Epidemiological differences for cutaneous melanoma in a relatively dark-skinned caucasian population with chronic sun exposure

Integrating Patient Data Into Skin Cancer Classification Using Convolutional Neural Networks: Systematic Review

BACKGROUND

Recent years have been witnessing a substantial improvement in the accuracy of skin cancer classification using convolutional neural networks (CNNs). CNNs perform on par with or better than dermatologists with respect to the classification tasks of single images. However, in clinical practice, dermatologists also use other patient data beyond the visual aspects present in a digitized image, further increasing their diagnostic accuracy. Several pilot studies have recently investigated the effects of integrating different subtypes of patient data into CNN-based skin cancer classifiers.

OBJECTIVE

This systematic review focuses on the current research investigating the impact of merging information from image features and patient data on the performance of CNN-based skin cancer image classification. This study aims to explore the potential in this field of research by evaluating the types of patient data used, the ways in which the nonimage data are encoded and merged with the image features, and the impact of the integration on the classifier performance.

METHODS

Google Scholar, PubMed, MEDLINE, and ScienceDirect were screened for peer-reviewed studies published in English that dealt with the integration of patient data within a CNN-based skin cancer classification. The search terms skin cancer classification, convolutional neural network(s), deep learning, lesions, melanoma, metadata, clinical information, and patient data were combined.

RESULTS

A total of 11 publications fulfilled the inclusion criteria. All of them reported an overall improvement in different skin lesion classification tasks with patient data integration. The most commonly used patient data were age, sex, and lesion location. The patient data were mostly one-hot encoded. There were differences in the complexity that the encoded patient data were processed with regarding deep learning methods before and after fusing them with the image features for a combined classifier.

CONCLUSIONS

This study indicates the potential benefits of integrating patient data into CNN-based diagnostic algorithms. However, how exactly the individual patient data enhance classification performance, especially in the case of multiclass classification problems, is still unclear. Moreover, a substantial fraction of patient data used by dermatologists remains to be analyzed in the context of CNN-based skin cancer classification. Further exploratory analyses in this promising field may optimize patient data integration into CNN-based skin cancer diagnostics for patients' benefits.

MelaNostrum: a consensus questionnaire of standardized epidemiologic and clinical variables for melanoma risk assessment by the melanostrum consortium

BACKGROUND

Many melanoma observational studies have been carried out across different countries and geographic areas using heterogeneous assessments of epidemiologic risk factors and clinical variables.

AIM

To develop a consensus questionnaire to standardize epidemiologic and clinical data collection for melanoma risk assessment.

METHODS

We used a stepwise strategy that included: compilation of variables from case-control datasets collected at various centres of the MelaNostrum Consortium; integration of variables from published case-control studies; consensus discussion of the collected items by MelaNostrum members; revision by independent experts; addition of online tools and image-based charts; questionnaire testing across centres and generation of a final draft.

RESULTS

We developed a core consensus questionnaire (MelanoQ) that includes four separate sections: A. general and demographic data; B. phenotypic and ultraviolet radiation exposure risk factors and lifestyle habits; C. clinical examination, medical and family history; and D. diagnostic data on melanoma (cases only). Accompanying online tools, informative tables, and image-based charts aid standardization. Different subsections of the questionnaire are designed for self-administration, patient interviews performed by a physician or study nurse, and data collection from medical records.

CONCLUSIONS

The MelanoQ questionnaire is a useful tool for the collection and standardization of epidemiologic and clinical data across different studies, centres, cultures and languages. This will expedite ongoing efforts to compile high-quality data for pooled analyses or meta-analyses and offer a solid base for the design of clinical, epidemiologic and translational studies on melanoma.

Current Data on Risk Factor Estimates Does Not Explain the Difference in Rates of Melanoma between Hispanics and Non-Hispanic Whites

United States Hispanics have seven times lower melanoma incidence rates than non-Hispanic whites (NHW). It is unclear whether this difference can be explained solely by phenotypic risk factors, like darker skin, or whether modifiable risk factors, like sun exposure, also play a role. The purpose of this paper is to summarize what is currently known about melanoma risk factors among Hispanics and NHWs, and whether or not those differences could explain the difference in melanoma incidence. Through literature review, relative risks and prevalence of melanoma risk factors in Hispanics and NHWs were identified and used to calculate the expected rate in Hispanics and rate ratio compared to NHWs. We found that melanoma risk factors either have similar frequency in Hispanics and NHWs (e.g., many large nevi) or are less frequent in Hispanics but do not explain a high proportion of disease variation (e.g., red hair). Considering current knowledge of risk factor prevalence, we found that melanoma incidence rates in the two groups should actually be similar. Sun exposure behavior among Hispanics may contribute to the explanation for the 7-fold difference in melanoma rates. Currently, limited data exist on sun exposure behavior among Hispanics, but possibilities for improving primary prevention by further studying these practices are substantial.

Replication and predictive value of SNPs associated with melanoma and pigmentation traits in a Southern European case-control study

Background

Genetic association studies have revealed numerous polymorphisms conferring susceptibility to melanoma. We aimed to replicate previously discovered melanoma-associated single-nucleotide polymorphisms (SNPs) in a Greek case-control population, and examine their predictive value.

Methods

Based on a field synopsis of genetic variants of melanoma (MelGene), we genotyped 284 patients and 284 controls at 34 melanoma-associated SNPs of which 19 derived from GWAS. We tested each one of the 33 SNPs passing quality control for association with melanoma both with and without accounting for the presence of well-established phenotypic risk factors. We compared the risk allele frequencies between the Greek population and the HapMap CEU sample. Finally, we evaluated the predictive ability of the replicated SNPs.

Results

Risk allele frequencies were significantly lower compared to the HapMap CEU for eight SNPs (rs16891982 – SLC45A2, rs12203592 – IRF4, rs258322 – CDK10, rs1805007 – MC1R, rs1805008 - MC1R, rs910873 - PIGU, rs17305573- PIGU, and rs1885120 - MTAP) and higher for one SNP (rs6001027 – PLA2G6) indicating a different profile of genetic susceptibility in the studied population. Previously identified effect estimates modestly correlated with those found in our population (r = 0.72, P<0.0001). The strongest associations were observed for rs401681-T in CLPTM1L (odds ratio [OR] 1.60, 95% CI 1.22–2.10; P = 0.001), rs16891982-C in SCL45A2 (OR 0.51, 95% CI 0.34–0.76; P = 0.001), and rs1805007-T in MC1R (OR 4.38, 95% CI 2.03–9.43; P = 2×10⁻⁵). Nominally statistically significant associations were seen also for another 5 variants (rs258322-T in CDK10, rs1805005-T in MC1R, rs1885120-C in MYH7B, rs2218220-T in MTAP and rs4911442-G in the ASIP region). The addition of all SNPs with nominal significance to a clinical non-genetic model did not substantially improve melanoma risk prediction (AUC for clinical model 83.3% versus 83.9%, p = 0.66).

Conclusion

Overall, our study has validated genetic variants that are likely to contribute to melanoma susceptibility in the Greek population.

Factors associated with the prevalence of atypical nevus in a Mediterranean pigmented skin lesion clinic

Atypical melanocytic nevi constitute central risk factor and are precursor lesions for cutaneous melanoma. Data regarding factors associated with their prevalence are mainly derived from fair-skinned populations, whereas little is known regarding their epidemiological associations in darker-skinned, chronically sun-exposed populations. The aim of this study was to identify risk factors for the occurrence of at least one atypical nevus on Crete, the southernmost island of Greece. This hospital-based case-control study included 143 patients and 189 controls with at least one atypical nevus presented at the pigmented skin lesion clinic of the University of Crete. All participants were interviewed and underwent complete skin examination by the same two experienced dermatologists. Multivariate logistic regression analysis was used to adjust for potential confounders. In the multivariate analysis, common melanocytic nevi [odds ratio (OR): of 2.2, 7.5, and 58.9 for the presence of 11-25, 26-100, and >100 common nevi, respectively] and recreational sun exposure (OR: 4.4) increased significantly the risk of the presence of atypical nevus. A decreased risk for atypical nevi was related to an increasing age (OR: 0.96/age), and professional sun exposure (OR: 0.5). Intermittent, recreational sun exposure is mainly associated with the prevalence of atypical nevi in our sample and this effect does not depend on skin phototype. Promotion of sun protection, especially in patients with high numbers of common nevi, might serve as a measure to prevent the development of atypical nevi.

Estimating the attributable fraction for melanoma: a meta-analysis of pigmentary characteristics and freckling

Epidemiologic research has demonstrated convincingly that certain pigmentary characteristics are associated with increased relative risks of melanoma; however there has been no comprehensive review to rank these characteristics in order of their importance on a population level. We conducted a systematic review of the literature and meta-analysis to quantify the contribution of pigmentary characteristics to melanoma, estimated by the population-attributable fraction (PAF). Eligible studies were those that permitted quantitative assessment of the association between histologically confirmed melanoma and hair colour, eye colour, skin phototype and presence of freckling; we identified 66 such studies using citation databases, followed by manual review of retrieved references. We calculated summary relative risks using weighted averages of the log RR, taking into account random effects, and used these to estimate the PAF. The pooled RRs for pigmentary characteristics were: 2.64 for red/red-blond, 2.0 for blond and 1.46 for light brown hair colour (vs. dark); 1.57 for blue/blue-grey and 1.51 for green/grey/hazel eye colour (vs. dark); 2.27, 1.99 and 1.35 for skin phototypes I, II and III respectively (vs. IV); and 1.99 for presence of freckling. The highest PAFs were observed for skin phototypes 1/II (0.27), presence of freckling (0.23), and blond hair colour (0.23). For eye colour, the PAF for blue/blue-grey eye colour was higher than for green/grey/hazel eye colour (0.18 vs. 0.13). The PAF of melanoma associated with red hair colour was 0.10. These estimates of melanoma burden attributable to pigmentary characteristics provide a basis for designing prevention strategies for melanoma.

Cutaneous melanoma in a desert climate zone: a retrospective study of 125 cases

BACKGROUND

With increasing incidence over the last few decades, cutaneous malignant melanoma (CM) represents 3% of all skin tumors, and accounts for 75% of all deaths because of cutaneous malignancies. Little is known about the nature and epidemiology of CM in individuals with pigmented skin.

METHOD

Data were collected from the records of four public and private histopathology laboratories of Kerman city from March 20, 1994 to March 20, 2004. Skin biopsies with a diagnosis of CM were reevaluated to confirm the diagnosis of CM. The medical records of the patients were also taken into consideration.

RESULTS

A total of 125 CMs were found. The male-to-female ratio was 1.08 : 1. The mean age at the time of diagnosis was 58.9 years; with a peak in the seventh decade of life. Acral-lentiginous melanoma (ALM) represented 28.8% and; nodular melanoma occurred in 20% of cases. Limbs were the site of occurrence in 44% of tumors; whereas 36% of tumors occurred in head and neck region. There was a significant correlation between age and ALM (P = 0.007) and also between gender and melanoma types (P = 0.024).

CONCLUSIONS

This study indicates that some demographic and histopathologic features of CM in this population differ from those in the literature. More studies including cohort studies are needed to fully describe the nature and survival rate of CM in this area.

Nutritional approach to sun protection: a suggested complement to external strategies

The increasing incidence of skin cancer despite the use of externally applied sun protection strategies, alongside research showing that nutrients reduce photo-oxidative damage, suggest nutritional approaches could play a beneficial role in skin cancer prevention. Penetrating photo-oxidative ultraviolet A radiation reduces skin and blood antioxidants and damages cell components, including DNA. Dietary antioxidant vitamins, minerals, and phytochemicals in addition to n-3 polyunsaturated fatty acids, n-9 monounsaturated fatty acids, and low pro-inflammatory n-6 polyunsaturated fatty acids, have demonstrated protective properties. The presence of these elements in the traditional Greek-style Mediterranean diet may have contributed to the low rates of melanoma in the Mediterranean region despite high levels of solar radiation. This suggests a potentially relevant model for studying dietary/nutritional supplementation for lifelong internal support of sun-protection mechanisms, which could complement external strategies.

Familial melanoma: a meta-analysis and estimates of attributable fraction

Melanoma commonly clusters in families, and the recent identification of numerous genotypes predicting higher risks of melanoma has led to the widespread perception that this cancer is predominantly a genetic disease. We conducted a systematic review of the literature and meta-analysis to quantify the contribution of familial factors to melanoma, estimated by the population attributable fraction (PAF). Eligible studies were those that permitted quantitative assessment of the association between histologically confirmed melanoma and family history of the disease; we identified 22 such studies using citation databases, followed by manual review of retrieved references. We calculated summary RRs using weighted averages of the log RR, taking into account random effects, and used these to estimate the PAF. Overall, family history was associated with a significant 2-fold increased risk of melanoma (odds ratio, 2.06; 95% confidence interval, 1.72-2.45); however, there was significant heterogeneity (P = 0.01). The pooled estimate for population-based studies (n = 11) was 2.03 (1.70-2.43), and 2.51 (1.55-4.07) for clinic/hospital-based studies (n = 11), both with significant heterogeneity (P = 0.049 and P = 0.013, respectively). Two studies used record linkage to verify family history in relatives; the pooled risk estimate from these two studies was 2.52 (2.11-3.00) with no evidence of heterogeneity (P = 0.258). Estimates of PAF associated with a positive family history ranged from 0.007 for Northern Europe to 0.064 for Australia (0.040 for all regions combined). Our findings suggest that only a small percentage of melanoma cases (always <7%) are attributable to familial risk; the majority of melanomas are presumably attributable to other factors.

Estimating the attributable fraction for cancer: A meta-analysis of nevi and melanoma

Epidemiologic research has shown convincingly that certain phenotypic attributes are associated with increased relative risks of melanoma. Although such findings have intrinsic utility, there have been few attempts to translate such knowledge into estimates of disease burden suitable for framing public health policy. We aimed to estimate the population attributable fraction (PAF) for melanoma associated with melanocytic nevi using relative risk estimates derived from a systematic review and meta-analysis. We identified eligible studies using citation databases, followed by manual review of retrieved references. Of 49 studies identified, 25 and 23, respectively, were included in meta-analyses of atypical and common nevi. For people with > or =1 atypical nevi, the summary relative risk was 3.63 (95% confidence interval, 2.85-4.62), with a PAF of 0.25. The relative risk increased by 1.017 (95% confidence interval, 1.014-1.020) for each common nevus; however, significant heterogeneity in risk estimates was observed. We estimated that 42% of melanomas were attributable to having > or =25 common nevi (PAF 25-49 nevi = 0.15; PAF > or =50 nevi = 0.27), whereas PAFs for low nevus counts were modest (PAF 0-10 nevi = 0.04; PAF 11-24 nevi = 0.07). We modeled PAF under scenarios of varying nevus prevalence; the highest melanoma burden was always among those with high nevus counts (PAF range of 0.31-0.62 for > or =25 common nevi). Patients with > or =25 common nevi and/or > or =1 atypical nevi are a high-risk group, which might be targeted for identification, screening, and education. This work is the necessary first step in designing targeted preventive strategies for melanoma, which must now be overlaid with information about cost and utility.

Sunburns and risk of cutaneous melanoma: does age matter? A comprehensive meta-analysis

PURPOSE

Sunburns are an important risk factor for melanoma and those occurring in childhood are often cited as posing the greatest risk. We conducted a meta-analysis to quantify the magnitude of association for melanoma and sunburns during childhood, adolescence, adulthood and over a lifetime.

METHODS

After reviewing over 1300 article titles and evaluating 270 articles in detail, we pooled odds ratios from 51 independent study populations for "ever" sunburned and risk of cutaneous melanoma. Among these, 26 studies reported results from dose-response analyses. Dose-response analyses were examined using both fixed-effects models and Bayesian random-effects models.

RESULTS

An increased risk of melanoma was seen with increasing number of sunburns for all time-periods (childhood, adolescence, adulthood, and lifetime). In an attempt to understand how risk between life-periods compares, we also report these same linear models on a scale of five sunburns per decade for each life-period. The magnitude of risk for five sunburns per decade is highest for adult and lifetime sunburns.

CONCLUSIONS

Overall, these results show an increased risk of melanoma with increasing number of sunburns during all life-periods, not just childhood. Prevention efforts should focus on reducing sunburns during all life-periods.

Pigmentary disorders in the Mediterranean area

The Mediterranean area represents the area of land that borders the Mediterranean basin. It is composed of several countries that share many geographic and racial characteristics. Although Mediterraneans seem to share common skin type and are subjected to similar enviromental factors, they still represent a genetic and socioeconomic diversity. True prevalence of pigmentary disorders in this area depends on large epidemiologic studies, including countries that are not available. This article, however, highlights and classifies the most important developmental (heritable-genetic) and acquired pigmentary disorders seen and reported in this important area of the world.

p53 codon 72 Pro homozygosity increases the risk of cutaneous melanoma in individuals with dark skin complexion and among noncarriers of melanocortin 1 receptor red hair variants

BACKGROUND

p53 has a common polymorphism at amino acid 72, encoding either arginine or proline. p53Arg and p53Pro exhibit differences in various biological activities, such as cell-cycle arrest and induction of apoptosis. Numerous epidemiological studies have examined the role of this polymorphism in several human malignancies, including cutaneous cancers, with contradictory results.

OBJECTIVES

To investigate the germline frequency of p53 codon 72 polymorphism in malignant melanoma in a Mediterranean population, and to examine possible associations with various clinicopathological factors.

METHODS

In this hospital-based case-control study we used allele-specific polymerase chain reaction for p53 codon 72 genotyping in blood specimens from 107 Greek patients with sporadic cutaneous melanoma and 145 healthy controls.

RESULTS

After adjustment for age, sex and phototype the Pro/Pro genotype was associated with increased risk for cutaneous melanoma compared with the Arg/Arg genotype (adjusted odds ratio, OR 3.17, 95% confidence interval, CI 1.03-9.78). This correlation was more pronounced in subjects with phototypes III or IV (adjusted OR 9.56, 95% CI 1.56-58.46), dark skin (adjusted OR 10.96, 95% CI 1.64-73.28), dark eyes (adjusted OR 8.86, 95% CI 1.69-46.52) and dark hair (adjusted OR 3.17, 95% CI 1.01-9.95), and among noncarriers of melanocortin 1 receptor gene (MC1R) red hair polymorphisms (adjusted OR 2.99, 95% CI 1.02-8.78).

CONCLUSIONS

p53 codon 72 Pro/Pro genotype could be a risk factor for the development of melanoma in the Greek population, especially in subgroups with darker skin pigmentation, as well as among noncarriers of the MC1R red hair polymorphic variants.

Melanoma incidence in central Italy will go on increasing also in the near future: A registry-based, age–period–cohort analysis

The aim of the study was to evaluate malignant melanoma incident trends in central Italy by means of an age-period-cohort approach. A total of 1977 malignant melanoma (15-84 years) incidents in the area of the Tuscany Cancer Registry between 1987 and 2001 were analysed. Poisson regression has been used to estimate age, cohort and period effect. A nonlinear regression model was used to estimate the expected number of new cases in the period 2002-2006. Incidence rates increased in all age, period and cohort groups. The model that best fitted the data included age and 'drift'. The linear effect ('drift') showed, in each age group, an increase of the risk of malignant melanoma diagnosis of about 36.6% every 5 years of period or cohort. For the period 2002-2006, 1112 new cases were predicted with a standardized rate (age 15-84 years) of 19.2x100.000. In the Tuscany Cancer Registry area, no clues for malignant melanoma incidence rates levelling off were documented. Growing rates and number of malignant melanoma are expected in the near future.

Melanoma/skin cancer screening in a Mediterranean country: results of the Euromelanoma Screening Day Campaign in Greece

BACKGROUND

Since the year 2000 a melanoma/skin cancer screening campaign has been organized annually in Greece in the context of the Euromelanoma Screening Day Campaign.

OBJECTIVES

We aimed to analyse the characteristics of the screened population, to recognize relevant risk factors and to identify the cases of histologically confirmed malignant melanoma (MM) in individuals with suspicious skin lesions.

METHODS

An analysis of the completed screening forms from the years 2000-2004 was performed with respect to relevant demographic, epidemiological and clinical data.

RESULTS

A total of 9723 individuals were screened, most of whom where below the age of 50 years (71%), female (59%), and of skin phototype II and III (76%). Sunburn during childhood was reported in 47% of participants, while 5% of the screened population had a personal or family history of melanoma. On clinical examination, 14.4% had actinic keratoses, 31.2% had dysplastic nevi, while 6.4% carried a presumptive diagnosis of non-melanoma skin cancer. In the 2003-2004 screening campaign, 19 out of the 171 clinically suspicious lesions were histologically proven to be MM, the majority of which (58%) were 'thin' melanomas (Breslow's thickness of<or=1 mm) of the superficial spreading type.

CONCLUSIONS

Our study suggested that, a melanoma/skin cancer screening programme in a Mediterranean country, supported by an intense publicity campaign, attracted many individuals at risk for skin cancer and detected mostly thin melanomas of the superficial spreading type.

Melanocortin Receptor-1 Gene Polymorphisms and the Risk of Cutaneous Melanoma in a Low-Risk Southern European Population

Individuals with melanocortin 1 receptor (MC1R) gene variants have been shown to carry an increased risk for the development of melanoma. In this study, we investigated the relationship of MC1R gene variants and the risk of melanoma in 123 melanoma patients and 155 control subjects from Greece. The entire MC1R gene was sequenced for polymorphisms and the results were correlated with host factors and pigmentary characteristics. MC1R polymorphisms were present in 59.4% of melanoma patients compared to 37.5% of controls, yielding an odds ratio (OR) of 2.43 (95% confidence interval (CI) = 1.50-3.96, P < 0.001) for melanoma among MC1R carriers. The risk of melanoma was enhanced in individuals carrying multiple variant alleles (OR = 6.97; 95% CI = 1.86-26.12, P = 0.004). Only the Val60Leu, Arg142His, and Arg151Cys variants were significantly associated with melanoma risk. In stratified analysis, the risk of melanoma among MC1R carriers was not influenced by skin phototype, skin color, or hair color. No association was found between MC1R genotype and the age of onset of melanoma, the tumor location, or the tumor thickness. In conclusion, MC1R polymorphisms are a predisposing factor of melanoma in a southern European population with a relatively low incidence of the disease.

Comparative analysis of incidence and clinical features of cutaneous malignant melanoma in Crete (Greece) and southern Germany (central Baden-Württemberg)

BACKGROUND

Comparative analysis of the incidence rates and epidemiological features of cutaneous malignant melanoma (CMM) between different ethnic groups exposed to varying environmental factors is critical for consideration of the causes of CMM but can also be utilized in a public health approach to control of the disease.

OBJECTIVES

To compare incidence rates and clinical features of CMM in a Greek and a central European population (central Baden-Württemberg, Germany).

METHODS

Incident cases of CMM were traced in all hospitals of the island of Crete for the period 1999-2002. Age-standardized incidence rates per 100 000 inhabitants per year for the European Standard Population were calculated based on the Cretan population statistics. A comparison was performed between the Cretan findings and those of southern Germany as registered by the hospital-based Central Malignant Melanoma Registry, which likewise documents more clinical features than normally recorded by population-based cancer registries.

RESULTS

Mean incidence rates in Crete for 1999-2002 were 4.01 per 100 000 inhabitants per year for males and 4.05 for females as compared with 10.6 for males and 11.1 for females in southern Germany. There were striking differences in the clinical characteristics of CMMs, with significantly higher tumour thickness in Crete (median 1.4 mm vs. 0.7 mm in southern Germany). Correspondingly, significantly more nodular melanomas were observed in Crete (29%) as compared with southern Germany (11%).

CONCLUSIONS

Incidence of CMM in Crete, with about four cases per 100 000 inhabitants per year, is clearly higher than previously estimated, and there is an urgent necessity for earlier recognition of CMM in Crete. However, the incidence of CMM in southern Germany is much higher.

The incidence and mortality of cutaneous melanoma in southern Germany

BACKGROUND

Cutaneous melanoma (CM) incidence and mortality have risen dramatically during the past 2 generations, particularly among Caucasian populations. Detailed, long-term trends of CM in relation to clinical and pathologic characteristics in a Central European population have not been published to date.

METHODS

The current study was based on 1980 patients with invasive CM diagnosed in Southern Germany during the years from 1976 to 2003 documented by the Central Malignant Melanoma Registry. The German standard population was used to calculate age-standardized rates, and the annual percent change was estimated by using age, anatomic site, histologic type, and tumor thickness.

RESULTS

During the study period, the incidence of CM approximately was tripled for males and females, reaching 10.3 and 13.3 per 100,000 per year, respectively (P < .001). The largest increases occurred for melanoma localized on the upper limbs (annual change, 5.9% for males and 5.0% for females; P < .001) and superficially spreading melanoma (annual change, 7.8% for males and 5.9% for females; P < .001). Thin tumors (Breslow thickness <1 mm) were presented significantly more often during the study period (annual change, 9.8% for males and 6.1% for females; P < .001), predominantly in younger patients. Thick tumors and nodular melanomas were more frequent among older patients (age >70 years), particularly among males. The age-standardized mortality decreased from 1.5 to 0.8 per 100,000 males and from 2.6 to 0.8 per 100,000 females with a significant downward trend for the female population (P < .001).

CONCLUSIONS

The current results indicated which diverging trends between incidence and mortality may be explained by improved public awareness regarding suspicious pigmented lesions and the earlier detection of these tumors. Continuation of the current preventive strategy and its expansion to include older age groups in the population are warranted.