple primary melanoma diagnosed in the last 2years of our study. Our findings highlight the importance of close, long-term follow-up of patients.

Short and long-term barriers and facilitators of skin self-examination among individuals diagnosed with melanoma

Background

Melanoma can be lethal if not detected early and treated. Early detection can be facilitated via skin self-examination (SSE) and as such, SSE is part of melanoma follow-up care for individuals with a prior history, who face a life-long risk of reoccurrence. The objective of the current study was to identify short- and long-term predictors of SSE among melanoma survivors to inform future prevention interventions in high-risk groups.

Method

This is an observational study with longitudinal assessments conducted with adult melanoma patients in active follow-up care.

Primary outcome measures

Behavioral outcomes, comprehensive SSE (checking up to 5 body areas in the last 3 months) and optimal SSE (checking the entire body at least monthly in the last 3 months) were assessed at 3, 12, and 24 months post a dermatological educational session on skin cancer prevention. T tests and chi square analyses were used to examine changes in outcomes from 3 to 12 and 24 months. Linear and logistic regression models were used to examine the association between predictors and the primary outcomes.

Results

Comprehensive SSE did not decrease significantly from 3 (M = 2.7, SD = 1.1) to 12 (M = 2.6, SD = 1.2) and 24 months (M = 2.4, SD = 1.2) post the education session, with the stronger predictor at all timepoints being intentions to perform SSE. Optimal SSE was higher at 3 months (59%) compared to 12 (46%) and 24 months (34%), with key predictors including self-efficacy and intentions to perform SSE and male sex at 3 months post; self-efficacy and reliance on medical advice at 12 months; and (lower) education and self-efficacy at 24 months.

Conclusions

The key findings of this study are that 1) survivors maintain SSE behaviour over time, but rates of SSE performed in agreement with medical recommendations are higher immediately post standard dermatological education (i.e. usual care) and decrease somewhat over a 24-month period; and 2) the strongest psycho-social predictors of SSE are intentions and self-efficacy to perform the behavior, which are highly modifiable, for example via motivational interviewing and goal setting health interventions.

New primary melanoma in a patient under triple therapy with vemurafenib, cobimetinib, and atezolizumab for metastatic melanoma

New primary melanomas (NPMs) in the era of combination treatments for melanoma constitute a challenge for physicians, especially due to the increased incidence of NPMs in patients treated with BRAF inhibitors. We present the unique case of a patient that developed an invasive NPM while under treatment with a combination of vemurafenib, cobimetinib, and atezolizumab. A 39-year-old white male was treated with vemurafenib, cobimetinib, and atezolizumab for a stage IV (T0, N3, M1) BRAF-V600E mutated malignant melanoma in the context of a clinical trial. Eight months from treatment initiation he was diagnosed with an NPM on his back that was found to be BRAF-wild type and neuroblastoma ras mutated, while he was in complete remission. Wide excision of the lesion followed, and the patient was not withdrawn from study treatment. Twenty-two months from treatment initiation, he is still in complete remission. NPMs are a well-known adverse effect of BRAF inhibitors and pose a challenge for the treating physician since these lesions are BRAF-wild type and usually have aggressive biologic behaviour. Invasive NPMs require an aggressive management strategy with clear guidelines to prevent the emergence of advanced or metastatic disease. The emergence of invasive NPMs in patients treated with triple regimens with BRAF/mitogen-activated protein kinase kinase inhibitors and PD1/PDL1 inhibitors is at least unexpected and constitutes a therapeutic stalemate for the physician. Through this case report, we aim to increase awareness about the diagnosis and management of patients with NPM and to express our concerns regarding further management of NPMs in patients under triple combination treatment.

Dermoscopic similarity is an independent predictor of BRAF mutational concordance in multiple melanomas

BACKGROUND

The association of clinical and dermoscopic features with BRAF mutational status has been poorly analysed in multiple primary melanomas (MPM).

OBJECTIVE

To investigate whether concordance of BRAF mutational status is associated with dermoscopic similarity in multiple melanomas of the same patient.

METHODS

Dermoscopic images and corresponding tissue sections of 124 melanomas from 62 patients with MPM were selected at four Italian Dermatology Departments. Similarity of dermoscopic appearance between multiple melanomas was evaluated according to the presence of the same prevalent dermoscopic feature. The BRAF^V600 mutational status was analysed with allele-specific TaqMan^TM assays or pyrosequencing. Spearman's correlation and univariate and multivariate regression analysis were used for statistical analysis.

RESULTS

A similar dermoscopic appearance was identified in 38.7% (24/62) of patients with MPM and was correlated with older age at first diagnosis (rho: 0.26; P: 0.042) and occurrence on sun-damaged skin (rho: 0.27; P: 0.037). The BRAF^V600 mutation was detected in 39.5% (49/124) of the tumors and a concordant BRAF mutational status between melanomas in 33/62 (53.2%) MPM patients. Dermoscopically similar melanomas showed 5.7-fold higher odds to be concordant for BRAF mutational status compared to dissimilar lesions (OR: 5.7; 95% CI 1.7-19.5; P: 0.005).

CONCLUSION

Dermoscopic similarity of multiple melanomas represents an independent clinical predictor of a concordant BRAF mutational status in MPM patients.

Concordance of somatic mutational profile in multiple primary melanomas

This study aimed to determine the frequency and concordance of BRAF and NRAS mutation in tumours arising in patients with multiple primary melanoma (MPM). Patients with MPM managed at one of three tertiary referral centres in Melbourne, Australia, from 2010 to 2015 were included. Incident and subsequent melanomas underwent mutation testing. Cohen's kappa (κ) coefficient assessed agreement between incident and subsequent primary melanomas for both BRAF and NRAS mutation status (mutant versus wild-type). Mutation testing of at least two primary tumours from 64 patients was conducted. There was poor agreement for both BRAF and NRAS mutation status between incident and subsequent melanomas (κ = 0.10, 95% CI -0.10 to 0.42; κ = 0.06, 95% CI -0.10 to 0.57, respectively). In view of the low concordance in BRAF mutation status between incident and subsequent melanomas, mutational analysis of metastatic tissue, rather than of a primary melanoma, in patients with MPM should be used to guide targeted therapy.

18F-FDG PET/CT and Melanoma: Value of Fourth and Subsequent Posttherapy Follow-up Scans for Patient Management

PURPOSE

We aimed to evaluate the added value of performing fourth and subsequent follow-up F-FDG-PET/CT scans to clinical assessment and impact on the patient's management in patients with melanoma.

METHODS

This was a retrospective study of 232 biopsy-proven melanoma patients who underwent F-FDG-PET/CT scans. Of these, 71 patients had 4 or more follow-up F-FDG-PET/CT scans after completion of primary treatment, with a total of 246 fourth or subsequent follow-up PET/CT scans. The added value of each follow-up PET/CT scan to the patient's clinical assessment and treatment management was established. Kaplan-Meier plots with a Mantel-Cox log-rank test were used to establish the patient's overall survival.

RESULTS

Of the 246 fourth and subsequent follow-up PET/CT scans, 61% (150/246) were negative for malignancy, and 39.0% (96/246) were positive for recurrence/metastases. FDG-PET/CT was helpful in identifying malignancy in 6.5% of the scans performed without prior clinical suspicion, which ruled out malignancy in 28.5% of the scans obtained with prior clinical signs suggestive of recurrence or for secondary therapy assessment. The PET/CT scan resulted in change of the patient's management in approximately 16.7% (41/246) of the scans. Change in management was significantly greater in patients whose scans were done with prior clinical signs suggestive of malignancy, or for therapy assessment than without prior clinical suspicion (29.3% vs 4.1%; P < 0.0001). Statistically significant difference was seen in the overall survival between patients with at least 1 positive and all negative fourth and subsequent follow-up PET/CT scans at patient level (P = 0.001).

CONCLUSIONS

The fourth and subsequent F-FDG-PET/CT scans obtained after completion of primary treatment added value to clinical assessment in patients with melanoma. Patients with clinical signs suggestive of recurrence or metastases or being monitored for treatment response are more likely to benefit from the fourth or subsequent FDG PET/CT than those without prior clinical suspicion.

Second Primary Melanoma: Risk Factors, Histopathologic Features, Survival, and Implications for Follow-Up

The impact on survival of a second primary melanoma (SPM) is unclear. We used our melanoma center's database to examine clinicopathologic risk factors and outcomes of stage 0 to IV cutaneous melanoma in patients with one versus two primaries. Among 12,325 patients with primary melanoma, 969 (7.86%) developed SPM. SPMs were significantly thinner than autologous primary melanomas ( P = 0.01), and 451 SPM patients had better overall and melanoma-specific survival than 451 prognostically matched non-SPM patients ( P < 0.0001 and 0.0001, respectively) at a median follow-up of 142.37 months. Patients with cutaneous melanoma are at high risk for development of SPM, but the development of SPM does not seem to impair survival.

Impact of Melanoma Diagnosis on Sun-Awareness and Protection: Efficacy of Education Campaigns in a High-Risk Population

Background:

Malignant melanoma is a significant cause of morbidity and mortality worldwide. Sun-awareness campaigns increase public knowledge but may not translate into behavioral changes in practice, which is particularly alarming when reported for individuals in high-risk groups. In particular, patients diagnosed with melanoma are at increased risk of developing subsequent primary melanomas compared with the general population.

Objectives:

The study was undertaken (1) to assess whether patients with known risk factors for developing melanoma had been exposed to preventative campaign messages prior to their diagnosis, (2) to quantify whether the diagnosis of melanoma changed sun-related attitudes and behavior, and (3) to assess the adequacy of sun-related advice given to patients with melanoma, as well as their compliance with the advice.

Methods:

Using an anonymous questionnaire, 217 patients previously diagnosed with melanoma were interviewed on the source and frequency of received sun-related advice, as well as on their knowledge, attitudes, and behavior toward sun protection before and after the diagnosis.

Results:

The number of patients who reported receiving sun-related advice after being diagnosed with melanoma increased by 36% (52% pre-vs. 88% postDiagnosis), with advice being given more frequently and more often by a physician (19% pre- vs. 49% postdiagnosis). Furthermore, sun-related attitudes and behavioral practices were positively altered. Yet, patients with known risk factors were not preferentially targeted for advice before their diagnosis.

Conclusions:

The diagnosis of melanoma leads to increased sunwareness and protection. While dermatologists should continue their efforts to promote and reinforce sun-awareness in patients with melanoma, additional emphasis on preventative targeting of high-risk individuals would be of marked benefit in decreasing the overall incidence of melanoma. Non-dermatologists, such as family physicians, can be key players in this preventative campign, and can be educated to recognize and educate patients at risk, as well as direct them to be followed under dermatology care.

Risk of subsequent melanoma after melanoma in situ and invasive melanoma: a population-based study from 1973 to 2011

BACKGROUND

Patients with melanoma in situ are at an increased risk of subsequent melanoma compared with the general population, but the risk of subsequent melanoma after initial melanoma in situ versus after initial invasive melanoma is not known.

OBJECTIVE

We sought to compare the risk of subsequent melanoma in the cohort whose first cancer was melanoma in situ to the risk in the cohort whose first cancer was invasive melanoma.

METHODS

In this cohort study, we identified individuals whose first cancer was either melanoma in situ or invasive melanoma from the Surveillance, Epidemiology, and End Results (SEER) program between 1973 and 2011 and used Cox proportional hazards models for comparison.

RESULTS

Compared with the invasive melanoma cohort, the melanoma in situ cohort was more likely to develop subsequent melanoma of any stage after 2 years, subsequent invasive melanoma after 10 years, and subsequent melanoma in situ at all the time points (P < .001, P = .003, P < .001, respectively).

LIMITATIONS

Underreporting of melanomas, particularly melanoma in situ cases, and missing cases of subsequent melanomas as a result of patient migration from the SEER registry areas could affect results.

CONCLUSION

Given the increased long-term risk of subsequent melanoma in the melanoma in situ cohort, the patients with melanoma in situ diagnosis may benefit from a long-term surveillance for subsequent melanomas.

Clinical practice guidelines for identification, screening and follow-up of individuals at high risk of primary cutaneous melanoma: a systematic review

Understanding how individuals at high-risk of primary cutaneous melanoma are best identified, screened and followed up will help optimize melanoma prevention strategies and clinical management. We conducted a systematic review of international clinical practice guidelines and documented the quality of supporting evidence for recommendations for clinical management of individuals at high risk of melanoma. Guidelines published between January 2000 and July 2014 were identified from a systematic search of Medline, Embase and four guideline databases; 34 guidelines from 20 countries were included. High-risk characteristics that were consistently reported included many melanocytic naevi, dysplastic naevi, family history, large congenital naevi, and Fitzpatrick Type I and II skin types. Most guidelines identify risk factors and recommend that individuals at high risk of cutaneous melanoma be monitored, but only half of the guidelines provide recommendations for screening based on level of risk. There is disagreement in screening and follow-up recommendations for those with an increased risk of future melanoma. High-level evidence supports long-term screening of individuals at high risk and monitoring using dermoscopy. Evidence is low for defining screening intervals and duration of follow-up, and for skin self-examination, although education about skin self-examination is widely encouraged. Clinical practice guidelines would benefit from a dedicated section for identification, screening and follow-up of individuals at high risk of melanoma. Guidelines could be improved with clear definitions of multiple naevi, family history and frequency of follow-up. Research examining the benefits and costs of alternative management strategies for groups at high risk will enhance the quality of recommendations.

Variability in melanoma post-treatment surveillance practices by country and physician specialty: a systematic review

There are no evidence-based guidelines for the surveillance of patients with melanoma following surgical treatment. We carried out a systematic review to identify by country and physician specialty the current stage-specific surveillance practices for patients with melanoma. Three major medical indices, MEDLINE, the Cochrane Library database, and Scopus, were reviewed to identify articles published from January 1970 to October 2011 that included detailed information about the surveillance of patients with melanoma after the initial surgical treatment. Data on surveillance intervals and recommended evaluation were extracted and categorized by country and, when reported, physician specialty. One hundred and four articles from 10 countries and four physician specialties (dermatology, surgical oncology, medical oncology, and general practice) fulfilled the inclusion criteria, including 43 providing specific patient-level data. The articles showed a wide variation with respect to the surveillance intervals and recommended evaluations. The variation was greatest for patients with stage I disease, for whom the follow-up frequency ranged from one to six visits per year during years 1 and 2 after treatment. All four physician specialties agreed that for years 1-3, the follow-up frequency should be four times per year for all patients. For years 4 and 5, surgical oncologists recommended two follow-up visits per year, whereas general practitioners, dermatologists, and medical oncologists recommended four visits per year. Recommended imaging and laboratory evaluations were most intense in the UK and most minimalist in the Netherlands. Although general practitioners did not recommend routine laboratory or imaging tests for surveillance, all other specialties utilized both in their surveillance practice. Self skin-examination was recommended for surveillance in all countries and by all practitioner specialties. There are significant intercountry and interspecialty variations in the surveillance of patients with melanoma. As the number of melanoma survivors increases, it will be critical to examine the benefits and costs of various follow-up strategies to establish consensus guidelines for melanoma post-treatment surveillance.

Barriers and facilitators of adherence to medical advice on skin self-examination during melanoma follow-up care

BACKGROUND

Melanoma is the fastest growing tumor of the skin, which disproportionately affects younger and middle-aged adults. As melanomas are visible, recognizable, and highly curable while in early stages, early diagnosis is one of the most effective measures to decrease melanoma-related mortality. Skin self-examination results in earlier detection and removal of the melanoma. Due to the elevated risk of survivors for developing subsequent melanomas, monthly self-exams are strongly recommended as part of follow-up care. Yet, only a minority of high-risk individuals practices systematic and regular self-exams. This can be improved through patient education. However, dermatological education is effective only in about 50% of the cases and little is known about those who do not respond. In the current literature, psychosocial variables like distress, coping with cancer, as well as partner and physician support are widely neglected in relation to the practice of skin self-examination, despite the fact that they have been shown to be essential for other health behaviors and for adherence to medical advice. Moreover, the current body of knowledge is compromised by the inconsistent conceptualization of SSE. The main objective of the current project is to examine psychosocial predictors of skin self-examination using on a rigorous and clinically sound methodology.

METHODS/DESIGN

The longitudinal, mixed-method study examines key psychosocial variables related to the acquisition and to the long-term maintenance of skin self-examination in 200 patients with melanoma. Practice of self-exam behaviors is assessed at 3 and 12 months after receiving an educational intervention designed based on best-practice standards. Examined predictors of skin self-exam behaviors include biological sex, perceived self-exam efficacy, distress, partner and physician support, and coping strategies. Qualitative analyses of semi-structured interviews will complement and enlighten the quantitative findings.

DISCUSSION

The identification of short and long-term predictors of skin self-examination and an increased understanding of barriers will allow health care professionals to better address patient difficulties in adhering to this life-saving health behavior. Furthermore, the findings will enable the development and evaluation of evidence-based, comprehensive intervention strategies. Ultimately, these findings could impact a wide range of outreach programs and secondary prevention initiatives for other populations with increased melanoma risk.

Multiple primary melanomas: do they look the same?

BACKGROUND

A series of studies has investigated epidemiological, clinical and genetic characteristics of patients with multiple primary melanoma (MPM). However, comparison of the clinical and dermoscopic features of MPM within a given individual has been described only in case reports.

OBJECTIVES

To describe the dermoscopic features of MPM for each given patient, and to evaluate the characteristics eventually associated with similar or dissimilar appearance.

METHODS

From the databases of three skin-lesion clinics in the U.S.A., Italy and Spain we collected the dermoscopic images of melanomas in patients diagnosed with MPM.

RESULTS

Among 58 patients with MPM, we found that 53% of patients had dermoscopically similar melanomas and 47% of patients had dermoscopically different melanomas. In older patients 59% of melanomas were dermoscopically similar vs. 47% in younger patients (P=0·377). Similar thickness was associated with the occurrence of dermoscopically similar melanomas (19/30 cases, 63%; P=0·039). Most (65%) of the synchronous lesions were similar, compared with 36% of nonsynchronous lesions (P=0·029), and most (69%) of the melanomas on sun-damaged skin were similar, vs. 37% of melanomas on nonsun-damaged skin (P=0·015; odds ratio 3·88, 95% confidence interval 1·11-13·98). The percentage of dermoscopically different melanomas was higher in patients with a family history of melanoma (67% vs. 48%).

CONCLUSIONS

MPMs in a given patient have almost the same chance of looking dermoscopically similar or different. However, a subset of elderly patients with sun-damaged skin may present multiple, similar, thin melanomas characterized by pigment-network and regression structures.

Single versus multiple primary melanomas: old questions and new answers

BACKGROUND

In patients with multiple primary melanomas (MPM), mean tumor thickness tends to decrease from the first melanoma to the second melanoma, and prognosis may be improved compared with the prognosis for patients who have a single primary melanoma (SPM). In this study, the authors compared the clinicopathologic features of patients with MPM and SPM to better characterize the differences between these 2 groups and to determine whether or not there is an inherent difference in tumor aggression.

METHODS

In total, 788 patients with melanoma who were enrolled prospectively in the Interdisciplinary Melanoma Cooperative Group database from 2002 to 2008 were studied. Patients with SPM and with MPM were compared with regard to clinical and primary melanoma characteristics.

RESULTS

Of 788 patients with melanoma, 61 patients (7.7%) had 2 or more primary melanomas. The incidence of developing a second primary melanoma 1 year and 5 years after initial melanoma diagnosis was 4.1% and 8.7%, respectively, and most of the risk accumulated within the first year. The incidence of MPM was greater in patients aged ≥60 years than in those aged ≤60 years. The absence or presence of mitosis and other tumor characteristics did not differ significantly between patients with SPM and patients with MPM (P = .61).

CONCLUSIONS

No difference was observed in the presence or absence of mitoses, a marker of tumor proliferation, in SPM and MPM. Because it has been demonstrated that the presence of mitosis is a powerful prognostic marker, the current findings suggested that the tumors behave similarly in patients with SPM and patients with MPM. The authors concluded that differences in tumor thickness and prognosis between SPM and MPM more likely are caused by factors other than tumor biology, such as increased surveillance.

Low back pain as the presenting sign in a patient with primary extradural melanoma of the thoracic spine--a metastatic disease 17 years after complete surgical resection

Primary spinal melanomas are extremely rare lesions. In 1906, Hirschberg reported the first primary spinal melanoma, and since then only 40 new cases have been reported. A 47-year-old man was admitted suffering from low back pain, fatigue and loss of body weight persisting for three months. He had a 17-year-old history of an operated primary spinal melanoma from T7-T9, which had remained stable for these 17 years. Routine laboratory findings and clinical symptoms aroused suspicion of a metastatic disease. Multislice computed tomography and magnetic resonance imaging revealed stage-IV melanoma with thoracic, abdominal and skeletal metastases without the recurrence of the primary process. Transiliac crest core bone biopsy confirmed the diagnosis of metastatic melanoma. It is important to know that in all cases of back ore skeletal pain and unexplained weight loss, malignancy must always be considered in the differential diagnosis, especially in the subjects with a positive medical history. Patients who have back, skeletal, or joint pain that is unresponsive to a few weeks of conservative treatment or have known risk factors with or without serious etiology, are candidates for imaging studies. The present case demonstrates that complete surgical resection alone may result in a favourable outcome, but regular medical follow-up for an extended period, with the purpose of an early detection of a metastatic disease, is highly recommended.

Clinicopathologic features of incident and subsequent tumors in patients with multiple primary cutaneous melanomas

BACKGROUND

0.6-12.7% of patients with primary cutaneous melanoma will develop additional melanomas. Pathologic features of tumors in patients with multiple primary cutaneous melanomas have not been well described. In this large, international, multicenter, case-control study, we compared the clinicopathologic features of a subsequent melanoma with the preceding (usually the first) melanoma in patients with multiple primary cutaneous melanomas, and with those of melanomas in patients with single primary cutaneous melanomas.

METHODS

Multiple primary melanoma (cases) and single primary invasive melanoma (controls) patients from the Genes, Environment and Melanoma (GEM) study were included if their tumors were available for pathologic review and confirmed as melanoma. Clinicopathologic characteristics of invasive subsequent and first melanomas in cases and invasive single melanomas in controls were compared.

RESULTS

A total of 473 pairs comprising a subsequent and a first melanoma and 1,989 single melanomas were reviewed. Forward stepwise regression modeling in 395 pairs with complete data showed that, compared with first melanomas, subsequent melanomas were more commonly contiguous with a dysplastic nevus, more prevalent on the head/neck and legs than other sites, and thinner. Compared with single primary melanomas, subsequent melanomas were more likely to be associated with a contiguous dysplastic nevus, more prevalent on the head/neck and legs, and thinner. The same differences were observed when subsequent melanomas were compared with single melanomas. First melanomas were more likely than single melanomas to have associated solar elastosis and no observed mitoses.

CONCLUSIONS

Thinner subsequent than first melanomas suggest earlier diagnosis, perhaps due to closer clinical scrutiny. The association of subsequent melanomas with dysplastic nevi is consistent with the latter being risk factors or risk markers for melanoma.

Hazard rates for recurrent and secondary cutaneous melanoma: an analysis of 33,384 patients in the German Central Malignant Melanoma Registry

BACKGROUND

Knowledge about the risk for recurrence and secondary cutaneous melanoma (CM) is an important basis for patient counseling and planning of follow-up examinations.

OBJECTIVES

This study aimed to analyze stage- and time-dependent hazard rates (HR) and discusses current surveillance recommendations.

METHODS

Follow-up data of 33,384 patients with incident CM in stages I to III (American Joint Committee on Cancer 2002) were recorded by the German Central Malignant Melanoma Registry in 1976 through 2007. Survival was based on Kaplan-Meier estimates and HRs were calculated.

RESULTS

Recurrences were recorded in 4999 patients (stage I, 7.1%; stage II, 32.8%; and stage III, 51.0%). Ten-year recurrence-free survival was 78.9% (95% confidence interval 73.1-90.5); in stage I, 89.0%; stage II, 56.9%; and stage III, 36.0%. Whereas HR for recurrent CM showed a constantly low level less than or equal to 1:125 per year for stage IA, clearly higher HRs of greater than or equal to 1:40 were recorded in stage IB for the first 3 years and generally in stages II to III. Of all patients 2.3% developed secondary melanomas, with a consistently low HR of less than 1:220 per year.

LIMITATIONS

As German recommendations discontinued regular follow-up examinations after 10 years, no information can be given beyond this time point. Follow-up data of longer than 5 years were available in 41.4% of patients.

CONCLUSION

For patients at stage IA with thin melanoma and low HR for recurrent CM the need for surveillance remains questionable. For patients with higher HR greater than 1:40 per year, intensified surveillance strategies should be taken into account.

Use of technology for educating melanoma patients

We evaluated the feasibility of using technology for melanoma patient education in a clinic setting. We assessed technology skill level and preferences for education. Data were collected using an adapted version of the Use of Technology Survey. Most participants owned a computer and DVD player and were skilled in the use of these devices, along with Internet and e-mail. Participants preferred the option of using in-clinic and at-home technology versus in-clinic only use. Computer and DVD applications were preferred because they were familiar and convenient. Using technology for patient education intervention is a viable option; however, patients' skill level and preferences for technology should be considered.

Interest in a psycho-educational group intervention among out-patients with malignant melanoma in relation to their need: which patients are likely to participate?

The aim of this study was to examine the interest which patients with malignant melanoma may have in a six week psycho-educational group intervention and determine factors that are associated with their degree of interest. Of 144 outpatients, 121 (84%) agreed to participate in the interview (78 women, 66 men, mean age 59, SD=15; mean time since surgery=57 months, SD=55). About one-third (29%) of the sample had either nodal or in-transit metastases. A semi-structured interview was conducted to assess patients' interest (perceived need) in the intervention. We administered the Hornheide questionnaire and other psychosocial measures to identify highly distressed patients (expert-defined need). Lower age, being male, having no partner and lower cognitive avoidance emerged as significant predictors for a general interest in the intervention (n=92). A substantial number of patients (42.5%) stated a willingness to participate in the intervention at that time. Two problematic subgroups could be identified in the sample: patients in an expert-defined need of support who lacked any interest ('avoiders') and interested patients without an expert-defined need ('skilled help-seekers'). In order to achieve consistent results when conducting future interventions, the interventions should either be limited to patients with expert-defined need or patients should be carefully controlled for this variable.

Sun protection and skin self-examination in melanoma survivors

OBJECTIVES

Patients diagnosed with melanoma are at risk for developing recurrent and second primary disease. Skin self-examination (SSE) and sun protection are standard clinical recommendations to minimize risk. In this study we examined performance of these behaviors in individuals with melanoma drawn from the general population.

METHODS

Potential participants (N=148) with a first primary melanoma diagnosed in 2000 were identified through a population-based cancer registry in New Jersey, USA. One hundred and fifteen individuals participated in a 30 min telephone interview concerning behavioral adherence with SSE and sun protection, self-efficacy for performing these behaviors, and perceived risk of developing another skin cancer. We utilized logistic regression to estimate potential associations of demographic, medical, and psychosocial factors with SSE and sun protection, respectively.

RESULTS

Seventeen percent of subjects reported performing comprehensive SSE at least once every two months and 23% engaged in regular sun protection. Utilization of SSE was related to the presence of moles (OR=4.2, 95% CI: 1.1-15) and higher SSE self-efficacy (OR=14.4, 95% CI: 1.9-112). Regular sun protection was related to older age (>60 years; OR=3.3, 95% CI: 1.3-8.7), being female (OR=2.8, 95% CI: 1.1-7.3), and higher sun protection self-efficacy (OR=5.0, 95% CI: 1.4-18). These factors remained significant in multivariate models.

CONCLUSION

In this group of primary melanoma survivors, the rates of SSE and sun protection are comparable to, but do not exceed, general population estimates. This study provides justification for further research to address barriers to prevention and control behaviors in melanoma survivors.

The value of screening in melanoma

The incidence of cutaneous melanoma has increased substantially in most white populations during the past several decades. Despite improvements in the early recognition of melanoma and the use of novel diagnostic techniques that enhance our diagnostic capabilities, disease-related mortality remains a significant public health issue. In the absence of effective treatment approaches for advanced disease, the best means for reducing deaths by melanoma are screening as well as professional and public education. The role of population-or community-based screening remains controversial, but evidence from self-selected screening campaigns, health care professional surveillance, and specialized pigmented lesions clinics underscores the value of screening and early detection programs, particularly in high-risk groups. Annual screening campaigns coupled with intense media promotion have become commonplace in many countries, and despite their low yield of melanoma detection, the dissemination of educational material and information to the public during these events is important in increasing public awareness. Future directions should include using screening campaigns to target middle-aged and older men and persons of lower socioeconomic status, who suffer most from the burden of the disease and its associated mortality. On a worldwide scale, comprehensive educational and screening campaigns should be implemented or intensified in underserved areas and geographic regions with lower survival rates, such as Eastern European countries. A better understanding of the biology of the disease, already occurring with notable strides, will help us to define better those individuals who will benefit most from screening and early detection efforts. Technologic advances and new diagnostic modalities will afford a more reliable and vigilant surveillance of high-risk individuals, whereas the wide use of the Internet will enhance the distribution of relevant information to the public with the ultimate goal of achieving a better control of melanoma.

Detection of second primary cutaneous melanomas

AIMS

There have been few studies investigating the value of follow-up in the detection of second primary melanomas (SPMs) and there is scant information on the role of self-surveillance by the patient. The aim of this study was to assess the frequency of patient detection of both first primary melanomas (FPMs) and SPMs.

PATIENTS AND METHODS

Patients were interviewed to determine who detected their FPM and SPM (in situ or invasive). The associations between clinical and pathological factors and the person who identified the FPM and SPM were examined using multivariate analysis.

RESULTS

One hundred and twelve patients with a recently diagnosed SPM were treated at the Sydney Melanoma Unit (July 2001 to March 2003). Patients detected 59% of the FPMs as compared with 46% of the SPMs. Female gender, greater Breslow tumour thickness and younger age were significant predictors for a patient-detected FPM (Odds Ratio: 4.9 (Confidence Interval 1.5-16.0), 3.2 (1.65-6.04), and 0.9 (0.9-1.0), respectively). Greater tumour thickness and ready visibility of the lesion to the patient were predicting factors for patient detection of a SPM (Odds Ratio: 1.9 (Confidence Interval 1.1-3.3) and 3.6 (1.4-9.1), respectively).

CONCLUSIONS

A history of melanoma does not increase the ability of patients to detect new or thinner primary melanomas themselves. Therefore, patients may benefit from regular clinical review by clinicians, who play an important role in the detection of new melanomas.

Screening, early detection, and trends for melanoma: Current status (2000-2006) and future directions

In the past 5 years, there have been notable strides toward the earlier recognition and discovery of melanoma, including new technologies to complement and augment the clinical examination and new insights to help clinicians recognize early melanoma. However, incidence and mortality rates throughout most of the developed world have risen over the past 25 years, while education and screening, potentially the best means for reducing the disease, continue to be severely underutilized. Much progress needs to be made to reach middle-aged and older men and persons of lower socioeconomic status who suffer a disproportionate burden of death from melanoma. Worldwide melanoma control must also be a priority, and comprehensive educational and screening programs should be directed to Northern Ireland and a number of Eastern European nations, whose 5-year survival rates range between 53% and 60%, mirroring those of the United States and Australia more than 40 years ago.

LEARNING OBJECTIVE

After completing this learning activity, participants should be aware of the most recent melanoma epidemiologic data, both in the United States and internationally; worldwide early detection and screening programs; clinical strategies to recognize and improve the detection of early melanoma; the latest technologies for early detection of melanoma; and public and professional education programs designed to enhance early detection.

Patient education and regular surveillance results in earlier diagnosis of second primary melanoma

BACKGROUND

As the incidence of cutaneous melanoma continues to rise, more individuals will be at risk for developing second primary melanomas. We hypothesize that patient education and follow-up surveillance will lead to the early detection of subsequent primary melanomas as demonstrated by a decrease in Breslow thickness at diagnosis.

METHODS

A computer-based investigation was performed to identify patients who had developed a second primary melanoma following treatment of in situ and American Joint Commission on Cancer (AJCC) Stage I or II melanoma. Patients are routinely educated on the increased risk of developing a second primary lesion and characteristic clinical features of melanoma. Patient surveillance was performed on a regular basis. Differences in Breslow thickness between the initial and subsequent primary melanomas were analyzed by a paired t-test.

RESULTS

Among 877 individuals identified in the Mount Sinai School of Medicine Department of Dermatopathology database with in situ or AJCC Stage I or II melanoma, 111 developed a second primary melanoma. The mean thickness was 0.239 +/- 0.661 mm for the initial melanoma and 0.1135 +/- 0.319 mm for the subsequent melanoma. By paired t-test, the difference in tumor thickness was statistically significant (P = 0.019).

CONCLUSIONS

Upon analysis of our data, subsequent primary cutaneous melanomas were found to be significantly thinner than initial primary melanomas at the time of diagnosis. This suggests that earlier diagnosis may be the result of patient education and careful follow up. Counselling on the risk of developing a second primary melanoma, education regarding clinical characteristics of melanoma, and routine lifelong follow up should be provided to all patients diagnosed with a cutaneous melanoma.

Malignant melanoma in the 21st century, part 1: epidemiology, risk factors, screening, prevention, and diagnosis

Malignant melanoma is an aggressive, therapy-resistant malignancy of melanocytes. The incidence of melanoma has been steadily increasing worldwide, resulting in an increasing public health problem. Exposure to solar UV radiation, fair skin, dysplastic nevi syndrome, and a family history of melanoma are major risk factors for melanoma development. The interactions between genetic and environmental risk factors that promote melanomagenesis are currently the subject of ongoing research. Avoidance of UV radiation and surveillance of high-risk patients have the potential to reduce the population burden of melanoma. Biopsies of the primary tumor and sampling of draining lymph nodes are required for optimal diagnosis and staging. Several clinically relevant pathologic subtypes have been identified and need to be recognized. Therapy for early disease is predominantly surgical, with a minor benefit noted with the use of adjuvant therapy. Management of systemic melanoma is a challenge because of a paucity of active treatment modalities. In the first part of this 2-part review, we discuss epidemiology, risk factors, screening, prevention, and diagnosis of malignant melanoma. Part 2 (which will appear in the April 2007 issue) will review melanoma staging, prognosis, and treatment.

Earlier Detection of Patients' Second Primary Basal Cell Carcinomas: A Quantitative Analysis

BACKGROUND

Basal cell carcinoma (BCC) is the most common occurring cancer in humans. No studies to date have compared the size of a patient's first and second primary BCC to determine whether we are detecting and treating second primary cancers at earlier stages of development.

OBJECTIVE

The objective was to ascertain whether patients who have had a primary BCC are diagnosed and treated for subsequent BCC at an earlier clinical stage of development.

METHODS AND MATERIALS

We performed a 4-year retrospective chart review of all patients presenting for Mohs micrographic surgery for two separate primary BCC. We compared the presenting clinical size of patients' first and second primary BCC.

RESULTS

We found a statistically significant decrease in size of the second primary BCC when compared to the first primary BCC (p<.0001). The mean difference was 116.6 mm2 and the median difference was 28.3 mm2.

CONCLUSION

Our results provide important quantitative data illustrating our effectiveness in detecting subsequent BCC at an earlier stage of development. Earlier detection of skin cancers can decrease the morbidity and chance of recurrence as well as lead to smaller scars and better cosmetic outcomes and may also allow for various treatment modalities and cost containment.

Breslow depth of cutaneous melanoma: impact of factors related to surveillance of the skin, including prior skin biopsies and family history of melanoma

BACKGROUND

Because the early detection of cutaneous melanoma can dramatically improve survival, identification and surveillance of persons at risk have received much attention.

OBJECTIVE

Our purpose was to examine the influences of personal or family history, patterns of detection, and prior skin biopsies (considered to be a measurement of surveillance by medical personnel) on the Breslow depth of cutaneous melanomas.

METHODS

A retrospective cohort analysis of 218 patients with a history of at least one invasive cutaneous melanoma who visited the Yale Pigmented Lesion Clinic between January 1995 and January 1996 was performed. Data on patterns of detection, melanocytic nevi, and skin biopsies before and after the initial diagnosis of melanoma were collected, and patients with a family history of melanoma were compared with sporadic patients.

RESULTS

Initial melanomas discovered by dermatologists were more likely to be 0.75 mm or less in depth than those found by other physicians (P = .03). Although patients detected 45% of the initial primary melanomas (98/218), dermatologists discovered 80% of the second primary tumors (33/41; P = .001). A personal history of melanoma was predictive of a thinner Breslow depth (P = .01), but a family history of melanoma was not. Having a biopsy of any type or combination of types of skin lesion(s) performed in the 5 years, 2 years, or 1 year before the first diagnosis of melanoma did not predict a melanoma of thinner Breslow depth among either familial or sporadic patients. The mean number of skin biopsies performed per patient was 8 times higher in the 5-year period after (5.6) versus the 5-year period before (0.7) the initial diagnosis of melanoma, with a peak in the first year after the diagnosis (2.3 vs 0.25 in the prior year). In 27 patients, one or more skin biopsies were performed in the year before the initial diagnosis of melanoma; 41% of these biopsies (23/56) were of lesions in normally exposed sites (eg, the face, neck, and forearms) compared with 22% of the melanomas (6/27).

LIMITATIONS

Since an invasive melanoma (with the possible exception of a nodular melanoma) would likely have been present for at least a year, plausible explanations for why evidence of previous dermatologic care did not appear to result in earlier detection include performance of a limited rather than a total body skin examination as well as subtle clinical features of early melanomas. However, this study cannot give weight to these explanations because at the time new Pigmented Lesion Clinic patients were not routinely asked about previous total body skin examinations.

CONCLUSIONS

The disappointing trends seen in this study, with neither the well-established risk factor of a family history of melanoma nor previously having a skin biopsy predicting thinner melanomas, highlight the need to establish criteria defining the subset of patients for whom appropriate management requires periodic total body skin examination.

Screening for Cutaneous Melanoma

Current data do not support widespread population-based screening for melanoma. While the incidence of melanoma is high, the overall mortality is low, and thus any potential benefit of screening the general population is hard to demonstrate. No randomized controlled trial showing reduction in mortality has ever been completed and, given the expense and time necessary for such a trial, probably will never be completed. The idea of skin screening remains appealing for this common, visible malignancy which is eminently treatable when detected early. Efforts should be focused on populations at particularly high risk of developing melanoma and on those at high risk of death from melanoma once diagnosed. Persons in kindreds of familial melanoma, and persons who have atypical mole syndrome, those who have a prior diagnosis of melanoma, or those who have diagnosed atypical nevi are all reasonable candidates for routine screening, based on lower-level evidence in the absence of randomized clinical trials targeting these groups. Programs targeting persons of low socioeconomic status and targeting white men over the age of 50 could address groups known to beat especially high risk of melanoma mortality.