Skin cancer screening and surveillance

Awareness, knowledge, and attitude toward nonmelanoma skin cancer and actinic keratosis among the general population of western Saudi Arabia

Background:

This study evaluated the levels of awareness, knowledge, and attitude, including sun-protection habits, toward basal cell carcinoma and actinic keratosis among the Saudi population.

Materials and Methods:

A cross-sectional study was conducted among the general population of Jeddah, Saudi Arabia using a 12-item survey concerning the knowledge and awareness of basal cell carcinoma and actinic keratosis, as well as associated preventive measures. A Chi-square test was used to determine associations among variables.

Results:

The majority of participants were unaware of basal cell carcinoma and actinic keratosis (80.7%), while 8.6% were aware of both, and 9.8% and 1% were aware of only basal cell carcinoma or actinic keratosis, respectively. The majority of participants who were educated up to high school level had no knowledge of either condition (96%, P < 0.0001). Among participants with high levels of awareness of basal cell carcinoma and actinic keratosis, medical practitioners were identified as the main source of information (72.5%, P < 0.0001, and 70.6%, P < 0.0001, respectively). The majority of participants whose knowledge of the relationship between sun exposure and skin cancer was insufficient also lacked sufficient awareness of either basal cell carcinoma or actinic keratosis (92.6%, P < 0.0001). The majority of participants (62.8%) declared using sunscreen “rarely”.

Conclusion:

This study showed a low level of knowledge about the risks associated with sun exposure and suitable protection methods, with only a small fraction of participants declaring a regular use of sunscreen. Public education campaigns are required to increase the awareness of cancer risks and protection methods among the Saudi population.

Skin Cancer Screening on a Fishing Island and in an Inland Agricultural Area of Japan

We performed skin cancer screening from 2000 to 2004 at two locations in Japan's Oita Prefecture: Himeshima, a small fishing island, and Naoiri, an inland agricultural area. We found 108 and 21 cases of AK in Himeshima and Naoiri, respectively. None of the AKs transformed into SCC, and 21.7% of the AKs underwent spontaneous remission during our observation period. The prevalence and incidence of AK in Himeshima were five times higher than in Naoiri: 1,399 and 826 per 100,000 population, respectively, in the fishing village, vs. 261 and 164 in the agricultural community. Seven and three cases of BCC were observed in Himeshima and Naoiri, respectively. There were two cases of SCC in Himeshima. The highest risk ratio of skin types I to III was 9.2 in Himeshima. Although people engaged in outdoor occupations are thought to be more prone to skin cancer and precancerous skin lesions, our results suggested different potentials for AK in people engaged in different outdoor occupations.

Surgical excision margins for primary cutaneous melanoma

BACKGROUND

Cutaneous melanoma accounts for 75% of skin cancer deaths. Standard treatment is surgical excision with a safety margin some distance from the borders of the primary tumour. The purpose of the safety margin is to remove both the complete primary tumour and any melanoma cells that might have spread into the surrounding skin.Excision margins are important because there could be trade-off between a better cosmetic result but poorer long-term survival if margins become too narrow. The optimal width of excision margins remains unclear. This uncertainty warrants systematic review.

OBJECTIVES

To assess the effects of different excision margins for primary cutaneous melanoma.

SEARCH STRATEGY

In August 2009 we searched for relevant randomised trials in the Cochrane Skin Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2009), MEDLINE, EMBASE, LILACS, and other databases including Ongoing Trials Registers.

SELECTION CRITERIA

We considered all randomised controlled trials (RCTs) of surgical excision of melanoma comparing different width excision margins.

DATA COLLECTION AND ANALYSIS

We assessed trial quality, and extracted and analysed data on survival and recurrence. We collected adverse effects information from included trials.

MAIN RESULTS

We identified five trials. There were 1633 participants in the narrow excision margin group and 1664 in the wide excision margin group. Narrow margin definition ranged from 1 to 2 cm; wide margins ranged from 3 to 5 cm. Median follow-up ranged from 5 to 16 years.

AUTHORS' CONCLUSIONS

This systematic review summarises the evidence regarding width of excision margins for primary cutaneous melanoma. None of the five published trials, nor our meta-analysis, showed a statistically significant difference in overall survival between narrow or wide excision.The summary estimate for overall survival favoured wide excision by a small degree [Hazard Ratio 1.04; 95% confidence interval 0.95 to 1.15; P = 0.40], but the result was not significantly different. This result is compatible with both a 5% relative reduction in overall mortality favouring narrower excision and a 15% relative reduction in overall mortality favouring wider excision. Therefore, a small (but potentially important) difference in overall survival between wide and narrow excision margins cannot be confidently ruled out.The summary estimate for recurrence free survival favoured wide excision [Hazard Ratio 1.13; P = 0.06; 95% confidence interval 0.99 to 1.28] but again the result did not reach statistical significance (P < 0.05 level).Current randomised trial evidence is insufficient to address optimal excision margins for primary cutaneous melanoma.

Methyl aminolaevulinate?photodynamic therapy: a review of clinical trials in the treatment of actinic keratoses and nonmelanoma skin cancer

Methyl aminolaevulinate-photodynamic therapy (MAL-PDT) has advanced the management of nonmelanoma skin cancer (NMSC), providing a treatment option for actinic keratosis (AK), basal cell carcinoma [both superficial (sBCC) and nodular (nBCC)] and Bowen's disease, with good clinical outcomes, low recurrence rates and enhanced cosmetic acceptability. Excellent results have been reported, with complete responses (CRs) in AK ranging from 69% to 93% at 3 months; CRs in Bowen's disease are 93% at 3 months and 68% at 24 months. In sBCC, CRs range from 85% to 93% at 3 months and are comparable with cryosurgery up to 60 months (75% vs. 74%). In nBCC, CRs range from 75-82% at 3 months to 77% at 60 months. MAL-PDT specifically targets diseased cells, leaving healthy tissue unharmed. This noninvasive treatment option is associated with minimal risk of scarring. Moreover, systemic uptake of MAL is negligible and the local phototoxic reactions that often occur during treatment rapidly heal to produce excellent cosmetic results. The side-effects of therapy, which are predominantly local phototoxic effects (burning, stinging and prickling sensations), are of mild-to-moderate intensity, of short duration and easily managed. Overall, the efficacy and low risk of side-effects afforded by this therapy have resulted in high patient preference in clinical trials. The current evidence base for MAL-PDT in the treatment of AK and NMSC is reviewed in this article.

Teledermatoscopy as a triage system for pigmented lesions: a pilot study

BACKGROUND

Skin-cancer screening should rely on simple, low-cost and high-sensitivity diagnostic procedures.

AIMS

To compare diagnosis and management options after the evaluation of clinical and dermatoscopic teleconsultations with a store-and-forward teledermatology screening system for pigmented lesions.

METHODS

Kappa values between telediagnoses and the gold standard (histological examination) were assessed. Referral rates, diagnostic confidence level (DCL), sensitivity and specificity were evaluated in both approaches. Picture quality and time and cost investments were also measured. In total, 61 teleconsultations were evaluated.

RESULTS

Sensitivity of the clinical and dermatoscopic teleconsultations was 1 for both, whereas specificities were 0.65 and 0.78, respectively (P < 0.05). DCL was higher for the dermatoscopic teleconsultations (4.75 vs. 4.14, P < 0.05). Agreement between the clinical and dermatoscopic teleconsultation was kappa = 0.89 (95% CI 0.81-0.97). Agreement with the gold standard was 0.91 (95% CI 0.82-1.00) for the clinical teleconsultation and 0.94 (95% CI 0.88-1.00) for teledermatoscopy (P > 0.05). Teledermatoscopy increased the economic investment of a teledermatology facility by 2.4 times. The GP spent 1.5 times longer on dermatoscopic teleconsultations.

CONCLUSIONS

Teledermatoscopy has improved the DCL, specificity and referral rates of a teledermatology-based screening system for pigmented lesions. A more detailed economic analysis remains to be performed before recommending teledermatoscopy as a routine screening procedure in pigmented-lesion clinics.

The development of the nurse biopsy role

Research shows that nurse surgery posts strengthen continuity of care and allow collaboration with other health professionals to ensure patients receive appropriate and timely care. The consistent and integrated approach provided with the nurse biopsy role fills gaps in service provision and avoids duplication of services. Skin cancer is the most common cancer in the UK and at Queen's Medical Centre in Nottingham they see approximately 160 suspected cases each week. Before the introduction of the nurse biopsy role there was an 8-week wait for a biopsy by the doctor and a further 8-week wait for the removal of the tumour. Now, a patient with a suspected skin cancer can have a biopsy on the first visit to the clinic, reducing the wait from 8 weeks to 0 weeks. This reduction in waiting time facilitates improved mortality and morbidity from the skin cancer. It took 3 years to develop the nurse biopsy role in Nottingham and another 2 years to provide the service that is currently available. The nurse-led biopsy service is now being adopted nationwide, as recommended by the All Parliamentary Group on Skin (2003). The dermatology department at Queen's Medical Centre in Nottingham also runs an annual course to teach the surgery skills required to primary- and secondary-care nurses.

Human melanomas express functional P2X7 receptors

Adenosine 5'-triphosphate is known to function as a potent extracellular messenger, producing its effects via a distinct family of cell surface receptors. Different receptor subtypes have been shown to modulate different cellular functions such as proliferation, differentiation and apoptosis. We have investigated the functional expression and apoptotic action of the P2 X (7) receptor in human malignant melanoma tissue and cells. Incubation of cells with the potent P2 X (7) receptor agonist 2'-3'-O-(4-benzoyl-benzoyl) adenosine 5'-triphosphate leads to a decrease in cell number, which is dose-dependent and reversible by the antagonist 1-N,O-bis-[5-isoquinoline-sulfonyl]-N-methyl-L-tyrosyl)-4-phenyl-piperazine. Synthesis of the P2 X(7) receptor by these cells has been established by reverse transcriptase-polymerase chain reaction, immunohistochemistry, immunocytochemistry and cellular accumulation of the fluorescent DNA-binding dye YO-PRO-1. The P2 X(7) receptors have been shown to mediate apoptotic actions of extracellular nucleotides and represent a novel target for melanoma therapy.

P2Y purinergic receptors regulate the growth of human melanomas

Adenosine 5'-triphosphate is known to function as a potent extracellular messenger producing its effects via a distinct family of cell surface receptors. Different receptor subtypes have been shown to modulate different cellular functions such as proliferation, differentiation and apoptosis. We investigated the functional expression and proliferative action of metabotropic P2Y receptors in human melanoma tissue and cells. Expression of functional P2Y1, P2Y2 and P2Y6 receptor subtypes was established by reverse transcriptase polymerase chain reaction, immunohistochemistry and intracellular calcium measurements using a Fluorometric Imaging Plate Reader. Incubation of A375 melanoma cells with the P2Y1 receptor-selective agonist 2-methylthioadenosine-5-diphosphate caused a decrease in cell number which was dose-dependent, whereas incubation with the P2Y2 receptor agonist uridine triphosphate caused a dose-dependent increase in cell number. The action of extracellular nucleotides on P2Y receptors was shown to mediate the growth of melanomas and the P2Y1 receptor is a putative target for melanoma therapy.

Awareness of, knowledge of and attitudes to nonmelanoma skin cancer (NMSC) and actinic keratosis (AK) among physicians

BACKGROUND

Nonmelanoma skin cancer (NMSC) is the most common type of cancer that affects the Caucasian population. Approximately 80% of NMSCs are basal cell carcinoma (BCC) and 20% are squamous cell carcinoma (SCC). Actinic keratosis (AK) is a precancerous lesion that may develop into SCC.

METHODS

A market research survey was conducted in which dermatologists and primary care physicians (PCPs) were randomly selected from seven countries (USA, Australia, UK, Italy, France, Germany and Spain). Their knowledge of nonmelanoma skin cancer and their current clinical practice were assessed.

RESULTS

In total, 2100 physicians took part in the survey. They had practised medicine for between 1 and 30 years and saw at least 30 patients in a typical week. The majority of dermatologists (97%) were familiar with BCC and AK, and treated each condition with a minimum of referrals. PCPs were more familiar with BCC (90%) than with AK (74%). Of the PCPs that were aware of BCC, only 31% treated the condition, and of those aware of AK, 40% treated the condition. Surgery was the most common choice of treatment for BCC. The most popular treatment choice for AK lesions was cryotherapy. Eighty to 100% of physicians reported that they discussed skin cancer prevention with their patients. A much lower number of physicians (ranging from 5 to 37%) provided educational material to patients. Overall, PCPs in the two countries that have a high incidence of NMSC (USA and Australia) were more familiar with BCC and AK and more likely to treat each condition than PCPs in Europe. All physicians rated BCC as a more serious condition than AK. Facial lesions were considered more serious than lesions on the head or trunk for both conditions.

CONCLUSIONS

As the burden of disease and the number of patients seeking treatment for NMSC increase, dermatologists are well placed to lead educational initiatives for PCPs and provide educational material for patients. This would increase awareness of AK and BCC and could improve early diagnosis.

Induction of apoptosis and/or necrosis following exposure to antitumour agents in a melanoma cell line, probably through modulation of Bcl-2 family proteins

Malignant melanoma cells have been reported to be highly resistant to chemotherapeutic agents. To gain insight into the molecular mechanisms underlying chemotherapeutic drug resistance, we examined the role of the Bcl-2 family members Bcl-2 and Bax in cell death in the melanoma cell line G361 following stimulation with cisplatin (CDDP) or dacarbazine (DTIC). Trypan blue dye exclusion showed that both CDDP and DTIC induced death of G361 cells. Apoptotic and necrotic cell death could be distinguished by flow cytometry using combined staining with annexin V and 7-amino-actinomycin D (7-AAD). CDDP-induced cell death at a low concentration (0.6 micro g/ml) was mainly due to apoptosis (annexin V+/7-AAD-), while a mixture of apoptosis and secondary necrosis (annexin V+/7-AAD+) was found at a high concentration (6 micro g/ml). DTIC at the concentrations used induced only apoptosis. CDDP-induced apoptosis and secondary necrosis were accompanied by activation of caspase-3 and modulation of Bcl-2 family members Bcl-2 and Bax. On Western blotting Bax was seen to be upregulated with concomitant downregulation of Bcl-2. Flow cytometry, which enables measurement of protein at the single-cell level, revealed that Bcl-2+/Bax- cells were decreased, with a slight concomitant rise in Bcl-2-/Bax+ cells on stimulation with CDDP. These findings suggest that the chemotherapeutic agents CDDP and DTIC induce apoptosis and/or secondary necrosis depending on dose, probably involving the modulation of Bcl-2 family proteins.