Incidence of and survival from malignant melanoma in Scotland: an epidemiological study

The descriptive epidemiology of melanoma in Italy has changed - for the better

A recent research project using data from a total of 40 cancer registries has provided new epidemiologic insights into the results of efforts for melanoma control in Italy between the 1990s and the last decade. In this article, the authors present a summary and a commentary of their findings. Incidence increased significantly throughout the study period in both sexes. However, the rates showed a stabilization or a decrease in men and women aged below 35 years. The risk of disease increased for successive cohorts born until 1973 (women) and 1975 (men) while subsequently tending to decline. The trend towards decreasing tumor thickness and increasing survival has continued, but a novel favorable prognostic factor has emerged since 2013 for patients - particularly for males - with thick melanoma, most likely represented by molecular targeted therapies and immune checkpoint inhibitors. Due to this, the survival gap between males and females has been filled out. In the meanwhile, and despite the incidence increase, dermatologists have not lowered their threshold to perform skin biopsy. Skin biopsy rate has increased because of the increasingly greater volume of dermatologic office visits, but the proportion of skin biopsies out of dermatologic office visits has remained constant. In summary, an important breakthrough in melanoma control in Italy has taken place. Effective interventions have been implemented across the full scope of care, which involve many large local populations - virtually the whole national population. The strategies adopted during the last three decades represent a valuable basis for further steps ahead in melanoma control in Italy.

Patient presentation, skin biopsy utilization and cutaneous malignant melanoma incidence and mortality in northern Italy: Trends and correlations

BACKGROUND

The global increase in incidence of cutaneous malignant melanoma (CMM) occurring in the past decades has been partly attributed to increased diagnostic scrutiny of early lesions, with a potential phenomenon of overdiagnosis. The reported positive linear relation between skin biopsy rate and incidence of early CMM is compatible with this hypothesis.

OBJECTIVES

We explored the ecological association between the trends in annual dermatologic office visit rates, skin biopsy rates, incidence rates of in situ and invasive CMM by tumour thickness category, and CMM mortality rates in the Emilia-Romagna Region (northern Italy).

METHODS

Four cancer registries covering a population of 2,696,000 provided CMM incidence data for the years 2003-2017. Dermatologic office visit rates and skin biopsy rates were calculated using the Regional outpatient care database. All rates were age-standardized. Trends were described with the estimated average annual per cent change (EAAPC). Correlations were tested with the Spearman correlation coefficient.

RESULTS

Incidence increased significantly. The increase was steeper for in situ CMM (EAAPC: men, 10.2; women, 6.9) followed by CMM <0.8 mm thick (9.1; 5.2), but the rates grew significantly for most subgroups of CMMs ≥0.8 mm thick. Mortality decreased significantly among women (-2.3) and non-significantly among men. For dermatologic office visit rate and skin biopsy rate the EAAPC were, respectively, 1.7 and 1.8 for men and 1.2 and 0.9 for women. Annual dermatologic office visit rate correlated with skin biopsy rate in both sexes. However, the proportion of skin biopsies out of dermatologic office visits was constant across the years (range: men, 0.182-0.216; women, 0.157-0.191).

CONCLUSIONS

In Italy, the increasing CMM incidence trend is, at least in part, genuine. Overdiagnosis-if any-is due to an increased patient presentation at dermatologic offices and not to a lower dermatologic threshold to perform biopsy.

The relative contribution of the decreasing trend in tumour thickness to the 2010s increase in net survival from cutaneous malignant melanoma in Italy: a population-based investigation

BACKGROUND

The long-term increase in survival from cutaneous malignant melanoma (CMM) is generally attributed to the decreasing trend in tumour thickness, the single most important prognostic factor.

OBJECTIVES

To determine the relative contribution of decreased tumour thickness to the favourable trend in survival from CMM in Italy.

METHODS

Eleven local cancer registries covering a population of 8 056 608 (13.4% of the Italian population in 2010) provided records for people with primary CMM registered between 2003 and 2017. Age-standardized 5-year net survival was calculated. Multivariate analysis of 5-year net survival was undertaken by calculating the relative excess risk (RER) of death. The relative contribution of the decrease in tumour thickness to the RER of death was evaluated using a forward stepwise flexible parametric survival model including the available prognostic factors.

RESULTS

Over the study period, tumour thickness was inversely associated with 5-year net survival and multivariate RER in both sexes. The median thickness was 0.90 mm in 2003-2007, 0.85 mm in 2008-2012 and 0.75 mm in 2013-2017 among male patients, and 0.78 mm, 0.77 mm and 0.68 mm among female patients, respectively. The 5-year net survival was 86.8%, 89.2% and 93.2% in male patients, and 91.4%, 92.0% and 93.4% in female patients, respectively. In 2013-2017, male patients exhibited the same survival as female patients despite having thicker lesions. For them, the increasing survival trend was more pronounced with increasing thickness, and the inclusion of thickness in the forward stepwise model made the RER in 2013-2017 vs. 2003-2007 increase from 0.64 [95% confidence interval (CI) 0.51-0.80] to 0.70 (95% CI 0.57-0.86). This indicates that the thickness trend accounted for less than 20% of the survival increase. For female patients, the results were not significant but, with multiple imputation of missing thickness values, the RER rose from 0.74 (95% CI 0.58-0.93) to 0.82 (95% CI 0.66-1.02) in 2013-2017.

CONCLUSIONS

For male patients in particular, decrease in tumour thickness accounted for a small part of the improvement in survival observed in 2013-2017. The introduction of targeted therapies and immune checkpoint inhibitors in 2013 is most likely to account for the remaining improvement.

Expression of the cancer stem cell marker OCT4 is associated with worse prognosis and survival in cutaneous melanoma

Cutaneous melanoma has an aggressive clinical presentation, showing rapid rate of growth and metastatic dissemination due to the permanence of cancer stem cells. The present study was to evaluate the expression of the self-renewal regulatory factor and the clinical significance of the transcription factor OCT4 in melanoma. Melanoma tissues were stained by immunohistochemistry and the correlation between the expression of this marker was determined through clinical-pathological variables and survival outcomes. Positive expression of nuclear and cytoplasmic OCT4 was observed in 49% and 41.2% of cases, respectively. The positive expression of nuclear OCT4 in melanoma was significantly associated with prognostic factors, such as Breslow depth, Clark's level, ulceration and metastasis. Survival of patients was 56% compared to positive nuclear OCT4 expression and 94.2% when compared to the low expression of the gene. Nuclear OCT4 positive genotype indicated aggressive tumor behavior with a worse clinical outcome, which indicates OCT4 as a useful biomarker in the prognosis of melanoma.

Chimeric antigen receptor T-cell therapy for melanoma

INTRODUCTION

In recent years, chimeric antigen receptor (CAR) T cell therapy has emerged as a cancer treatment. After initial therapeutic success for hematologic malignancies, this approach has been extended for the treatment of solid tumors including melanoma.

AREAS COVERED

T cells need to be reprogramed to recognize specific antigens expressed only in tumor cells, a difficult problem since cancer cells are simply transformed normal cells. Tumor antigens, namely, CSPG4, CD70, and GD2 have been targeted by CAR-T cells for melanoma. Moreover, different co-stimulatory signaling domains need to be selected to direct T cell fate. In this review, various approaches for the treatment of melanoma and their effectiveness are comprehensively reviewed and the current status, challenges, and future perspective of CAR-T cell therapy for melanoma are discussed. Literature search was accomplished in three databases (PubMed, Google scholar, and Clinicaltrials.gov). Published papers and clinical trials were screened and relevant documents were included by checking pre-defined eligibility criteria.

EXPERT OPINION

Despite obstacles and the risk of adverse events, CAR T cell therapy could be used for patients with treatment-resistant cancer. Clinical trials are underway to determine the efficacy of this approach for the treatment of melanoma.

Mid-term trends and recent birth-cohort-dependent changes in incidence rates of cutaneous malignant melanoma in Italy

In Oceania, North America and north-western Europe, after decades of increase, cutaneous malignant melanoma (CMM) rates began to stabilise or decline before 2000. Anecdotal evidence suggests that the reversal of the incidence trend is extending to southern Europe. To obtain a formal confirmation, this nationwide study from Italy investigated the incidence trends by birth cohort. Twenty-one local cancer registries covering a population of 15 814 455 provided incidence data for primary CMM registered between 1994 and 2013. Trends in age-standardised rates were analysed using joinpoint regression models and age-period-cohort models. Age-standardised incidence showed a consistent increase throughout the period (estimated annual percent change, 3.6 [95% confidence interval, 3.2-4.0] among men and 2.5 [2.0-3.1] among women). This pattern was confirmed by a sensitivity analysis with removal of low-risk populations of southern Italy. The rates, however, showed a stabilisation or a decrease in men and women aged below 35. Using the cohort of 1949-the median cohort with respect to the number of cases for both genders-as a reference, the incidence rate ratio increased for successive cohorts born until 1973 (women) and 1975 (men), and subsequently tended to decline. For the most recent cohorts in both genders, the risk of disease returned to the level of the cohort of 1949. The changes observed in the latest generations can be interpreted as the earliest manifestations of a birth-cohort-dependent incidence decrease. Our study adds to previous data indicating that the reversal of the long-term upward incidence trend of CMM is extending to southern Europe.

The importance of total-body photography and sequential digital dermatoscopy for monitoring patients at increased melanoma risk

BACKGROUND AND OBJECTIVES

The incidence of melanoma is rising and prevention plays an important role. Multiple nevi as well as a medical history of melanoma are important risk factors. In affected patients, a two-step algorithm consisting of total-body photography (TBP) and sequential digital dermatoscopy (SDD) is a helpful diagnostic tool.

PATIENTS AND METHODS

This was a retrospective observational study that lasted six years in order to evaluate the significance of the two-step algorithm. Cases were evaluated based on distinct dermoscopic patterns and statistical analyses were performed with the latest version of SPSS.

RESULTS

6020 dermoscopic images of 214 patients were included. TBP was performed at a mean interval of 16.9 months (SD ± 1.43 months), while SDD was performed every 9.9 months (SD ± 1.68 months). The number needed to excise was 4.6 and the number needed to monitor was 548. Excisions were mostly performed because dynamic changes were observed. A total of eleven melanomas were detected and had a mean tumor thickness of 0.44 mm (SD ± 0.15 mm; range 0.2-0.6 mm).

CONCLUSIONS

Invasive melanomas had a tumor thickness of less than 0.6 mm, thus providing evidence of an effective strategy for early melanoma detection. Excisions of benign nevi were minimized as indicated by a low number needed to excise.

Apolipoprotein A-I anti-tumor activity targets cancer cell metabolism

Previously, we reported apolipoprotein A-I (apoA-I), the major protein component of high-density lipoprotein (HDL), has potent anti-melanoma activity. We used DNA microarray and bioinformatics to interrogate gene expression profiles of tumors from apoA-I expressing (A-I Tg+/-) versus apoA-I-null (A-I KO) animals to gain insights into mechanisms of apoA-I tumor protection. Differential expression analyses of 11 distinct tumors per group with > 1.2-fold cut-off and a false discovery rate adjusted p < 0.05, identified 176 significant transcripts (71 upregulated and 105 downregulated in A-I Tg+/- versus A-I KO group). Bioinformatic analyses identified the mevalonate and de novo serine/glycine synthesis pathways as potential targets for apoA-I anti-tumor activity. Relative to A-I KO, day 7 B16F10L melanoma tumor homografts from A-I Tg+/- exhibited reduced expression of mevalonate-5-pyrophosphate decarboxylase (Mvd), a key enzyme targeted in cancer therapy, along with a number of key genes in the sterol synthesis arm of the mevalonate pathway. Phosphoglycerate dehydrogenase (Phgdh), the first enzyme branching off glycolysis into the de novo serine synthesis pathway, was the most repressed transcript in tumors from A-I Tg+/-. We validated our mouse tumor studies by comparing the significant transcripts with adverse tumor markers previously identified in human melanoma and found 45% concordance. Our findings suggest apoA-I targets the mevalonate and serine synthesis pathways in melanoma cells in vivo, thus providing anti-tumor metabolic effects by inhibiting the flux of biomolecular building blocks for macromolecule synthesis that drive rapid tumor growth.

Time trends and age-period-cohort analysis of cutaneous malignant melanoma incidence rates in the Romagna Region (northern Italy), 1986-2014

After a long-term increase, the incidence of cutaneous malignant melanoma has stabilized recently or even decreased in several populations of North-western Europe, USA, Canada, Australia and New Zealand, but not in southern Europe. The incidence trends of primary invasive cutaneous malignant melanoma (International Classification of Diseases, 10th revision, codes C43.0-C43.9) in the Romagna Region (northern Italy, 1.2 million inhabitants) for the period 1986-2014 were analysed with an age-period-cohort modelling approach. The series included 2466 men and 2481 women, a total of 4947 patients. Using the method of model building, the best-fitting models were found to be an age-drift model for men and an age-period model for women. Among men, the age-specific incidence rates increased in each successive cohort born between 1916 and 1981 with an attenuation of the trend for younger ones in the last cohorts. Among younger women, a slight decrease occurred for the cohorts born after 1961. For men, the quasi-parallel appearance of incidence curves by age group and cohort on a log scale suggested that the observed change was explained by a linear cohort effect. For women, the curves tended to overlap, suggesting an interaction between age and cohort that could be explained as a nonlinear period effect. In conclusion, the long-term upward incidence trend in the study area is stabilizing among women and an attenuation of the increasing trend is occurring among younger men in the most recent cohorts. These observations need to be confirmed with longer-term studies.

Epidemiology of Skin Cancer: Update 2019

Melanoma and keratinocyte skin cancer (KSC) are the most common types of cancer in White-skinned populations. Both tumor entities showed increasing incidence rates worldwide but stable or decreasing mortality rates. Rising incidence rates of cutaneous melanoma (CM) and KSC are largely attributed to increasing exposure to ultraviolet (UV) radiation, the main causal risk factor for skin cancer.Incidence rates of KSC, comprising of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are much higher than that of melanoma. BCC development is mainly the cause of an intensive UV exposure in childhood and adolescence, while SCC development is related to chronic, cumulative UV exposure over decades. Although mortality is relatively low, KSC is an increasing problem for health care services causing significant morbidity.Cutaneous melanoma is rapidly increasing in White populations, with an estimated annual increase of around 3-7% over the past decades. In contrast to SCC, melanoma risk is associated with intermittent and chronic exposure to sunlight. The frequency of its occurrence is closely associated with the constitutive color of the skin and the geographical zone. Changes in outdoor activities and exposure to sunlight during the past 70 years are an important factor for the increasing incidence of melanoma. Mortality rates of melanoma show stabilization in the USA, Australia, and in European countries. In the USA even dropping numbers of death cases were recently reported, probably reflecting efficacy of the new systemic treatments.Among younger cohorts in some populations (e.g., Australia and New Zealand,), stabilizing or declining incidence rates of CM are observed, potentially caused by primary prevention campaigns aimed at reducing UV exposure. In contrast, incidence rates of CM are still rising in most European countries and in the USA. Ongoing trends towards thinner melanoma are largely ascribed to earlier detection.

Evaluation of Diffusion-Weighted MRI and FDG-PET/CT to Assess Response to AdCD40L treatment in Metastatic Melanoma Patients

The purpose was to evaluate the potential of diffusion-weighted-magnetic resonance imaging (DW-MRI) and ¹⁸F-fludeoxy-glucose-positron emission tomography integrated with CT (FDG-PET/CT) for prediction of overall survival (OS) following AdCD40L-immunotherapy in patients with metastatic malignant melanoma (MMM). Twenty-four patients with refractory MMM were treated with immunostimulatory AdCD40L gene therapy in a phase I/IIa study. Pre-therapeutic DW-MRI and FDG-PET/CT were performed and then repeated at 5 and 9 weeks post-treatment. Evaluation was conducted according to RECIST 1.1 and EORTC criteria. Apparent diffusion coefficient (ADC), true diffusion coefficient (D), maximum standardized uptake value (SUV_max) were measured in the injected lesions. Fold changes (F) in ADC (F ADC), D (F D), SUV_max (F SUV_max) were statistically assessed. F D ≥ 1 and F ADC ≥ 1 were associated with better OS in scans at week 5 and 9 respectively. F SUVmax was not correlated to OS. F ADC ≥ 1 in both post-treatment scans and F D ≥ 1 at week 5 were related to a significant decrease of size of the injected lesions. These results suggest that in patients with MMM treated with AdCD40l, functional parameters of DW-MRI are better early predictors of OS than the established metabolic and morphologic criteria for FDG-PET/CT and MRI, respectively.

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

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

Dermatological cancer screening: Evaluation of a new community pharmacy service

BACKGROUND

Skin cancer accounts for one third of all cancers. Prognosis is inversely related to identification stage.

OBJECTIVES

To describe a novel service, mole scans, performed in community pharmacy, the findings from the first 3.5 years it was in place, and to explore patient acceptability of the service.

METHODS

Norwegian Boots' pharmacies offer a mole scanning service in cooperation with ScreenCancer. Scans are undertaken within pharmacy consultation rooms. Image interpretation is undertaken remotely by a specialist. Number and result of scans performed from 2010 to 2014 are reported. A satisfaction questionnaire was returned by 10% of participants.

RESULTS

A total of 25836 scans were performed on 15777 individuals. Of these, 83.6% had normal scans, 1% had melanoma, and 15.4% had another skin condition. In 2014 the service identified 4.1% of melanoma cases registered in the Norwegian Cancer Registry. Most responders (88%) would use a similar service again. Nearly all (99%) felt the pharmacy was a suitable venue, and 95% would recommend the service to others. In total, 99% of respondents scored their overall satisfaction as "good" or higher.

CONCLUSIONS

This approach was acceptable among participants who provided feedback. Providing mole scanning through pharmacies enables individuals to obtain a rapid check of moles causing concern, in an acceptable environment with a high level of satisfaction.

A Fast-Track Referral System for Skin Lesions Suspicious of Melanoma: Population-Based Cross-Sectional Study from a Plastic Surgery Center

Introduction. To minimize delay between presentation, diagnosis, and treatment of cutaneous melanoma (CM), a national fast-track referral system (FTRS) was implemented in Denmark. The aim of this study was to analyze the referral patterns to our department of skin lesions suspicious of melanoma in the FTRS. Methods. Patients referred to the Department of Plastic Surgery and Breast Surgery in Zealand University Hospital were registered prospectively over a 1-year period in 2014. A cross-sectional study was performed analyzing referral patterns, including patient and tumor characteristics. Results. A total of 556 patients were registered as referred to the center in the FTRS for skin lesions suspicious of melanoma. Among these, a total of 312 patients (56.1%) were diagnosed with CM. Additionally, 41 (7.4%) of the referred patients were diagnosed with in situ melanoma. Conclusion. In total, 353 (63.5%) patients had a malignant or premalignant melanocytic skin lesion. When only considering patients who where referred without a biopsy, the diagnostic accuracy for GPs and dermatologists was 29% and 45%, respectively. We suggest that efforts of adequate training for the referring physicians in diagnosing melanocytic skin lesions will increase diagnostic accuracy, leading to larger capacity in secondary care for the required treatment of malignant skin lesions.

Incidence of cutaneous malignant melanoma by socioeconomic status in Canada: 1992-2006

BACKGROUND

There are no nationwide studies documenting changes in cutaneous malignant melanoma incidence or association of incidence with socioeconomic status (SES) in Canada. We sought to determine whether melanoma incidence increased from 1992 to 2006 and if there was an association between SES and melanoma incidence. Additionally, we studied whether there was a correlation between province of residence and melanoma incidence.

METHODS

Cases from the Canadian Cancer Registry were reviewed. Demographic and socioeconomic information were extracted from the Canadian Census of Population data. Cases were linked to income quintiles by postal code. A negative binomial regression was performed to identify relationships among these variables.

RESULTS

Overall incidence of melanoma in Canada increased by 67 % from 1992 to 2006 (p < 0.0001). The increase in incidence was greater for melanoma in situ compared with invasive melanoma (136 % versus 52 % [p < 0.0001]). Incidence was positively correlated with higher income quintiles; the incidence rates among patients in the lowest income quintiles were 67 % of that for the highest income quintiles (p < 0.0001).

DISCUSSION

A wide variety of explanations have been postulated for an increased incidence in melanoma among persons of higher SES, including access to and awareness of screening, more access to vacations in sunny climates, and increased leisure time. Variations in incidence of melanoma by urban vs. rural location and province may indicate differences in access to dermatologists across Canada.

CONCLUSIONS

Melanoma incidence is increasing in Canada and is higher among people in high SES groups. This rise is likely due to a combination of factors including a true rise in incidence due to increases in sun exposure, and also an increased detection rate, particularly in those who are more aware of the disease and have access to resources for detection.

Prevalence of sunbed use, and characteristics and knowledge of sunbed users: results from the French population-based Edifice Melanoma survey

BACKGROUND

In addition to natural sunlight, indoor tanning has emerged as a common source of ultraviolet (UV) radiation associated with an increased risk of melanoma. It is classified as a class I human carcinogen by the World Health Organization.

OBJECTIVES

This analysis presents data on the prevalence of sunbed use in France, on factors associated with sunbed use, and on risk factors, attitude and awareness of risk among sunbed users and non-users.

METHODS

Edifice Melanoma, a nationwide observational survey, was conducted in France via telephone interviews among a representative sample of 1502 subjects aged ≥18 years, using the quota method. Sunbed users were defined as individuals who reported having used a sunbed at least once in their lifetime. Logistical regressions were conducted in order to identify which factors differentiate the population of sunbed users from that of non-users.

RESULTS

One in ten respondents was a sunbed user and three out of four declared having used tanning facilities for over one year. In multivariate analysis, factors significantly associated with the sunbed-user group were female gender (OR = 3.897 [2.573-5.903], P < 0.001), a higher socio-professional category (OR = 2.227 [1.542-3.217]; P < 0.001), fair hair (OR = 1.583 [1.025-2.447], P = 0.039), fair skin (OR = 1.879 [1.086-3.253]; P = 0.024), freckles (OR = 1.570 [1.071-2.302]; P = 0.021) and a history of smoking (OR = 2.383 [1.633-3.476]; P < 0.001). In a second multivariate model, the fact of having a large number of melanoma risk factors was strongly associated with sunbed use (P = 0.001). Sunbed users were more likely to be informed of the role of sun exposure in reducing the skin's regenerative capacity (OR = 2.181 [1.319-3.607]; P = 0.002) but were nevertheless more likely to consider that a tan makes a person look more attractive (OR = 2.309 [1.312-4.064]; P = 0.004) and protects the skin (OR = 2.490 [1.532-4.046]; P < 0.001); they were also more frequently exposed to natural sunlight (OR = 2.214 [1.196-4.102]; P = 0.011).

CONCLUSIONS

Compared to non-users, sunbed users cumulate risk factors for melanoma. Knowledge, attitudes and intentions of individuals are critical targets for public education programmes. However, awareness campaigns focusing on sunbed use, and more generally on skin cancer, should also take social and cultural norms into account.

Investigating work-related neoplasia associated with solar radiation

BACKGROUND

Both solar and non-solar exposures associated with occupation and work tasks have been reported as skin carcinogens. In the UK, there are well-established surveillance schemes providing relevant information, including when exposures took place, occupation, location of work and dates of symptom onset and diagnosis.

AIMS

To add to the evidence on work-related skin neoplasia, including causal agents, geographical exposure and time lag between exposure and diagnosis.

METHODS

This study investigated incident case reports of occupational skin disease originating from clinical specialists in dermatology reporting to a UK-wide surveillance scheme (EPIDERM) by analysing case reports of skin neoplasia from 1996 to 2012 in terms of diagnosis, employment, suspected causal agent and symptom onset.

RESULTS

The suspected causal agent was 'sun/sunlight/ultraviolet light' in 99% of the reported work-related skin neoplasia cases. Most cases reported (91%) were in males, and the majority (62%) were aged over 65 at the time of reporting. More detailed information on exposure was available for 42% of the cases, with the median time from exposure to symptom onset ranging from 44 (melanoma) to 57 (squamous cell carcinoma) years. Irrespective of diagnostic category, the median duration of exposure to 'sun/sunlight/ultraviolet light' appeared longer where exposures occurred in the UK (range 39-51 years) rather than outside the UK (range 2.5-6.5 years).

CONCLUSIONS

It is important to provide effective information about skin protection to workers exposed to solar radiation, especially to outdoor workers based outside the UK.

Incidence and survival in patients with cutaneous melanoma by morphology, anatomical site and TNM stage: a Danish Population-based Register Study 1989-2011

INTRODUCTION

The incidence of melanoma of the skin has risen in Denmark in recent decades, the increase being steeper from 2004. It is unclear whether this represents a true rise in incidence or whether it is caused by an increased awareness of the condition.

METHODS

To assess whether the increase was characterised by early-stage melanomas and a higher proportion of melanomas with superficial spreading morphology, we studied all skin melanoma patients registered in the Danish Cancer Register 1989-2011 (n=27,010) and followed up for death through 2013. Trends in age-standardised incidence by sex, subsite and morphology, relative survival, TNM stage distribution and stage-specific relative survival from 2004 were analysed.

RESULTS

The incidence of melanoma more than doubled over 23 years. A steeper increase from 2004 was driven mainly by superficial spreading tumours, but the proportion of nodular melanomas in patients 50 years of age and over also increased significantly. The largest increase occurred for stage I tumours and for tumours on the trunk. From 1989-1993 to 2009-2011 the 5-year relative survival increased at 12% and 6% points for male and female patients, respectively.

INTERPRETATION

Greater awareness, and thus lower stage at diagnosis (mediated by a large skin cancer prevention campaign from 2007), might explain part of the increase, but the increase in nodular melanoma also points to a genuine increase in the risk of melanoma.

Malignant cancer and invasive placentation: A case for positive pleiotropy between endometrial and malignancy phenotypes

Cancer metastasis is an invasive process that involves the transplantation of cells into new environments. Since human placentation is also invasive, hypotheses about a relationship between invasive placentation in eutherian mammals and metastasis have been proposed. The relationship between metastatic cancer and invasive placentation is usually presented in terms of antagonistic pleiotropy. According to this hypothesis, evolution of invasive placentation also established the mechanisms for cancer metastasis. Here, in contrast, we argue that the secondary evolution of less invasive placentation in some mammalian lineages may have resulted in positive pleiotropic effects on cancer survival by lowering malignancy rates. These positive pleiotropic effects would manifest themselves as resistance to cancer cell invasion. To provide a preliminary test of this proposal, we re-analyze data from Priester and Mantel (Occurrence of tumors in domestic animals. Data from 12 United States and Canadian colleges of veterinary medicine. J Natl Cancer Inst 1971; 47: :1333-44) about malignancy rates in cows, horses, cats and dogs. From our analysis we found that equines and bovines, animals with less invasive placentation, have lower rates of metastatic cancer than felines and canines in skin and glandular epithelial cancers as well as connective tissue sarcomas. We conclude that a link between type of placentation and species-specific malignancy rates is more likely related to derived mechanisms that suppress invasion rather than different degrees of fetal placental aggressiveness.

[Sequential digital dermatoscopic imaging. How much time is required per patient?]

BACKGROUND

Melanoma screening is possible using the naked eye, a loupe, a dermatoscope or a sequential digital dermatoscopic imaging (SDDI) device. The latter provides photodocumentation and makes it possible to assess changes over time. One potential disadvantage of this method has been felt to be in the time expenditure per patient.

OBJECTIVES

Objective was to prospectively assess the time required for routine melanoma screening, using a SDDI device.

MATERIALS AND METHODS

All patients screened for melanoma using a SDDI system (Mole Max2) in a private dermatology practice during 1 year were included prospectively. The time needed per patient was measured. Suspicious lesions were excised and histologically evaluated. The number needed to treat (NNT) was calculated. Excisions performed exclusively due to cosmetic reasons were not included.

RESULTS

381 patients with 10,356 melanocytic lesions were documented using SDDI and clinically assessed (mean: 27.18 melanocytic lesions per patient; min:1, max:110). Mean time consumption per lesion was 15.4 s. (min:3, max:57) and per patient about 7 min. 98 suspicious lesions were excised, among them13 melanomas; yielding a NNT of 7.54.

CONCLUSIONS

SDDI can be easily integrated into the daily routine; a variety of systems are available. The time required is reasonable, about 7 min per patient and about 15 s per lesion. The quality of the evaluation is operator-dependent; it can be evaluated by determining the NNT. A major advantage of this diagnostic procedure is the photodocumentation which makes it possible to assess potential progression of a melanocytic lesion.

Socioeconomic status and cutaneous malignant melanoma in Northern Europe

Socioeconomic status (SES) is associated with cutaneous malignant melanoma (CMM) in Northern Europe, despite equal access to health care. SES per se is not responsible for this association, which must be ascribed to important risk factors for CMM such as intermittent ultraviolet radiation (UVR) exposure, and screening for CMM possibly owing to a greater knowledge and understanding of CMM. Our review of the literature showed that high SES is associated with increased risk of CMM, thinner tumours, increased survival and decreased mortality from CMM - the latter shown among women, and in recent studies also among men. There is evidence that high SES is associated with sun holidays, whereas low SES is associated with the use of sunbeds. Findings suggest that high SES is associated with the use of physicians and dermatologists for marks and moles, possibly owing to more knowledge and better understanding of CMM. We conclude that there has been a true increase in CMM incidence among high SES individuals in Northern Europe probably due to past intense intermittent UVR exposure, especially in connection with sun holidays. However, the increased risk of CMM and a better outcome of CMM in high SES individuals may also be conditioned by frequent recourse to physicians, which may be ascribed to more knowledge and better understanding of CMM, although more studies on this subject are warranted. Thicker CMM tumours and increased CMM mortality among low SES individuals in recent decades may reflect exposure to intermittent UVR, such as the use of sunbeds, as well as delayed diagnosis.

Burden of disease due to cutaneous melanoma has increased in the Netherlands since 1991

BACKGROUND

The burden of disease, describing loss of health and death due to a disease, has not been fully studied for melanoma in the general population over time.

OBJECTIVES

To determine the burden of disease due to melanoma in the Netherlands.

METHODS

Age- and sex-specific incidence data from all patients with melanoma in the Netherlands between 1991 and 2010 were obtained from the Netherlands Cancer Registry. Melanoma-specific mortality and life expectancy data were obtained from Statistics Netherlands. Melanoma duration was calculated using the DISMOD software from the World Health Organization. The years of life lived with disability (YLD) and years of life lost (YLL) due to melanoma were calculated using Dutch disability weights, incidence and mortality of melanoma, and the life expectancy from the general population. The number of disability-adjusted life-years (DALYs) was estimated by adding YLD and YLL.

RESULTS

The world-standardized incidence rates of melanoma have more than doubled for both men (7·1 per 100 000 inhabitants in 1991 to 17·0 in 2010) and women (9·4 per 100 000 inhabitants in 1991 to 19·8 in 2010). Likewise, the burden of melanoma to society has increased rapidly. The YLD for men increased from 4795 (1991-4) to 12 441 (2007-10), and for women from 7513 (1991-4) to 16 544 (2007-10). In 2007-10 the total YLL due to melanoma was 30 651 for men and 26 244 for women compared with 17 238 and 16 900, respectively, in 1991-4. The DALYs increased by 96% for men, from 22 033 (1991-4) to 43 092 (2007-10), and by 75% for women, from 24 413 (1991-4) to 42 788 (2007-10).

CONCLUSIONS

Melanoma is becoming a great burden to Dutch society.

Exploring patterns of recurrent melanoma in Northeast Scotland to inform the introduction a digital self-examination intervention

BACKGROUND

Melanoma incidence is growing and more people require follow-up to detect recurrent melanoma quickly. Those detecting their own recurrent melanoma appear to have the best prognosis, so total skin self examination (TSSE) is advocated, but practice is suboptimal. A digital intervention to support TSSE has potential but it is not clear which patient groups could benefit most. The aim of this study was to explore cutaneous melanoma recurrence patterns between 1991 and 2012 in Northeast Scotland. The objectives were to: determine how recurrent melanomas were detected during the period; explore factors potentially predictive of mode of recurrence detection; identify groups least likely to detect their own recurrent melanoma and with most potential to benefit from digital TSSE support.

METHODS

Pathology records were used to identify those with a potential recurrent melanoma of any type (local, regional and distant). Following screening of potential cases available secondary care-held records were subsequently scrutinised. Data was collected on demographics and clinical characteristics of the initial and recurrent melanoma. Data were handled in Microsoft Excel and transported into SPSS 20.0 for statistical analysis. Factors predicting detection at interval or scheduled follow-up were explored using univariate techniques, with potentially influential factors combined in a multivariate binary logistic model to adjust for confounding.

RESULTS

149 potential recurrences were identified from the pathology database held at Aberdeen Royal Infirmary. Reliable data could be obtained on 94 cases of recurrent melanoma of all types. 30 recurrences (31.9%) were found by doctors at follow-up, and 64 (68.1%) in the interval between visits, usually by the patient themselves. Melanoma recurrences of all types occurring within one-year were significantly more likely to be found at follow-up visits, and this remained so following adjustment for other factors that could be used to target digital TSSE support.

CONCLUSIONS

A digital intervention should be offered to all newly diagnosed patients. This group could benefit most from optimal TSSE practice.

Conditional survival of malignant melanoma in The Netherlands: 1994-2008

BACKGROUND

Cutaneous malignant melanoma causes the majority of skin cancer related deaths and features increasing incidence and mortality rates in the Netherlands. Conditional survival analysis is performed on patients who survived the preceding year(s).

METHODS

Patients with invasive melanoma, as recorded in the population-based Netherlands Cancer Registry, were included. To assess prognosis of melanoma survivors according to gender and Breslow thickness, conditional five-year relative survival was calculated for lymph node negative melanoma patients and conditional one-year relative survival was analysed for melanoma patients with and without nodal involvement.

FINDINGS

Between 1994 and 2008, 40,050 patients developed a melanoma (stage I-III, of whom 6% with nodal involvement). Six to 8years after diagnosis, survival of patients with a 1-2mm (T2) thick melanoma equalised the general population. Conditional five-year relative survival for patients with >4mm thick (T4) melanomas increased from about 60% at diagnosis to 90% at 7years after diagnosis. Largest improvements were found in patients with thick melanomas and female patients with nodal involvement.

INTERPRETATION

The prognosis for melanoma survivors improved with each additional year of survival after diagnosis, except for patients with a ⩽1mm thick melanoma, who never had any excess mortality during follow-up. Conditional survival of melanoma was better amongst females, amongst those with lower Breslow thickness and nodal stage.

Increasing incidence of melanoma among middle-aged adults: an epidemiologic study in Olmsted County, Minnesota

OBJECTIVE

To identify changes in the incidence of cutaneous melanoma over time in the fastest-growing segment of the US population-middle-aged adults.

PATIENTS AND METHODS

By using the Rochester Epidemiology Project resource, we identified patients aged 40 to 60 years who had a first lifetime diagnosis of melanoma between January 1, 1970, and December 31, 2009, in Olmsted County, Minnesota. The incidence of melanoma and overall and disease-specific survival rates were compared by age, sex, year of diagnosis, and stage of disease.

RESULTS

Between 1970 and 2009, age- and sex-adjusted incidence increased significantly over time (P<.001) from 7.9 to 60.0 per 100,000 person-years, with a 24-fold increase in women and a 4.5-fold increase in men. Although not significant (P=.06), the incidence of melanoma increased with age. Overall and disease-specific survival improved over time, with hazard ratios of 0.94 (P<.001) and 0.93 (P<.001) for each 1-year increase in the year of diagnosis, respectively. Each 1-year increase in the age at diagnosis was associated with an increased risk of death from any cause (hazard ratio, 1.07; P=.01) but was not significantly associated with disease-specific death (P=.98). Sex was not significantly associated with death from any cause (P=.81) or death from disease (P=.23). No patient with malignant melanoma in situ died from disease. Patients with stage II, III, and IV disease were more than 14 times more likely to die from disease than were patients with stage 0 or I disease (P<.001).

CONCLUSION

The incidence of cutaneous melanoma among middle-aged adults increased over the past 4 decades, especially in middle-aged women, whereas mortality decreased.

Cutaneous malignant melanoma in central iran: a 20-year study

BACKGROUND

Skin cancers are the most common cancers around the world. Cutaneous malignant melanoma (CMM) is the malignancy of melanocytes that are mainly located in the skin and mucous membranes.

OBJECTIVE

This study tried to evaluate the incidence and mean survival time of cutaneous malignant melanoma (CMM) in Yazd, Iran. It seems that the epidemiology and clinical aspects of CMM in Iran are different from those in other parts of the world; also due to the limited and scattered studies there isn't lot in the literature regarding CMM in Iran.

MATERIALS AND METHODS

This study used data obtained from the cancer registry center in the province of Yazd for a period of 21 years (1988 - 2008). Population and statistical data were gathered from "National Organization for Civil Registration". Population-based data were analyzed, focusing on the incidence and mean survival time over this 21 year period.

RESULTS

The mean incidence rate for CMM in Yazd-Iran between 1988 and 2008 was 0.40 per 100,000 for males and 0.27 per 100,000 for females per year, and the incidence of CMM was relatively constant during this period of time. The mean survival rates for women were better than men (80.5% and 76.3% respectively).

CONCLUSIONS

CMM in Yazd is a low-incidence skin tumor that shows a relatively fixed incidence between 1988 and 2008, Higher incidences of CMM were found in sun-exposed areas (especially head and neck areas), with more incidence in men. Skin cancers and CMM incidence in Iran is lower than western countries, most probably due to geographical zone, genetic factors, skin type, society-related customs including clothing styles.

Incidence of childhood and adolescent melanoma in the United States: 1973-2009

OBJECTIVE

Childhood and adolescent melanoma is rare but has been increasing. To gain insight into possible reasons underlying this observation, we analyzed trends in melanoma incidence diagnosed between the ages of 0 and 19 years among US whites by gender, stage, age at diagnosis, and primary site. We also investigated incidence trends by UV-B exposure levels.

METHODS

By using Surveillance, Epidemiology, and End Results (SEER) program data (1973-2009), we calculated age-adjusted incidence rates (IRs), annual percent changes, and 95% confidence intervals for each category of interest. Incidence trends were also evaluated by using joinpoint and local regression models. SEER registries were categorized with respect to low or high UV-B radiation exposure.

RESULTS

From 1973 through 2009, 1230 children of white race were diagnosed with malignant melanoma. Overall, pediatric melanoma increased by an average of 2% per year (95% confidence interval, 1.4%-2.7%). Girls, 15- to 19-year-olds, and individuals with low UV-B exposure had significantly higher IRs than boys, younger children, and those living in SEER registries categorized as high UV-B. Over the study period, boys experienced increased IRs for melanoma on the face and trunk, and females on the lower limbs and hip. The only decreased incidence trend we observed was among 15- to 19-year-olds in the high UV-B exposure group from 1985 through 2009. Local regression curves indicated similar patterns.

CONCLUSIONS

These results may help elucidate possible risk factors for adolescent melanoma, but additional individual-level studies will be necessary to determine the reasons for increasing incidence trends.

Host risk factors, ultraviolet index of residence, and incident malignant melanoma in situ among US women and men

The incidences of malignant melanoma in situ (MMIS) and invasive malignant melanoma are rising in the United States, but few studies have examined risk factors for MMIS. We evaluated the risk of MMIS according to the host phenotype and the ultraviolet index of the state of residence. Prospective data were collected via biennial questionnaires from 250,151 women and men aged ≥20 years in the Nurses' Health Study (1980-2008), the Nurses' Health Study 2 (1989-2009), and the Health Professionals Follow-up Study (1986-2008). During 7,144,820 person-years of follow-up, 888 incident MMIS lesions occurred, representing 33% of all incident malignant melanoma. Meta-analysis across the cohorts demonstrated that the presence of multiple nevi on the extremities conferred the highest relative risk for MMIS (relative risk = 3.18, 95% confidence interval: 2.59, 3.90). Family history of melanoma, number of severe sunburns, sunburn susceptibility, hair color, and Fitzpatrick skin types I, II, and III were significantly associated with an increased risk of MMIS. Conversely, the ultraviolet index of the state of residence at birth, at age 15 years, and at age 30 years was not associated with increased risk of MMIS. Continued study of MMIS and associated risk factors will help identify persons who are most at risk and elucidate the role of MMIS within the spectrum of cutaneous melanoma.

Prognosis of patients with transected melanomas

BACKGROUND

The management of melanoma is directly related to Breslow's depth. Biopsying melanomas in a fashion that transects the deep margin precludes an accurate measurement of the true depth.

OBJECTIVE

To examine the prognosis of melanomas transected along the deep margins, as well as cases where no residual melanoma was seen on re-excision after transection.

METHODS

Records from a cohort of patients at one institution were examined from 1996 through 2007. Patients were considered to have "transected" melanomas if tumor cells were present on the deep margin of the biopsy. Overall survival was determined.

RESULTS

Seven hundred fourteen patients were examined. 171 (24%) of all melanomas were transected. 101(59%) of those lacked tumor cells on re-excision. Patients with transected melanomas were older (OR = 1.03, p < .001), and had higher Breslow's depths (OR = 1.21, p < .001) than those without transected tumors. Those with no residual melanoma after transection were younger (OR = 0.98, p = .010) and more likely to have no lymph node involvement (OR = 2.23, p = .037). Neither transection (p = .760), nor lack of residual melanoma on re-excision after transection (p = .793) influenced survival.

CONCLUSION

A high number of melanomas are transected at diagnosis, many of which lack visible tumor. The original Breslow's depth of transected melanomas without residual tumor on re-excision accurately predicts survival and prognosis.

Comparing personal risk, melanoma knowledge and protective behaviour in people with and without melanoma: a postal survey to explore educational needs in northeast Scotland

In Northeast Scotland, 132 people with melanoma and 139 people never affected by melanoma completed a questionnaire measuring risk, level of concern, protective behaviour and knowledge. In adjusted analysis, people with melanoma had significantly higher personal risk, level of concern, protective behaviour and melanoma knowledge scores than those never affected. These data suggest that people diagnosed with melanoma in Northeast Scotland are being educated about how to avoid a second primary. The results of the adjusted analysis also suggest that in Northeast Scotland, melanoma education should be targeted at older people, men and those of lower educational status. It is also likely that this questionnaire could be used in the healthy population of Northeast Scotland to detect those most likely to benefit from targeted education to help prevent melanoma, and to measure the effects of and quality of melanoma public education campaigns.

Melanoma in Hong Kong between 1983 and 2002: a decreasing trend in incidence observed in a complex socio-political and economic setting

The aim of this study was to examine the incidence and mortality of cutaneous melanoma (CM) in Hong Kong. The epidemiology, clinical, and pathological features of melanoma in Asians are different from those in the European population, yet there is little in the literature that describes about melanoma in Asians. Data from the Hong Kong Cancer Registry from 1983 to 2002 were collected and reviewed. Population-based data were analyzed, focusing on the mortality and incidence rates over this 20-year period. The mean Hong Kong CM incidence rate between 1983 and 2002 was 0.8/100 000 for men and 0.6/100 000 for women. There was an overall decrease in the incidence of CM in Hong Kong between 1983 and 2002 (P<0.001). The crude mortality rate of melanoma varied from year-to-year in Hong Kong between 1983 and 2002, showing an overall increase within this period (P <0.001). Unlike most parts of the world, the overall incidence in Hong Kong is shown to trend downward between 1983 and 2002. Various factors including ethnic shifts within the Hong Kong population and the organization of the health care system may play a role in this observation. In addition, the mortality of melanoma increased between 1940 and 1990 in most parts of the world, but in Hong Kong, the mortality rate in the past 20 years reveals a modest upward trend. Its significance requires further investigation.

A melanoma epidemic in Iceland: possible influence of sunbed use

Since 1980, sunbed use and travel abroad have dramatically increased in Iceland (64°-66°N). The authors assessed temporal trends in melanoma incidence by body site in Iceland in relation to sunbed use and travel abroad. Using joinpoint analysis, they calculated estimated annual percent changes (EAPCs) and identified the years during which statistically significant changes in EAPC occurred. Between 1954 and 2006, the largest increase in incidence in men was observed on the trunk (EAPC = 4.6%, 95% confidence interval: 3.2, 6.0). In women, the slow increase in trunk melanoma incidence before 1995 was followed by a significantly sharper increase in incidence, mainly among women aged less than 50 years, resembling an epidemic incidence curve (1995-2002: EAPC = 20.4%, 95% confidence interval: 9.3, 32.8). In 2002, the melanoma incidence on the trunk was higher than the incidence on the lower limbs for women. Sunbed use in Iceland expanded rapidly after 1985, mainly among young women, and in 2000, it was approximately 2 and 3 times the levels recorded in Sweden and in the United Kingdom, respectively. Travels abroad were more prevalent among older Icelanders. The high prevalence of sunbed use probably contributed to the sharp increase in the incidence of melanoma in Iceland.

Skin cancer risk factors among primary school children: investigations in Western Hungary

OBJECTIVE

To evaluate the factors associated with sunburns and with sun protection practice in Hungarian primary school children.

METHOD

We investigated children's (the median age: 8, range 5 to 12 years) and parents' assessment of sun sensitivity and sun protection characteristics in cities Gyor and Zalaegerszeg (Hungary) in 2004. This cross-sectional study was part of a programme intended to increase children's and parents' awareness of harmful effects of excessive sunbathing. Analyses were based on 1804 multiple choice questionnaires.

RESULTS

At multivariate analysis a significant association between sunburns and fairness of complexion, freckles, use of sunscreens and T-shirts, and higher school-class level was observed. Sunburn was inversely associated with hat-wearing. Parents were more likely to apply sunscreen to children with light eyes and to the younger ones, to protect fair skinned children with T-shirts; to protect males and children with fair skin and light eyes with hats.

CONCLUSION

Since environmental factors play an important role in the development of skin cancer, morbidity could be reduced by primary prevention. Sun protection habits should therefore be taught early in life, and parents' behaviour adapted. Phenotype is not only related to sunburns but it also appears to influence parents' sun safety behaviour.

Patient understanding of moles and skin cancer, and factors influencing presentation in primary care: a qualitative study

Background

Melanoma incidence in the UK has doubled over two decades, yet there is conflicting evidence about factors which prompt or delay patients seeking advice. Aim: To explore patient understanding of pigmented skin lesions (moles) and skin cancer, and factors which influence seeking help in primary care.

Method

Semi-structured interviews with forty MoleMate Trial participants, analysed using the theoretical framework of the Safer-Andersen model of Total Patient Delay.

Results

Patient understanding and awareness was influenced by personal, family and friends' experiences of moles, skin cancer and other cancers, knowledge of risk factors, and the lay media. The route to consulting was complex and often iterative. For lesions that people could see, detecting and appraising change was influenced by comparisons with a normal mole on themselves, a family member, friend or image. Inferring illness came about with recognition of changes (particularly size) as serious, and associated 'internal' symptoms such as pain. For lesions that people could not see, family, friends and health professionals detected and appraised changes. Deciding to seek help was often prompted by another person or triggered by rapid or multiple changes in a mole. Three of four people subsequently diagnosed with melanoma did not seek help; instead, their GP opportunistically noticed the lesion.

Conclusions

Changing moles are often perceived as trivial and not signifying possible skin cancer. This study contributes to current national strategies to improve patient awareness and earlier diagnosis of cancer by highlighting factors that can trigger or act as barriers to seeking help.

(ISRCTN79932379)

Primary cutaneous melanoma: an 18-year study

BACKGROUND

Primary cutaneous melanoma still constitutes the main cause of skin cancer death in developed countries, and its incidence in recent years has been increasing in a steady, worrisome manner.

OBJECTIVES

This study evaluated the clinical, epidemiological and demographic aspects of this disease, and correlated them with patient prognosis.

METHODS

Using epidemiologic and clinical data, we analyzed 84 patients with mild to severe primary cutaneous melanoma treated between 1990 and 2007. Slides containing surgical specimens were analyzed, and new slides were made from archived paraffin sections when necessary.

RESULTS

The melanoma incidence was higher in areas of sun exposure, with lesions commonly observed in the trunk for males, and lower limbs for females. In addition to Breslow's thickness and ulceration (p = 0.043 and p < 0.001, respectively), the mitotic rate per mm(2) also correlated with worse patient outcome (p = 0.0007). The sum of ulceration (0 when absent or 1 when present), the Breslow index (1 when <1 mm, 2 when >1 mm and <4 mm, 3 when >4 mm) and the mitotic index (0 when absent or 1 when > or =1 per mm(2)) allowed the establishment of a prognostic score: if the sum was equal to or over three, nearly all (91.7%) patients had systemic disease. The 5-year survival was approximately seventy percent.

CONCLUSION

Because American Join Committee of Cancer Staging will update the classification of malignant tumors (TNM) staging in the near future, and introduce mitosis as a prognostic factor, our results show the importance of such a feature. Additional studies are necessary to confirm the importance of a prognostic score as proposed herein.

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.