Melanoma screening: critique and proposal

Día del Euromelanoma. Resultados en España de las campañas de 2000, 2001 y 2002

BACKGROUND

In the year 2000, the European Academy of Dermatology and Venereology initiated a campaign, called "Euromelanoma Day," for the early detection of melanoma.

OBJECTIVE

To discuss the results of "Euromelanoma Day" in Spain for the campaigns carried out in 2000, 2001 and 2002.

MATERIAL AND METHODS

Participating members of the Spanish Academy of Dermatology examined everyone who requested an appointment, free of charge, in order to detect suspicious lesions. Four months after the visit, telephone contact was made with all patients who had been diagnosed with suspected melanoma to ask them whether the lesions had been excised, and if so, the result of the histological study of the specimen.

RESULTS

33,750 calls to set up an appointment were received, and 12,487 patients were examined. The average participation by dermatologists was 399 academy members per year. A total of 164 lesions suspected of being melanoma were detected, above all in Andalusia and Catalonia, and the diagnosis was histologically confirmed in 31 cases. The clinicopathological correlation was 23.3 %, a higher figure than the one for the USA and similar to the one for Mediterranean countries. The average thickness of the tumors was 0.93 mm.

CONCLUSIONS

Although these campaigns have the drawback of possible bias in the findings and may cause some degree of public alarm, the benefit to the population was unquestionable in terms of heightening awareness of a health problem.

Cutaneous melanoma: patient surveillance and tumor progression

BACKGROUND

The goal of surveillance examinations (SVE) in patients at high risk for cutaneous melanoma (CM) is to diagnose premetastatic tumors.

OBJECTIVE

We attempted to determine whether SVE before CM diagnosis influences the histopathologic features of tumor progression.

METHODS

A retrospective review was conducted of consecutive patients who presented with an intact primary CM during a 36 month period (1991 to 1994) in a university dermatology ambulatory setting.

RESULTS

Thirty-nine intact CMs were diagnosed in 34 patients. Compared with 23 CMs in as many patients presenting at the first encounter, 16 CMs diagnosed in 11 patients during SVE had a smaller mean tumor diameter (P = .007) and tumor thickness (P = .002) and were more likely anatomic level I or II (P = .003) with microscopic thickness less than 0.76 mm (P = .01) and less than 0.50 mm (P = .002).

CONCLUSION

Primary CMs are more likely to be smaller and thinner when diagnosed during SVE than at first encounter, features that are likely to have a positive impact on CM mortality.

Skin cancer screening

The key to reducing morbidity and mortality from skin cancer is early detection. Prevention through education is, of course, ultimately the best outcome of collective human efforts. Many questions are still unresolved, but skin cancer screening by general internists, family practitioners, dermatologists, and other health professionals could prove cost-effective and reliable. As more knowledge becomes available, clinicians will have the resources to improve skills in prevention and early detection.

A pigmented lesion clinic: analysis of the first year's 1055 patients

The Pigmented Lesion Clinic (PLC) at Frenchay Hospital was started in January 1993 to deal rapidly and effectively with a growing number of referrals of suspicious pigmented lesions. Its objectives were to offer expert assessment and either reassurance or excision at the first PLC following referral by the patient's general practitioner. During 1993, 1055 patients were seen in 37 PLCs and 357 excision biopsies were performed. We have compared the Breslow thicknesses of malignant melanomas diagnosed from the PLCs with those of all other (non-PLC) malignant melanomas referred to our unit over the same period. We discuss the development and results of the first year of our PLC and the advantages it confers.

Barriers to effective skin cancer detection

BACKGROUND

In response to the dramatic rise in melanoma incidence, numerous health care specialists have encouraged primary care providers to increase skin cancer detection efforts. Although primary care providers currently find more melanomas than do dermatologists, many detection opportunities are missed. In addition, primary care providers occasionally incorrectly reassure patients about specific lesions. Nevertheless, there is little evidence that efforts to detect skin cancer are growing. This paper discusses barriers to skin cancer detection and potential ways to increase screening.

METHODS

Methods involve the review of the medical literature and the author's synthesis of this information.

RESULTS

The principle barriers to skin cancer detection are that it is a low priority in primary care, that the majority of exams do not result in significant findings, and that many providers lack expertise to adequately identify high risk lesions. Lack of reimbursement for preventive care, inadequate time for complete skin exams, and distraction by other health problems also play a role in limiting skin cancer detection efforts.

CONCLUSIONS

Relying on primary care-based skin cancer detection as the only means to increase skin cancer identification is an unwise policy. Approaches that may be able to increase skin cancer prevention and detection include increased (1) collaboration between skin cancer specialists and experts in primary care, (2) focus on providers of pediatric care, (3) advocacy for reimbursement of preventive health care, (4) educational efforts for the public to request skin exams, and (5) education directed to providers in high risk areas.

Public education projects in skin cancer. Experience of the Canadian Dermatology Association

The mandate of the Canadian Dermatology Association's Sun Awareness Program is to increase awareness of the dangers of the sun's ultraviolet (UV) rays and to provide information on prevention and early detection of skin cancer. Major projects include an annual national press campaign, which reaches an increasing number of Canadians each year, and the production and distribution of educational materials. Each year during Sun Awareness Week, screening stations have been established across the country, staffed by volunteer dermatologists and members of the Canadian Cancer Society. In Vancouver between 1991 and 1993, 1767 people were screened for skin cancer. Results indicate that these events can attract people at risk for skin cancer, even though people older than age 65 are probably underrepresented as a group. Although popular with the public, these screenings are difficult to organize and are limited by human resources. These events continue in limited numbers, because they provide an excellent venue for the dissemination of educational material. Cooperation with federal agencies has been a major focus of the program. For the past 2 years, educational material on protecting newborns and children from the sun has been made available free to every new mother in Canada, while Environment Canada's Ultraviolet index program provides daily information on UV intensity along with public health messages. With the realization that health promotion requires a sustained change in behavior of an individual, we are now embarking on a national program to evaluate the knowledge, attitudes, and behavior of Canadians concerning UV radiation. With this information, we hope to adapt our educational materials so that people will adopt and maintain healthy behavior choices while out in the sun.

Basal cell and squamous cell carcinomas are important risk factors for cutaneous malignant melanoma. Screening implications

BACKGROUND

This study was designed to determine the risk of developing malignant melanoma (MM) in patients with a history of basal cell and/or squamous cell skin cancer (BCC/SCC) and to determine whether surveillance efforts can be directed toward these patients for the detection of early MMs.

METHODS

The study cohort was followed by annual total cutaneous examination (TCE). Controls consisted of individuals from the United States population matched for age, sex, and length of follow-up. The anatomic locations of the study cohorts' newly diagnosed MMs were plotted on an anatomic chart. The setting was a private dermatology practice. Two hundred, ninety consecutive white patients with a history of BCC/SCC but with no personal or family history of MM were followed by annual TCEs. The main outcome measures were the relative risk of developing MM and their prognosis.

RESULTS

Ten of the 290 patients developed an MM within an average of 109 months of follow-up (range, 3-17 years). All MMs were less than 0.70 mm in Breslow thickness and 80% occurred on usually clothed cutaneous sites. The expected number of MMs in the control population was 0.59 (P = 0.006), resulting in a relative risk of 17.

CONCLUSION

Patients with BCC/SCC skin cancer are at substantial increased risk for developing MM. Regular and life-long surveillance TCE is an inexpensive and effective method for detecting curable MMs in such patients.