Melanoma detection in British Columbia, Canada

Factors associated with the melanoma diagnostic interval in Ontario, Canada: a population-based study

BACKGROUND

Protracted times to diagnosis of cancer can lead to increased patient anxiety, and in some cases, disease progression and worse outcomes. This study assessed the time to diagnosis for melanoma, and its variability, according to patient-, disease-, and system-level factors.

METHODS

This is a descriptive, cross-sectional study in Ontario, Canada from 2007-2019. We used administrative health data to measure the diagnostic interval (DI)-and its two subintervals-the primary care subinterval (PCI) and specialist care subinterval (SCI). Multivariable quantile regression was used.

RESULTS

There were 33,371 melanoma patients. The median DI was 36 days (interquartile range [IQR]: 8-85 days), median PCI 22 days (IQR: 6-54 days), and median SCI 6 days (IQR: 1-42 days). Increasing comorbidity was associated with increasing DI. Residents in the most deprived neighbourhoods and those in rural areas experienced shorter DIs and PCIs, but no differences in SCI. There was substantial variation in the DI and SCI across health regions, but limited differences in the PCI. Finally, patients with a history of non-melanoma skin cancer, and those previously established with a dermatologist experienced significantly longer DI, PCI, and SCI.

DISCUSSION

This study found variability in the melanoma DI, notably by system-level factors.

Cutaneous Malignant Melanoma: A Review of Early Diagnosis and Management

Cutaneous melanoma (CM) is a malignant tumor formed from pigment-producing cells called melanocytes. It is one of the most aggressive and fatal forms of skin malignancy. In the last decades, CM's incidence has gradually risen, with 351,880 new cases in 2015. Since the 1960s, its incidence has increased steadily, in 2019, with approximately 96,000 new cases. A greater understanding of early diagnosis and management of CM is urgently needed because of the high mortality rates due to metastatic melanoma. Timely detection of melanoma is crucial for successful treatment, but diagnosis with histopathology may also pose a significant challenge to this objective. Early diagnosis and management are essential and contribute to better survival rates of the patient. To better control this malignancy, such information is expected to be particularly useful in the early detection of possible metastatic lesions and the development of new therapeutic approaches. This article reviews the available information on the early diagnosis and management of CM and discusses such information's potential in facilitating the future prospective.

The Development of a Skin Cancer Classification System for Pigmented Skin Lesions Using Deep Learning

Recent studies have demonstrated the usefulness of convolutional neural networks (CNNs) to classify images of melanoma, with accuracies comparable to those achieved by dermatologists. However, the performance of a CNN trained with only clinical images of a pigmented skin lesion in a clinical image classification task, in competition with dermatologists, has not been reported to date. In this study, we extracted 5846 clinical images of pigmented skin lesions from 3551 patients. Pigmented skin lesions included malignant tumors (malignant melanoma and basal cell carcinoma) and benign tumors (nevus, seborrhoeic keratosis, senile lentigo, and hematoma/hemangioma). We created the test dataset by randomly selecting 666 patients out of them and picking one image per patient, and created the training dataset by giving bounding-box annotations to the rest of the images (4732 images, 2885 patients). Subsequently, we trained a faster, region-based CNN (FRCNN) with the training dataset and checked the performance of the model on the test dataset. In addition, ten board-certified dermatologists (BCDs) and ten dermatologic trainees (TRNs) took the same tests, and we compared their diagnostic accuracy with FRCNN. For six-class classification, the accuracy of FRCNN was 86.2%, and that of the BCDs and TRNs was 79.5% (p = 0.0081) and 75.1% (p < 0.00001), respectively. For two-class classification (benign or malignant), the accuracy, sensitivity, and specificity were 91.5%, 83.3%, and 94.5% by FRCNN; 86.6%, 86.3%, and 86.6% by BCD; and 85.3%, 83.5%, and 85.9% by TRN, respectively. False positive rates and positive predictive values were 5.5% and 84.7% by FRCNN, 13.4% and 70.5% by BCD, and 14.1% and 68.5% by TRN, respectively. We compared the classification performance of FRCNN with 20 dermatologists. As a result, the classification accuracy of FRCNN was better than that of the dermatologists. In the future, we plan to implement this system in society and have it used by the general public, in order to improve the prognosis of skin cancer.

Incidence, Mortality, and Spatiotemporal Distribution of Cutaneous Malignant Melanoma Cases Across Canada

Background:

We recently reported a steady increase in the incidence and mortality of cutaneous malignant melanoma (CMM) in Canada during 1992-2010.

Objectives:

The objective of this article is to examine the distribution of Canadian CMM patients at the level of provinces, cities, and forward sortation area (FSA) postal codes.

Methods:

Using 3 Canadian population-based registries, we conducted an in-depth examination of the incidence and mortality trends for 72 565 Canadian CMM patients over the period 1992-2010.

Results:

We found that among 20- to 39-year-olds, the incidence of CMM in women (7.17 per 100 000 individuals) was significantly higher than in men (4.60 per 100 000 individuals per year). Women age 80 years and older had an incidence of CMM (58.46 cases per 100 000 women per year) more than 4 times greater than the national average (12.29 cases per 100 000 population per year) and a corresponding high mortality rate (20.18 deaths per 100 000 women per year), when compared with the Canadian melanoma mortality of 2.4 deaths per 100 000 per year. In other age groups men had higher incidence and corresponding melanoma mortality rates. We also studied CMM incidence by province, city, and FSA postal codes and identified several high-incidence communities that were located near the coast/waterfronts. In addition, plotting latitude measures for cities and FSAs vs CMM incidence rate confirmed the inverse relationship between geographical latitude and incidence of melanoma in Canada (slope = –0.22 ± 0.05).

Conclusions:

This research may help develop sex-, age- and geographic region-specific recommendations to decrease the future burden of CMM in Canada.

Cutaneous malignant melanoma incidence and mortality trends in Canada: A comprehensive population-based study

BACKGROUND

The incidence of cutaneous malignant melanoma (CMM) is on the rise in many parts of the world. However, there is limited knowledge on the epidemiology of CMM in Canada.

OBJECTIVE

To conduct a comprehensive population-based study of CMM in Canada.

METHODS

We examined patient clinical and pathologic characteristics as well as the incidence and mortality trends of CMM in Canada using 3 independent population-based registries.

RESULTS

In total, 72,565 Canadian patients were given CMM diagnoses during 1992-2010; 47.5% were women. Average age at the time of diagnosis was 56.5 years for women and 60.4 years for men. We report a steady increase in CMM incidence and mortality rates in both sexes. The overall incidence rate of CMM in Canada was 12.29 cases/100,000 person-years. We also report important differences in the incidence and mortality rates between Canadian provinces and territories; the highest incidence of this cancer was documented in Nova Scotia and Prince Edward Island.

LIMITATIONS

Data on race, clinical disease stage, and Breslow depth of CMM was not available.

CONCLUSION

This study, for the first time, defines the disease burden of CMM in Canada and highlights important longitudinal, geographic, and spatial differences in the distribution of CMM in this country.

When Patients Tell Their Own Stories: A Meta-Narrative Study of Web-Based Personalized Texts of 214 Melanoma Patients' Journeys in Four Countries

Malignant melanoma is an aggressive, recalcitrant disease. Its impact on people can be compounded by the physical and psychosocial consequences of medical management. Providing melanoma patients with patient-centered care that is effective, safe, and supportive throughout their journey requires knowledge of patients' progressive experiences and evolving perspectives. With ethical approval, we undertook a meta-narrative study of 214 experiential accounts of melanoma collected from the personal story sections of melanoma and cancer support websites. Using a narrative approach, we qualitatively examined the care experiences represented in these accounts and identified needs for supportive care in a framework reflective of the personal patient journey. We differentiate these across three key periods: lead-up to diagnosis; diagnosis, treatment, and recovery; and posttreatment and recurrence, and provide a visual representation of the patient journey. This article contributes to the growing body of work that utilizes Internet content as sources of qualitative, experiential health care data.

Delay in cutaneous melanoma diagnosis: Sequence analyses from suspicion to diagnosis in 211 patients

Advanced melanoma is an incurable disease with complex and expensive treatments. The best approach to prevent melanoma at advanced stages is an early diagnosis. A knowledge of factors associated with the process of detecting cutaneous melanomas and the reasons for delays in diagnosis is essential for the improvement of the secondary prevention of the disease.Identify sociodemographic, individual, and medical aspects related to cutaneous melanoma diagnosis delay.Interviews evaluated the knowledge of melanoma, signals, symptoms, persons who were suspected, delays in seeking medical attention, physician's deferrals, and related factors of 211 patients.Melanomas were self-discovered in 41.7% of the patients; healthcare providers detected 29.9% of patients and others detected 27%. The main component in delay was patient-related. Only 31.3% of the patients knew that melanoma was a serious skin cancer, and most thought that the pigmented lesion was not important, causing a delay in seeking medical assistance. Patients (36.4%) reported a wait interval of more than 6 months from the onset of an observed change in a pigmented lesion to the first visit to a physician. The delay interval from the first physician visit to a histopathological diagnosis was shorter (<1 month) in 55.5% of patients. Improper treatments without a histopathological confirmation occurred in 14.7% of patients. A professional delay was related to both inappropriate treatments performed without histopathological confirmation (P = 0.003) and long requirements for medical referrals (P < 0.001).A deficient knowledge in the population regarding melanoma and physicians' misdiagnoses regarding suspicious lesions contributed to delays in diagnosis.

Time to Diagnosis of Melanoma: Same Trend in Different Continents

Background:

Patients and physicians both play an important role in the diagnosis of malignant melanoma.

Objective:

The purpose of this study was to assess important factors of delay in diagnosis at different centers and on three continents.

Methods:

Between October 2001 and October 2002, patients with histologically confirmed invasive melanoma were included in the study and given an established questionnaire. Recorded patients and tumor characteristics included age, sex, anatomic location, Breslow thickness, patients' awareness of the lesion and time with suspicion, and physicians' time (delay) before the operation.

Results:

The study included 985 patients (486 males, 499 females): 253 from Germany, 464 from Sweden, 58 from Brazil, and 210 from Australia. More females detected their lesions by themselves. The change to a darker color (21 %) and enlargement of the area of the lesion (19%) were the major signs. The highest knowledge among patients that early detection may improve the outcome was found in Sweden and Australia. At each center, the media (newspaper, magazine, radio, and television) provided the best sources of information about melanoma. Twenty to 33% of all physicians initially consulted missed the melanoma diagnosis, independent of their specialty.

Conclusions:

There are still factors for the delay in melanoma diagnosis in different countries and continents, but the differences are rather small. The results should be included in planning prevention campaigns in this specific field and in the education of medical students, physicians of all specialties, and other health professionals.

Clinical and histologic factors associated with melanoma thickness in New Zealand Europeans, Maori, and Pacific peoples

BACKGROUND

Thickness is the major prognostic indicator for patients with melanoma. In many countries, the incidence of thick melanoma has not decreased. To reduce mortality, knowledge of the characteristics associated with melanoma depth is needed.

METHODS

To examine the relation between melanoma thickness and other factors in Europeans, Maori, and Pacific peoples, the authors analyzed the 14,802 melanoma registrations in New Zealand between 1996 and 2006. Notifications of invasive cutaneous melanoma from 1996 to 2006 were extracted from the New Zealand Cancer Registry. Ethnicity was categorized using the Statistics New Zealand prioritization algorithm. The geometric mean tumor thickness was calculated using log-transformed Breslow depth. Multivariate linear regression was used to examine the relation of predictor variables, their interactions, and melanoma thickness.

RESULTS

Melanoma thickness increased by 1% per year from 1996 to 2006. Although melanoma is rare in Maori and Pacific peoples, after adjustment, melanoma thickness was significantly greater in those populations compared with Europeans. Among Europeans, melanoma thickness was associated significantly with age at diagnosis, year of registration, sex, histology subtype, and extent of disease at diagnosis. In Maori, thick melanomas were likely to be nodular and to have regional or lymph node spread. The most important determinant of melanoma thickness in Pacific peoples was body site.

CONCLUSIONS

Differences in melanoma thickness among ethnic groups were not explained fully by tumor subtype, site, or extent of disease. The current results indicated that the thicker melanomas in darker skinned populations probably can be accounted for in part by more aggressive lesions. Research is needed to identify additional characteristics to explain ethnic variations in melanoma thickness.

Efficacy of skin self-examination for the early detection of melanoma

The National Cancer Institute's "Melanoma Action Plan" calls for reduction of melanoma mortality through early detection. Routine skin self-examination (SSE) has the potential to increase chances of early detection and treatment and may be the key to melanoma survival. We provide a focused review of the accuracy of SSE for detecting premalignant lesions and cutaneous risk factors for melanoma, with suggestions for future directions for enhancing measurement of SSE accuracy and ways in which to improve the public's perceptions of melanoma efficacy. We examined published data on the efficacy of skin self-examination for the early detection of melanoma. We searched the MEDLINE database for publications between January 1, 1987 and June 1, 2007 using search terms for "melanoma" and "self-examination." We found that sensitivity of skin self-examination is low, ranging from 25% to 93%, while specificity is generally higher (83% to 97%). Attempts to increase improve the lay public's perceptions of the early signs of melanoma have proved effective, while those aimed at increasing accuracy of SSE with targeted interventions have been moderately successful. SSE's insensitivity for detection of pigmented lesions should prompt further investigation of educational interventions to enhance its accuracy and lead to its adoption as a cheap, simple screening tool. Assessment of the accuracy and efficacy of SSE should proceed using standardized definitions and measurements such that it is easier to pool data on the overall value of SSE as a screening modality.

Factors associated with large cutaneous squamous cell carcinomas

BACKGROUND

Large cutaneous squamous cell carcinoma (SCC) is associated with a higher risk of disfigurement, local recurrence, and metastasis; however, little is known about factors associated with tumor size at diagnosis.

OBJECTIVES

We sought to evaluate factors associated with SCC size, including diagnostic/treatment delay and patient and tumor characteristics.

METHODS

We studied a stratified sample of 308 patients with SCC recently treated at a dermatologic referral center in Italy. Medical records were reviewed and telephone interviews conducted. Multiple logistic regression was used to examine factors associated with SCC size.

RESULTS

With univariate analyses, among both invasive and in situ cases, SCC greater than 2 cm was significantly associated with male gender, tumors arising in chronic lesions, and tumors located on not easily visible sites. Long delay before surgical removal was significantly associated with large SCC size only for invasive SCC (P < .001). Among patients with invasive SCC, when controlling for age and gender, multivariate analysis showed a significantly higher likelihood of SCC greater than 2 cm with a total delay longer than 18 months before surgical removal (odds ratio=4.18; 95% confidence interval 2.45-7.13) and for tumors arising in chronic lesions (odds ratio=6.42; 95% confidence interval 3.13-13.2).

LIMITATIONS

The study was cross-sectional and based on a single center.

CONCLUSIONS

Long total delay in removal significantly increased the likelihood of invasive SCC greater than 2 cm. Our findings highlight the importance of early detection and treatment to prevent large invasive SCCs, which are associated with a higher risk of disfigurement, recurrence, and metastasis. Particular attention should be paid to chronic skin lesions and not easily visible body sites during physician- and patient-performed examinations.

The case for early detection of melanoma

BACKGROUND AND OBJECTIVE

The incidence and mortality from melanoma continue to rise worldwide. Unfortunately, there is still no consistently effective treatment for metastatic disease. The fact that survival for melanoma has increased dramatically over the last 30 years highlights the importance of early detection of this malignancy.

CONCLUSION

With continued public education and the advent of new technologies, it is hoped that we will be able to improve on what has been accomplished to date to reduce the health burden of melanoma even further. This article reviews issues related to patient and physician detection of melanoma and highlights newer technologies being used for this purpose.

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.

Retrospective review of primary melanomas excised at Waikato Hospital, New Zealand, 2002?2003

The aim of this study was to review and compare melanomas referred by general practitioners and melanomas identified at specialist clinics. The medical records relating to 113 primary melanomas excised at Waikato Hospital (a specialist regional base hospital) during 2002 and 2003 were reviewed retrospectively. Forty-seven melanomas (41%) were detected when patients attended specialist clinics (mainly plastic surgery and dermatology), and 66 melanomas (59%) were specifically referred by general practitioners. The melanomas detected at specialist clinics had a lower mean Breslow thickness than those referred by general practitioners (0.57 mm compared with 1.45 mm). Patients referred by general practitioners waited a mean of 26.5 days (range 0-94 days) for first specialist assessment. Following specialist assessment, patients waited a mean of 24.2 days (0-81 days) before excision biopsy.

Cutaneous melanoma and intervention strategies to reduce tumor-related mortality: what we know, what we don't know, and what we think we know that isn't so

The care of patients who have cutaneous melanoma (CM) has undergone a dramatic change during the past five decades. In an increasing majority of cases, CM is being discovered in a premetastatic phase of tumor progression. Most patients are being treated in the ambulatory setting with a minimum of inconvenience and economic cost, and modest re-excision margins have largely replaced the mutilating surgical exonerations that were once standard only four decades ago. Histopathologic assessment of the primary tumor is the most widely used staging procedure to determine who is most likely to develop metastatic disease. For patients who develop distant metastases, there is no therapy currently available, based on large-scale randomized trials, that will prolong patient survival. Therefore, establishing an early diagnosis in a premetastatic phase of tumor development must be the overriding goal of any intervention strategy that seeks to reduce CM-related mortality. Unfortunately, as a result of public messages that emphasize the role of ultraviolet radiation (UVR) exposure in tumor development, most general physicians and lay people believe that most if not all cases of CM are the direct result of UVR exposure. In fact, we do not know the case fraction of CM directly attributable to UVR, and the unintended consequences of current messages directly linking UVR exposure and CM development may be thwarting the primary intervention goal of reducing tumor-related mortality. More likely to have an immediate positive impact on CM-related mortality are public messages that encourage skin awareness and self-examination by patients, total skin screening examinations by physicians during routine care, and periodic lifetime surveillance of patients determined to have a high CM risk based on identifiable historic and phenotypic traits.