The value of screening in melanoma

Thick melanoma in Tuscany

BACKGROUND

The epidemiologic trends of cutaneous melanoma are similar in several countries with a Western-type lifestyle, where there is a progressively increasing incidence and a low but not decreasing mortality - even increasing in selected cases, especially in the older age groups. Also in Tuscany there is a steady rise in the incidence with prevalence of in situ and invasive thin melanomas, with also an increase of thick melanomas. It is necessary to reduce the frequency of thick melanomas to reduce specific mortality. The objective of the current survey has been to compare, in the Tuscany population, by a case-case study, thin and thick melanoma cases, trying to find out those personal and tumor characteristics which may help to customize preventive interventions.

METHODS

The study included nine centers involved in the melanoma diagnosis. A consecutive series of incident invasive melanomas diagnosed in a period of about 18 months (July 2010 to December 2011) was collected and matched according in a ratio of one thick melanoma (cutoff thickness: 1 mm) every two thin melanomas. The investigators filled in a questionnaire on patients' self-reported sun exposure, way of melanoma detection, awareness and performance of self-skin examination, as well as propensity to prevention in general.

RESULTS

The results of this survey confirm that older age and the lower education level are associated with a later detection. The habit of performing skin self-examination is crucial in the early diagnosis of thick melanoma. The results of this survey seem to suggest that population aged over 50 years, with few total and few atypical nevi, and limited sun exposure and burning are at higher risk of late diagnosis. It can be assumed that part of the population is not effectively reached by prevention campaigns because they do not recognize themselves as being at risk for skin cancers.

CONCLUSIONS

In order to achieve a higher rate of early diagnosis of skin melanoma, a new strategy must be implemented. It could be useful to rethink educational campaigns - which seem to unintentionally leave out subjects more at risk for melanoma - and to renew the active involvement of the general practitioners.

Exploring Differential Connexin Expression across Melanocytic Tumor Progression Involving the Tumor Microenvironment

The incidence of malignant melanoma, one of the deadliest cancers, continues to increase. Here we tested connexin (Cx) expression in primary melanocytes, melanoma cell lines and in a common nevus, dysplastic nevus, and thin, thick, and metastatic melanoma tumor progression series involving the tumor microenvironment by utilizing in silico analysis, qRT-PCR, immunocyto-/histochemistry and dye transfer tests. Primary melanocytes expressed GJA1/Cx43, GJA3/Cx46 and low levels of GJB2/Cx26 and GJC3/Cx30.2 transcripts. In silico data revealed downregulation of GJA1/Cx43 and GJB2/Cx26 mRNA, in addition to upregulated GJB1/Cx32, during melanoma progression. In three melanoma cell lines, we also showed the loss of GJA1/Cx43 and the differential expression of GJB1/Cx32, GJB2/Cx26, GJA3/Cx46 and GJC3/Cx30.2. The dominantly paranuclear localization of connexin proteins explained the ~10–90 times less melanoma cell coupling compared to melanocytes. In melanocytic tumor tissues, we confirmed the loss of Cx43 protein, fall of cell membrane and elevated paranuclear Cx32 with moderately increased cytoplasmic Cx26 and paranuclear Cx30.2 positivity during tumor progression. Furthermore, we found Cx43, Cx26 and Cx30 proteins upregulated in the melanoma adjacent epidermis, and Cx43 in the tumor flanking vessels. Therefore, differential connexin expression is involved in melanocytic tumor progression where varying connexin isotypes and levels reflect tumor heterogeneity-related bidirectional adaptive interactions with the microenvironment.

A Multicenter Survey: How Do Transplant Dermatologists Monitor Organ Transplant Recipients With Nevi?

OBJECTIVES

The incidence and mortality of melanoma are increased in organ transplant recipients. Multiple acquired common and dysplastic nevi are risk factors for melanoma. A new or changing nevus may suggest melanoma. Strategies used by transplant dermatologists to monitor nevi are unknown. Herein, we aimed to assess the methods used by transplant dermatologists for monitoring multiple acquired common nevi, dysplastic nevi, and new or changing nevi.

MATERIALS AND METHODS

A questionnaire was e-mailed to 63 members of the Skin Care in Organ Transplant Patients, Europe.

RESULTS

Thirty-eight (92.7%) of 41 responders reported that they instruct their patients to perform regular self-skin examinations. Of 41 responders, 41.5% prescribed screening every 6 months, 36.6% prescribed it every 12 months, 12.2% prescribed it every 3 months, and 9.7% performed screening without regular intervals. Regarding type of examination, 80.5% performed full-body skin examinations with the naked eye, 70.7% performed dermoscopy of clinically suspicious nevi, 53.6% offered dermoscopic photography of dermoscopically suspicious nevi, 36.6% provided close-up photography of clinically suspicious nevi, 34.1% performed baseline total body photography, and 24.4% conducted dermoscopy of all nevi. We also found that 7.3%, 4.9%, and 4.9% performed only full-body skin examination with the naked eye, only dermoscopy of clinically suspicious nevi, and only dermoscopy of all nevi, respectively.

CONCLUSIONS

Dedicated transplant dermatologists perform a wide variety of nevi screening procedures in organ transplant recipients. Transplant dermatologists should include sequential digital dermoscopic imaging in their armamentarium to follow organ transplant recipients with melanocytic lesions. A combination of techniques is advisable for detecting early posttransplant melanomas.

Evaluation of a Skin Self-Examination Programme: a Four-Stage Recursive Model

Background: Effective skin self-examination can enable early diagnosis and treatment of skin cancer, which otherwise could result in significant morbidity and mortality. We compare the effects of watching a DVD and reading printed materials on self skin examination. Methods: Longitudinal data from the Randomized Skin Awareness Trial were analysed (n=984). The control group were provided with written materials describing how to conduct effective skin self-examination. The intervention group received additional instruction from a DVD. It was hypothesized that self skin examination may be confounded by unobserved variables. A recursive model was specified to control for this potential source of bias. Results: At six months only watching the DVD had a statistically significant effect on diagnosed skin cancer. By 12 months both interventions were statistically significant; reading the printed materials was 63% as effective as watching the DVD. Conclusion: Watching a DVD was associated with the largest increase in diagnosed skin cancer. However, reading written materials was also associated with an increase in diagnosed skin cancer. Both visual and written communication should be considered when designing an effective skin self-examination programme.

Cost-Effectiveness Analysis of a Skin Awareness Intervention for Early Detection of Skin Cancer Targeting Men Older Than 50 Years

OBJECTIVES

To assess the cost-effectiveness of an educational intervention encouraging self-skin examinations for early detection of skin cancers among men older than 50 years.

METHODS

A lifetime Markov model was constructed to combine data from the Skin Awareness Trial and other published sources. The model incorporated a health system perspective and the cost and health outcomes for melanoma, squamous and basal cell carcinomas, and benign skin lesions. Key model outcomes included Australian costs (2015), quality-adjusted life-years (QALYs), life-years, and counts of skin cancers. Univariate and probabilistic sensitivity analyses were undertaken to address parameter uncertainty.

RESULTS

The mean cost of the intervention was A$5,298 compared with A$4,684 for usual care, whereas mean QALYs were 7.58 for the intervention group and 7.77 for the usual care group. The intervention was thus inferior to usual care. When only survival gain is considered, the model predicted the intervention would cost A$1,059 per life-year saved. The likelihood that the intervention was cost-effective up to A$50,000 per QALY gained was 43.9%. The model was stable to most data estimates; nevertheless, it relies on the specificity of clinical diagnosis of skin cancers and is subject to limited health utility data for people with skin lesions.

CONCLUSIONS

Although the intervention improved skin checking behaviors and encouraged men to seek medical advice about suspicious lesions, the overall costs and effects from also detecting more squamous and basal cell carcinomas and benign lesions outweighed the positive health gains from detecting more thin melanomas.

Melanoma awareness and prevalence of dermoscopic examination among internet users: a cross-sectional survey

Introduction

Melanoma presents the greater threat to health the later the disease is detected and treated, although treatment results can be improved by the widespread use of dermoscopy. However, scarce data are available concerning the awareness of dermoscopy and the frequency of its performance in the non-patient population.

Aim

To assess the awareness of melanoma detection by dermoscopic examination among the audience of a scientific website.

Material and methods

Respondents were invited to participate in an online cross-sectional survey. They were asked to complete an online questionnaire designed by the authors. The preliminary analysis of 5,154 collected forms and the exclusion of incomplete forms yielded 4,919 fully completed questionnaires; the resulting database was analyzed statistically using logistic regression with the R software program (95% CI).

Results

Less than two-fifths (39.2%) of respondents reported ever having sought the advice of a medical professional (dermatologist or other specialist), and 25.4% of the respondents had undergone dermoscopy at least once in their life. Furthermore, approximately one-tenth of respondents (10.7%) were not aware of this detection tool. The study respondents gained knowledge about dermoscopic examination from television and magazines. The performance of dermoscopy was more increasingly associated with inhabitants of larger locales, the use of higher-SPF sunscreens, and greater awareness of the relationship between the risk of melanoma and sunburn.

Conclusions

Awareness of melanoma and sun care varied within the analyzed population. A subset of individuals at high risk of melanoma was identified. This group included those who engaged in risky sun exposure behaviors and who had never been examined by dermoscopy.

How Patient Involvement Can Contribute to the Development of Information Materials About Malignant Melanoma for Healthy Older Men

The incidence for malignant melanoma (MM) in older men is 3 to 4 times higher than the rest of the population. Patient information about MM could be a way to reach men. The aim of the study was to design and develop a pamphlet in collaboration with older men. The study was conducted in two steps. In the first step, 73 men were interviewed; in the second step, the pamphlets were sent out to 306 men. All men were recruited in connection with an aorta screening. Men wanted concisely written information with illustrations and 85% of the men reported that they have read the pamphlet. The study demonstrates a cost-effective method to reach out with information to older men about MM.

Awareness, Attitude, and Adherence to Preventive Measures in Patients at High Risk of Melanoma. A Cross-Sectional Study on 185 Patients

Melanoma is potentially curable if diagnosed at its earliest stages and treated properly. The best approaches for reducing deaths due to melanoma are primary and secondary prevention. The objective of this study is to evaluate patient awareness of the risk factors for developing melanoma and attitudes toward its prevention. Also, this study aims to assess observance of recommended preventive measures and to identify possible factors associated with a low adoption of these measures. This cross-sectional study based on an online questionnaire included 185 consecutively enrolled subjects at risk of developing melanoma monitored in a pigmented lesion unit in Valencia (Spain). Level of knowledge, attitude, and observance of preventive measures were evaluated. Statistical analysis was carried out using contingency tables, chi-squared test, and Spearman correlation. Out of those who reported practicing skin self-examination, only 24.1 % performed it in the optimal way. A better attitude was observed in low-risk patients (r = -0.28, p < 0.01). Being female (p < 0.01), aged 18-35 (p = 0.02), fair-haired (p = 0.02), having skin phototype I-II (p < 0.01), and a suitable attitude (p = 0.05) and knowledge (p < 0.01) were related to a better use of sunscreens and avoidance of sun exposure. Knowledge was inversely associated with age (p = 0.01). Despite the high level of knowledge and positive attitude, inadequate practice of compliance with recommended primary and secondary preventive measures was observed in our risk population.

Melanoma: A new strategy to reduce morbidity and mortality

BACKGROUND

Public awareness campaigns could address risk factors for melanoma to reinforce their sun protection message. The objective of this study is to prioritise risk factors associated with malignant melanoma (MM) to improve public awareness.

METHOD

DESIGN

A cross-sectional study with retrospective data analysis from 2004 to 2010.

SETTING

Western Australian Melanoma Advisory Service (WAMAS), a tertiary referral multidisciplinary organisation providing MM management advice. WAMAS data files were analysed with histologically confirmed cutaneous MM. Forty- seven patients had two or more melanomas, but the patient file was counted only once. Six MM data files with missing or incomplete information were excluded.

MAIN OUTCOME MEASURES

The number of naevi, blood relatives with MM, and previous sunburns were the primary variables collected.

RESULTS

The results showed that 70.9 per cent (268/378) had previous sunburn; 40.2 per cent (152/378) had multiple naevi; and 22.5 per cent (85/378) had a positive family history. In the 110 MM data files not associated with sunburn, multiple naevi and a positive family history represented 34.5 per cent (38/110) and 20.0 per cent (22/110), respectively.

CONCLUSION

The results confirm the findings of previous studies that multiple naevi and a positive family history are important risk factors associated with MM. We suggest that MM can be detected earlier and its mortality decreased by focusing on these high-risk groups who are not targeted by current public awareness campaigns.

Demographic, behavioural and physician-related determinants of early melanoma detection in a low-incidence population

BACKGROUND

Knowledge of the factors that influence early detection of melanoma is important in developing strategies to reduce associated mortality.

OBJECTIVES

To identify sociodemographic, behavioural and medical care-related factors associated with melanoma thickness in a low-incidence population but with a high case fatality.

PATIENTS AND METHODS

In a multicentre, retrospective, survey-based study of 202 patients with a recent diagnosis of invasive melanoma (< 1 year), we collected data on demographic and behavioural factors, attitudes towards prevention, access to medical care, frequency of skin self-examination (SSE) and physician skin examination (PSE) in relation to melanoma thickness.

RESULTS

Thinner tumours (≤ 1 mm, 80 melanomas) were associated with female sex (P ≤ 0.049), nonnodular (superficial spreading melanoma, lentigo maligna melanoma, acral lentiginous melanoma) histological subtypes (P < 0.001), absence of ulceration (P ≤ 0.001), and location other than lower extremity or trunk location (P ≤ 0.004). Patients married at the time of diagnosis or who performed SSE during the year prior to diagnosis were more likely to have thinner tumours than those who did not [odds ratio (OR) 3.45, 95% confidence interval (CI) 1.48-8.04 and OR 2.43, 95% CI 1.10-5.34, respectively]. Full-body skin examination by a physician was not significantly associated with thinner melanoma (OR 1.99, 95% CI 0.66-6.07).

CONCLUSIONS

SSE was shown to be an important factor in the detection of thin melanoma, in contrast to partial or full-body PSE, which did not show any statistically significant effect on tumour thickness.

Role of obesity on the thickness of primary cutaneous melanoma

BACKGROUND

Thick primary cutaneous melanoma (PCM) is associated with older age, male sex, being single, a low educational level, self-detection and general practice detection, nodular melanoma (NM) and acral lentiginous melanoma (ALM) types; and are found in the head-neck and lower limb locations. Obesity plays a direct role on melanoma tumour growth, as it has been shown in animal models, but its role in the thickness of PCM remains unknown.

OBJECTIVES

We investigated the impact of obesity on the thickness of invasive PCM.

METHODS

A cross-sectional study was performed in a prospective cohort for which we collected several clinical and histological data already known to be associated with thick PCM and the Body Mass Index from new cases of invasive PCM which were referred to the dermatology department in Valence.

RESULTS

Four hundred and twenty-seven patients were studied. In an univariate analysis, thick PCM was associated with low educational level, obesity, identification by the patient or the general practitioner (GP), location on the cephalic extremity, in a non-visible area of the body, the NM and ALM type, and an ulceration. In a multivariate analysis, NM, ulceration, topography of the melanoma and identification of the melanoma by the patient or GP were significantly associated with thick melanoma. When including only clinical features in the model, low educational level, mode of melanoma identification and obesity were significantly associated with a risk of thick melanoma.

CONCLUSIONS

Obesity is a clinical independent risk factor of thick PCM. For health policies, governments should pay greater attention to detect melanoma in obese patients. Our results encourage the basic research on tumoural growth mechanisms due to obesity in melanoma.

Cell cycle analysis can differentiate thin melanomas from dysplastic nevi and reveals accelerated replication in thick melanomas

Cell replication integrates aberrations of cell cycle regulation and diverse upstream pathways which all can contribute to melanoma development and progression. In this study, cell cycle regulatory proteins were detected in situ in benign and malignant melanocytic tumors to allow correlation of major cell cycle fractions (G1, S-G2, and G2-M) with melanoma evolution. Dysplastic nevi expressed early cell cycle markers (cyclin D1 and cyclin-dependent kinase 2; Cdk2) significantly more (p < 0.05) than common nevi. Post-G1 phase markers such as cyclin A, geminin, topoisomerase IIα (peaking at S-G2) and aurora kinase B (peaking at G2-M) were expressed in thin (≤1 mm) melanomas but not in dysplastic nevi, suggesting that dysplastic melanocytes engaged in the cell cycle do not complete replication and remain arrested in G1 phase. In malignant melanomas, the expression of general and post-G1 phase markers correlated well with each other implying negligible cell cycle arrest. Post-G1 phase markers and Ki67 but none of the early markers cyclin D1, Cdk2 or minichromosome maintenance protein 6 (Mcm6) were expressed significantly more often in thick (>1 mm) than in thin melanomas. Marker expression did not differ between metastatic melanomas and thick melanomas, with the exception of aurora kinase A of which the expression was higher in metastatic melanomas. Combined detection of cyclin A (post-G1 phase) with Mcm6 (replication licensing) and Ki67 correctly classified thin melanomas and dysplastic nevi in 95.9 % of the original samples and in 93.2 % of cross-validated grouped cases at 89.5 % sensitivity and 92.6 % specificity. Therefore, cell cycle phase marker detection can indicate malignancy in early melanocytic lesions and accelerated cell cycle progression during vertical melanoma growth.

Predictors of skin self-examination before and after a melanoma diagnosis: the role of medical advice and patient's level of education

BACKGROUND

Cutaneous melanoma is the fastest growing tumor of the skin and the median life span of patients with advanced disease is less than a year. Melanoma-related mortality can be reduced through early detection via clinical skin exams and patient self-examination. Despite the potential to reducing the medical burden associated with clinical skin exams, systematic and regular skin self-examinations (SSE) are rarely performed. The current study examined psychosocial predictors of SSE and changes in SSE behavior from pre- to post-diagnosis in order to guide future melanoma prevention initiatives.

FINDINGS

A consecutive sample of 47 melanoma survivors was drawn from a tertiary care clinic. Most melanomas had been detected by patients, spouses and other laypersons. Higher education was related to more frequent SSE at pre-diagnosis, more thorough SSE at post-diagnosis, and more frequent reports of having been advised to perform SSE at post-diagnosis. SSE behaviors increased significantly from pre- to post-diagnosis.

CONCLUSIONS

These findings suggest that different patient subgroups display varied knowledge base, readiness for change, and receptiveness for medical advice. Thus, interventions seeking to enhance skin self-exam practice may be most effective when the individual's psychosocial characteristics are taken into account.

Cutaneous melanoma in situ: translational evidence from a large population-based study

BACKGROUND

Cutaneous melanoma in situ (CMIS) is a nosologic entity surrounded by health concerns and unsolved debates. We aimed to shed some light on CMIS by means of a large population-based study.

METHODS

Patients with histologic diagnosis of CMIS were identified from the Surveillance Epidemiology End Results (SEER) database.

RESULTS

The records of 93,863 cases of CMIS were available for analysis. CMIS incidence has been steadily increasing over the past 3 decades at a rate higher than any other in situ or invasive tumor, including invasive skin melanoma (annual percentage change [APC]: 9.5% versus 3.6%, respectively). Despite its noninvasive nature, CMIS is treated with excision margins wider than 1 cm in more than one third of cases. CMIS is associated with an increased risk of invasive melanoma (standardized incidence ratio [SIR]: 8.08; 95% confidence interval [CI]: 7.66-8.57), with an estimated 3:5 invasive/in situ ratio; surprisingly, it is also associated with a reduced risk of gastrointestinal (SIR: 0.78, CI: 0.72-0.84) and lung (SIR: 0.65, CI: 0.59-0.71) cancers. Relative survival analysis shows that persons with CMIS have a life expectancy equal to that of the general population.

CONCLUSIONS

CMIS is increasingly diagnosed and is often overtreated, although it does not affect the life expectancy of its carriers. Patients with CMIS have an increased risk of developing invasive melanoma (which warrants their enrollment in screening programs) but also a reduced risk of some epithelial cancers, which raises the intriguing hypothesis that genetic/environmental risk factors for some tumors may oppose the pathogenesis of others.

Testing the effectiveness of a skin cancer narrative in promoting positive health behavior: a pilot study

OBJECTIVE

The aim of this experiment was to examine the differential impact of a narrative and a non-narrative skin cancer message on health promoting actions and information-seeking behaviors.

METHODS

Participants were 230 Flemish university students aged 18 to 25 years who participated in a web based experiment in February 2009. Students were randomly assigned to a narrative skin cancer message, a non-narrative message or a no-message control condition. The messages contained identical information about recommended actions to prevent or detect skin cancer. Four weeks after exposure to the stimuli, respondents received a questionnaire assessing their actual health behaviors.

RESULTS

Multinomial logistic regression results indicated that participants who had been exposed to the narrative message were two to four times more likely to have engaged in health promoting actions, compared to participants in the control group. In contrast, the impact of the non-narrative condition only differed from that of the control group for searching more information about skin cancer.

CONCLUSIONS

These findings suggest that narrative messages may be a powerful means for promoting positive health actions.