Factors associated with a high tumour thickness in patients with melanoma

Nevus Count, Pigmentary Characteristics, and Melanoma-specific Mortality among Norwegian Women with Melanoma >1.0 mm Thick

Little is known about if and how nevi and pigmentation are associated with melanoma-specific mortality. However, increased melanoma awareness in people with lighter pigmentation and many nevi may result in earlier diagnosis of thinner less-lethal tumors. The aim of this study was to investigate associations between nevus count (asymmetrical > 5 mm and small symmetrical), pigmentary characteristics (hair colour, eye colour, skin colour, freckling, pigmentary score), and melanoma-specific mortality in subjects with melanomas > 1 mm. Data from the Norwegian Women and Cancer cohort, established in 1991, with complete follow-up of melanoma patients until 2018 through the Cancer Registry of Norway, were used to estimate hazard ratios with 95% confidence intervals for the associations between nevus count, pigmentary characteristics, and melanoma-specific mortality, stratified by tumor thickness using Cox regression. Estimated hazard ratios consistently indicated a higher risk of melanoma death for those with darker vs lighter pigmentary characteristics in patients with tumors > 1.0-2.0 mm and > 2.0 mm thick (e.g. pigmentary score hazard ratio 1.25, 95% confidence interval (0.74-2.13)). Among women with melanomas > 1.0 mm thick, lighter pigmentation and asymmetrical nevi may be associated with lower melanoma-specific mortality, suggesting that factors that increase the risk of melanoma may also be associated with decreased risk of death from melanoma.

Cutaneous melanoma diagnosis delay: socioeconomic and demographic factors influence

OBJECTIVE

Malignant cutaneous melanoma is the most aggressive type of skin cancer, and its early detection and prompt initiation of treatment play an important role in reducing disease-associated morbidity and mortality. Many factors influence the diagnosis of melanoma, and its recognition is essential for the development of strategies for its early detection. This study was carried out to Identify the main variables related to the delay in diagnosis of Malignant Cutaneous Melanoma and correlate them with the time interval for making the definitive diagnosis.

METHODS

Retrospective analysis of 103 patient records from January 2015 to December 2020 correlating social, economic, demographic, and cultural factors with the time elapsed between the onset of symptoms and the diagnosis of malignant cutaneous melanoma.

RESULTS

The average time to seek medical services from the onset of symptoms was 29.54 months. The mean time for a referral from the primary to the referral service was 1.35 months, and the factors that contributed to a faster diagnosis were lesion Breslow (>1 mm), lesion growth, income range (≤1.5 minimum wages), lower phototypes (I and II), not having gone to the Basic Healthcare Units, profession (household), smoking, and type of housing.

CONCLUSIONS

Our findings demonstrate that there is still a great delay in the recognition of signs and symptoms related to the diagnosis of malignant cutaneous melanoma in our country, influenced by several socioeconomic and demographic factors.

Factors Related to Delayed Diagnosis of Cutaneous Melanoma in the Brazilian Public Health System

In Brazil, 75% of the population uses the Sistema Único de Saúde (SUS), public health system, where the general practitioner (GP) is responsible for melanoma diagnosis. Identify the factors related to the delay in diagnosing melanoma patients assisted by SUS. A prospective observational study based on a questionnaire and medical records review assessed the sociodemographic features, melanoma signs and symptoms, previous knowledge of the disease, and factors related to delays in seeking medical care. One hundred sixty-six patients were included. Healthcare professionals suspected a lesion in only 23.5% of cases. The average time between lesion suspicion by patient/relative and first medical appointment with GP was over 6 months (31%). The time between the first GP exam and biopsy conducted by a specialist ranged from less than 1 month (34.9%) to more than 1 year (18.7%). Half of the patients (49.4%) experienced delays in histopathological diagnosis due to SUS bureaucracy/slowness. Most (80%) patients did not know what melanoma was before diagnosis. Delay in melanoma diagnosis was related to a lack of knowledge about the disease's signs and symptoms for both the study population and the primary physicians, indicating that both players must receive proper education about melanoma. Also, the infrastructure and work processed at SUS impeded the patient flow, contributing to the diagnosis of the lesions at more advanced stages.

Germline variants are associated with increased primary melanoma tumor thickness at diagnosis

Germline genetic variants have been identified, which predispose individuals and families to develop melanoma.

Tumor thickness is the strongest predictor of outcome for clinically localized primary melanoma patients. We sought to determine whether there is a heritable genetic contribution to variation in tumor thickness. If confirmed, this will justify the search for specific genetic variants influencing tumor thickness.

To address this, we estimated the proportion of variation in tumor thickness attributable to genome-wide genetic variation (variant-based heritability) using unrelated patients with measured primary cutaneous melanoma thickness. As a secondary analysis, we conducted a genome-wide association study (GWAS) of tumor thickness.

The analyses utilized 10 604 individuals with primary cutaneous melanoma drawn from nine GWAS datasets from eight cohorts recruited from the general population, primary care and melanoma treatment centers. Following quality control and filtering to unrelated individuals with study phenotypes, 8125 patients were used in the primary analysis to test whether tumor thickness is heritable. An expanded set of 8505 individuals (47.6% female) were analyzed for the secondary GWAS meta-analysis. Analyses were adjusted for participant age, sex, cohort and ancestry.

We found that 26.6% (SE 11.9%, P = 0.0128) of variation in tumor thickness is attributable to genome-wide genetic variation. While requiring replication, a chromosome 11 locus was associated (P < 5 × 10⁻⁸) with tumor thickness. Our work indicates that sufficiently large datasets will enable the discovery of genetic variants associated with greater tumor thickness, and this will lead to the identification of host biological processes influencing melanoma growth and invasion.

Primary Melanoma Histologic Subtype: Impact on Survival and Response to Therapy

BACKGROUND

Two primary histologic subtypes, superficial spreading melanoma (SSM) and nodular melanoma (NM), comprise the majority of all cutaneous melanomas. NM is associated with worse outcomes, which have been attributed to increased thickness at presentation, and it is widely expected that NM and SSM would exhibit similar behavior once metastasized. Herein, we tested the hypothesis that primary histologic subtype is an independent predictor of survival and may impact response to treatment in the metastatic setting.

METHODS

We examined the most recent Surveillance, Epidemiology, and End Results (SEER) cohort (n = 118 508) and the New York University (NYU) cohort (n = 1621) with available protocol-driven follow-up. Outcomes specified by primary histology were studied in both the primary and metastatic settings with respect to BRAF-targeted therapy and immunotherapy. We characterized known driver mutations and examined a 140-gene panel in a subset of NM and SSM cases using next-generation sequencing. All statistical tests were two-sided.

RESULTS

NM was an independent risk factor for death in both the SEER (hazard ratio [HR] = 1.55, 95% confidence interval [CI] = 1.41 to 1.70, P < .001) and NYU (HR = 1.47, 95% CI = 1.05, 2.07, P = .03) cohorts, controlling for thickness, ulceration, stage, and other variables. In the metastatic setting, NM remained an independent risk factor for death upon treatment with BRAF-targeted therapy (HR = 3.33, 95% CI = 1.06 to 10.47, P = .04) but showed no statistically significant difference with immune checkpoint inhibition. NM was associated with a higher rate of NRAS mutation (P < .001), and high-throughput sequencing revealed NM-specific genomic alterations in NOTCH4, ANK3, and ZNF560, which were independently validated.

CONCLUSIONS

Our data reveal distinct clinical and biological differences between NM and SSM that support revisiting the prognostic and predictive impact of primary histology subtype in the management of cutaneous melanoma.

Cutaneous melanoma in Argentina: an analysis of its characteristics and regional differences

Purpose

This study aims to increase the knowledge about the characteristics of cutaneous melanoma in Argentina, their association with the risk of having Breslow ≥1 mm and mortality trends for the period 2002-2017.

Patients and methods

Descriptive statistics and regression analyses were done for 10.199 cases within the Argentine Melanoma Registry in the period 2002-2018. Trends in age-standardised mortality rates (ASMR) were analysed using the Join point Regression Model.

Results

Cases showed lesions mainly located in males' trunk (37%) and in females' lower limbs (29%). The level of invasion was higher in males who also showed higher mortality. Cases from the North West and North East regions showed a major risk of Breslow >1 mm and harboured CM in lower limbs more frequently than in other regions. Nearly, 25% of tumours over 2 mm were in cases aged <50 years and 37.6% in patients ≥50 years. In the North West, North East and Patagonia, the frequency of cases in young people was higher than in older people. In 43% of cases, the melanoma subtype was not specified in the report. The number of superficial spreading melanomas, the most common histology, was nearly twice that of Nodular melanomas the following histology in importance (3,403 and 1,754, respectively). Melanoma mortality rates in all Argentine population increased in the elderly. Lower melanoma mortality rates were observed in the North West. In 2007-2017, ASMR decreased significantly in females (average 1.4% p/year) while it increased nonsignificantly in males (0.4% p/year).The tumours with the worst prognosis were associated with the elderly, males, nodular or acrolentiginous morphologies, residing somewhere other than Centro and Patagonia and with tumors located in the head/neck and legs.

Conclusion

The geographical variations found for melanoma characteristics and their mortality in Argentina, makes it imperative that epidemiological research is continued to avoid generalisations and improve future preventive actions.

Use of Smartphones for Early Detection of Melanoma: Systematic Review

Background

The early diagnosis of melanoma is associated with decreased mortality. The smartphone, with its apps and the possibility of sending photographs to a dermatologist, could improve the early diagnosis of melanoma.

Objective

The aim of our review was to report the evidence on (1) the diagnostic performance of automated smartphone apps and store-and-forward teledermatology via a smartphone in the early detection of melanoma, (2) the impact on the patient’s medical-care course, and (3) the feasibility criteria (focusing on the modalities of picture taking, transfer of data, and time to get a reply).

Methods

We conducted a systematic search of PubMed for the period from January 1, 2007 (launch of the first smartphone) to November 1, 2017.

Results

The results of the 25 studies included 13 concentrated on store-and-forward teledermatology, and 12 analyzed automated smartphone apps. Store-and-forward teledermatology opens several new perspectives, such as it accelerates the care course (less than 10 days vs 80 days), and the related procedures were assessed in primary care populations. However, the concordance between the conclusion of a teledermatologist and the conclusion of a dermatologist who conducts a face-to-face examination depended on the study (the kappa coefficient range was .20 to .84, median κ=.60). The use of a dermoscope may improve the concordance (the kappa coefficient range was .29 to .87, median κ=.74). Regarding automated smartphone apps, the major concerns are the lack of assessment in clinical practice conditions, the lack of assessment in primary care populations, and their low sensitivity, ranging from 7% to 87% (median 69%). In this literature review, up to 20% of the photographs transmitted were of insufficient quality. The modalities of picture taking and encryption of the data were only partially reported.

Conclusions

The use of store-and-forward teledermatology could improve access to a dermatology consultation by optimizing the care course. Our review confirmed the absence of evidence of the safety and efficacy of automated smartphone medical apps. Further research is required to determine quality criteria, as there was major variability among the studies.

The role of spatially-derived access-to-care characteristics in melanoma prevention and control in Los Angeles county

Among 10,068 incident cases of invasive melanoma, we examined the effects of patient characteristics and access-to-care on the risk of advanced melanoma. Access-to-care was defined in terms of census tract-level sociodemographics, health insurance, cost of dermatological services and appointment wait-times, clinic density and travel distance. Public health insurance and education level were the strongest predictors of advanced melanomas but were modified by race/ethnicity and poverty: Hispanic whites and high-poverty neighborhoods were worse off than non-Hispanic whites and low-poverty neighborhoods. Targeting high-risk, underserved Hispanics and high-poverty neighborhoods (easily identified from existing data) for early melanoma detection may be a cost-efficient strategy to reduce melanoma mortality.

Inclusion of populations at risk of advanced melanoma in an opportunistic targeted screening project involving general practitioners

OBJECTIVE

The study objective was to measure the rates of inclusion of populations at risk of advanced melanoma in a pilot targeted screening project involving general practitioners.

DESIGN

This cross-sectional database study compared the inclusion rates of patients who signed inclusion in a targeted screening project with those of patients who did not, during a period in which both groups of patients consulted investigators.

SETTING

Data were extracted from the national healthcare insurance records in western France from 11 April to 30 October 2011.

PATIENTS

Patients, older than 18, considered for the data extraction had consulted one of the 78 participating GPs during the study period, and were affiliated with the national healthcare insurance.

MAIN OUTCOME MEASURES

Inclusion in the screening was the main outcome measure. Patients at risk of advanced melanoma were characterized by male gender, age over 50, low income, rural residence, farmer, and presence of chronic disease.

RESULTS

A total of 57,279 patients consulted GPs during the inclusion period and 2711 (4.73%) were included in the targeted screening. Populations at risk of advanced melanoma were less included: men (OR = 0.67; 95%CI [0.61-0.73]; p < 0.001), older than 50 (OR = 0.67; 95%CI [0.60-0.74]; p < 0.001), low income (OR = 0.65; 95%CI [0.55-0.77]; p < 0.001), farmer (OR = 0.23; 95%CI [0.17-0.30]; p < 0.001) and presence of a chronic disease (OR = 0.87; 95%CI [0.77-0.98]; p < 0.028).

CONCLUSION

This study demonstrated inequalities in the inclusion of patients in a melanoma screening. Patients at risk of advanced cancer were screened less often. Further studies should focus on GPs ability to identify and screen these patients. KEY POINTS Advanced melanoma is more frequently diagnosed in men, older patients and socioeconomically disadvantaged populations, which leads to survival inequalities. • Despite the involvement of general practitioners, the implementation of targeted melanoma screening did not avoid inclusion inequalities. • Men, older patients, patients suffering from chronic diseases, and low-income patients were less likely to benefit from screening. • The display of a conventional or an alarmist poster in the waiting room did not statistically reduce these inclusion inequalities.

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.

Cutaneous malignant melanoma show geographic and socioeconomic disparities in stage at diagnosis and excess mortality

Background Preventive measures are needed to counteract the increasing burden of cutaneous malignant melanoma (CMM). As a basis for rational melanoma prevention, we investigated geographic differences and impact from socioeconomic factors related to incidence, clinical stage at diagnosis and outcome. Material and methods All patients with primary invasive CMM diagnosed in 2004-2013 in the southern and the western Swedish health care regions with a population of 2.9 million adults were eligible for the study. Population-based data were obtained from the national Cancer Register and the national Melanoma Quality Register. Geographic and socioeconomic differences in incidence per stage at diagnosis were mapped and correlated to excess mortality. Results Disease mapping based on 9743 cases in 99 municipalities and 20 metropolitan districts showed marked, regional disparities in stage-specific incidence of CMM. The incidence of stage I-II tumors was higher in the western health care region, whereas the incidence of stage III-IV CMMs was higher in the southern region. The divergent incidence patterns per stage at diagnosis were consistent across population strata based on educational level. The geographic disparities in CMM stage influenced relative survival with an excess five-year mortality ratio in the southern region versus the western region of 1.49 (95% confidence interval 1.22-1.82). The excess mortality ratio for patients with low versus high educational level was 1.81 (1.37-2.40). Conclusion Residential region and educational level influenced CMM stage and, thereby, excess mortality. These observations suggest that geographic as well as socioeconomic data should be considered in prevention of CMM.

Localized melanoma in older patients, the impact of increasing age and comorbid medical conditions

BACKGROUND

Elderly patients experience a different spectrum of disease and poorer outcomes than younger patients. This study investigated the impact of age and medical comorbidities on the management and outcome of patients ≥65 years.

METHODS

A retrospective review of all patients ≥65 years (481 patients with 525 primary melanomas) presenting with AJCC clinical stage I-II melanoma to an Australian cancer centre between 2000 and 2008.

RESULT

The median age was 74 years (65-94) with a male predominance (313 males, 65.0%) and median tumour thickness of 1.90 mm (IQR = 0.40-2.90, T1 = 33%, T2 = 20%, T3 = 24%, T4 = 23%). Inadequate surgical margins of excision (<10 mm) were common in older patients independent of site, thickness and ulceration (OR = 1.04, 95%CI = 1.00-1.07, p = 0.038). Inadequate excision margins were strongly associated with time to local recurrence, independent of age, thickness, ulceration and mitotic rate (HR = 3.00, 95%CI = 1.49-6.03, p = 0.0021), but not time to progression (p = 0.10) or disease specific survival (DSS, p = 0.27). Overall survival (OS) was strongly related to increasing age (HR = 1.04, 95%CI = 1.01-1.07, p = 0.015) and comorbid medical conditions (HR = 1.26, 95%CI = 1.12-1.42, p < 0.001), as assessed by the Charlson comorbidity index (CCI). DSS was significantly related to CCI (HR = 1.20, 95%CI = 1.01-1.42, p = 0.041) and not age (p = 0.46), when adjusting for thickness, ulceration and mitotic rate on multivariate analysis.

CONCLUSION

Older patients present with poor prognosis melanomas yet are less likely to receive adequate surgical excision margins resulting in higher rates of local recurrence. In melanoma patients ≥65 years, the increasing number of medical comorbidities explains much of the age related variations in OS and DSS and should be considered when planning treatment.

Demographic, behavioural and physician-related determinants of early melanoma detection in a low-incidence population

BACKGROUND

Knowledge of the factors that influence early detection of melanoma is important in developing strategies to reduce associated mortality.

OBJECTIVES

To identify sociodemographic, behavioural and medical care-related factors associated with melanoma thickness in a low-incidence population but with a high case fatality.

PATIENTS AND METHODS

In a multicentre, retrospective, survey-based study of 202 patients with a recent diagnosis of invasive melanoma (< 1 year), we collected data on demographic and behavioural factors, attitudes towards prevention, access to medical care, frequency of skin self-examination (SSE) and physician skin examination (PSE) in relation to melanoma thickness.

RESULTS

Thinner tumours (≤ 1 mm, 80 melanomas) were associated with female sex (P ≤ 0.049), nonnodular (superficial spreading melanoma, lentigo maligna melanoma, acral lentiginous melanoma) histological subtypes (P < 0.001), absence of ulceration (P ≤ 0.001), and location other than lower extremity or trunk location (P ≤ 0.004). Patients married at the time of diagnosis or who performed SSE during the year prior to diagnosis were more likely to have thinner tumours than those who did not [odds ratio (OR) 3.45, 95% confidence interval (CI) 1.48-8.04 and OR 2.43, 95% CI 1.10-5.34, respectively]. Full-body skin examination by a physician was not significantly associated with thinner melanoma (OR 1.99, 95% CI 0.66-6.07).

CONCLUSIONS

SSE was shown to be an important factor in the detection of thin melanoma, in contrast to partial or full-body PSE, which did not show any statistically significant effect on tumour thickness.

Role of obesity on the thickness of primary cutaneous melanoma

BACKGROUND

Thick primary cutaneous melanoma (PCM) is associated with older age, male sex, being single, a low educational level, self-detection and general practice detection, nodular melanoma (NM) and acral lentiginous melanoma (ALM) types; and are found in the head-neck and lower limb locations. Obesity plays a direct role on melanoma tumour growth, as it has been shown in animal models, but its role in the thickness of PCM remains unknown.

OBJECTIVES

We investigated the impact of obesity on the thickness of invasive PCM.

METHODS

A cross-sectional study was performed in a prospective cohort for which we collected several clinical and histological data already known to be associated with thick PCM and the Body Mass Index from new cases of invasive PCM which were referred to the dermatology department in Valence.

RESULTS

Four hundred and twenty-seven patients were studied. In an univariate analysis, thick PCM was associated with low educational level, obesity, identification by the patient or the general practitioner (GP), location on the cephalic extremity, in a non-visible area of the body, the NM and ALM type, and an ulceration. In a multivariate analysis, NM, ulceration, topography of the melanoma and identification of the melanoma by the patient or GP were significantly associated with thick melanoma. When including only clinical features in the model, low educational level, mode of melanoma identification and obesity were significantly associated with a risk of thick melanoma.

CONCLUSIONS

Obesity is a clinical independent risk factor of thick PCM. For health policies, governments should pay greater attention to detect melanoma in obese patients. Our results encourage the basic research on tumoural growth mechanisms due to obesity in melanoma.

Later stage at diagnosis and worse survival in cutaneous malignant melanoma among men living alone: a nationwide population-based study from Sweden

PURPOSE

To investigate the association between cohabitation status, clinical stage at diagnosis, and disease-specific survival in cutaneous malignant melanoma (CMM).

METHODS

This nationwide population-based study included 27,235 patients from the Swedish Melanoma Register diagnosed with a primary invasive CMM between 1990 and 2007 and linked data to nationwide, population-based registers followed up through 2012.

RESULTS

After adjustment for age at diagnosis, level of education, living area, period of diagnosis, and tumor site, the odds ratios (ORs) of higher stage at diagnosis were significantly increased among men living alone versus men living with a partner (stage II v stage I: OR, 1.42; 95% CI, 1.29 to 1.57; stage III or IV v stage I: OR, 1.43; 95% CI, 1.14 to 1.79). The OR for stage II versus stage I disease was also increased among women living alone (OR, 1.15; 95% CI, 1.04 to 1.28). After adjustments for the factors listed earlier, the CMM-specific survival was significantly decreased among men living alone (hazard ratio [HR] for death, 1.48; 95% CI, 1.33 to 1.65; P < .001). After additional adjustments for all potential and established prognostic factors, CMM-specific survival among men living alone versus men living with a partner remained significantly decreased (HR, 1.31; 95% CI, 1.18 to 1.46; P < .001), suggesting a residual adverse effect on survival not accounted for by these parameters.

CONCLUSION

In all age groups among men, living alone is significantly associated with reduced CMM-specific survival, partially attributed to a more advanced stage at diagnosis. This emphasizes the need for improved prevention and early detection strategies for this group.

Melanoma thickness: the role of patients' characteristics, risk indicators and patterns of diagnosis

BACKGROUND

Factors associated with early vs. late diagnosis of cutaneous melanoma remain poorly understood.

OBJECTIVE

To identify factors with a significant impact on melanoma thickness.

METHODS

Patients with previous melanoma (n = 347, median age at diagnosis: 56.5 years, 44.7% female, 55.3% male) were recruited for this monocentre, non-randomized, observational study between April 2012 and March 2013. All patients were assessed by means of a structured interview and systematic clinical and dermoscopic full-body examination. Melanoma thickness in association with patients' characteristics, risk indicators and patterns of diagnosis was submitted to statistical analyses.

RESULTS

Univariate analyses revealed associations between a statistically significant lower Breslow thickness and participation in specialized dermoscopic screening programs, personal history of more than one previous melanoma, diagnostic examination with a dermatoscope, diagnostic examination by board certified dermatologist, high number of common and/or atypical nevi, younger age at time of diagnosis, higher level of education, or superficial spreading or lentigo maligna melanoma subtype (all P ≤ 0.01). In a multivariate regression analysis only three of these criteria: (i) participation in specialized screening programs (P < 0.0001); (ii) melanoma subtype (P < 0.0001); and (iii) diagnostic examination with a dermatoscope (P = 0.040) and one interaction term ('younger age' x 'female sex', P < 0.0001) showed an independent influence on a significantly lower melanoma thickness.

CONCLUSIONS

The screening of patients in specialized surveillance programs resulted in melanoma detection at significantly earlier stages. The use of dermoscopy, SSM or LMM histotype and younger age in connection with female sex were also characteristics that were independently associated with significantly thinner melanomas in multivariate analyses.

Health-care delay in malignant melanoma: various pathways to diagnosis and treatment

We aimed to describe and compare patients diagnosed with malignant melanoma (MM), depending on their initial contact with care and with regard to age, sex, and MM type and thickness, and to explore pathways and time intervals (lead times) between clinics from the initial contact to diagnosis and treatment. The sample from northern Sweden was identified via the Swedish melanoma register. Data regarding pathways in health care were retrieved from patient records. In our unselected population of 71 people diagnosed with skin melanoma of SSM and NM types, 75% of patients were primarily treated by primary health-care centres (PHCs). The time interval (delay) from primary excision until registration of the histopathological assessment in the medical records was significantly longer in PHCs than in hospital-based and dermatological clinics (Derm). Thicker tumors were more common in the PHC group. Older patients waited longer times for wide excision. Most MM are excised rapidly at PHCs, but some patients may not be diagnosed and treated in time. Delay of registration of results from histopathological assessments within PHCs seems to be an important issue for future improvement. Exploring shortcomings in MM patients' clinical pathways is important to improve the quality of care and patient safety.

The influence of dermatologist and primary care physician visits on melanoma outcomes among Medicare beneficiaries

BACKGROUND

Ambulatory visits to dermatologists and primary care physicians (PCPs) may improve melanoma outcomes through early detection. We sought to measure the effect of dermatologist and PCP visits on melanoma stage at diagnosis and mortality.

METHODS

We used data from the database linking Surveillance Epidemiology and End Results (SEER) and Medicare data (1994 to 2005) to examine patterns of dermatologist and PCP ambulatory visits before diagnosis for 18,884 Medicare beneficiaries with invasive melanoma or unknown stage at diagnosis. Visits were assessed during the 2-year time interval before the month of diagnosis. We examined whether dermatologist and PCP visits were associated with diagnosis of thinner melanomas (defined as local stage tumors having Breslow thickness <1 mm) and lower melanoma mortality.

RESULTS

Medicare beneficiaries visiting both a dermatologist and PCP before diagnosis had greater odds of diagnosis of a thin melanoma (adjusted odds ratio, 1.26; 95% confidence interval, 1.12-1.41) and lower melanoma mortality (adjusted hazard ratio 0.66, 95% confidence interval, 0.57-0.76) compared with those without such visits. The mortality findings were attenuated once stage at diagnosis was adjusted for in the multivariable model.

CONCLUSION

Improved melanoma outcomes among Medicare beneficiaries may depend on adequate access and use of dermatologist and PCP services.

A comparison of trends in melanoma mortality in New Zealand and Australia: the two countries with the highest melanoma incidence and mortality in the world

Background

New Zealand and Australia have the highest incidence and mortality rates from cutaneous melanoma in the world. The predominantly fair-skinned New Zealanders and Australians both enjoy sun, tanned skin and the outdoors, and differences in these activities among generations have been important determinants of trends in melanoma mortality.

We examined whether New Zealand trends in melanoma mortality mirror those in Australia, through detailed comparison of the trends in both countries from 1968 to 2007.

Methods

Five-year age-specific and age-standardised mortality rates were calculated for each country for 5-year time periods. Tests for trends in age-specific rates were performed using the Mantel-Haenszel extension chi-square test. The age-adjusted mortality rate ratios for New Zealand/Australia were plotted against period of death to show relative changes in mortality over time. Age-specific mortality rates were plotted against period and the median year of birth to illustrate age-group and birth cohort effects. To compare the mortality of birth cohorts, age-adjusted melanoma mortality rate ratios were calculated for the birth cohorts in the quin-quennial tables of mortality rates.

Results

The age-standardised mortality rate for melanoma increased in both sexes in New Zealand and Australia from 1968 to 2007, but the increase was greater in New Zealanders and women in particular. There was evidence of recent significant decreases in mortality in younger Australians and less so in New Zealand women aged under 45 years. Mortality from melanoma increased in successive generations born from about 1893 to 1918. In Australia, a decline in mortality started for generations born from about 1958 but in New Zealand there is possibly a decrease only in generations born since 1968.

Conclusions

Mortality trends in New Zealand and Australia are discrepant. It is too early to know if the pattern in mortality rates in New Zealand is simply a delayed response to melanoma control activities compared with Australia, whereby we can expect the same downward trend in similar age groups in the next few years. Specific research is needed to better understand and control the increases in mortality and thickness of melanoma in New Zealand.

Coping styles in decision-making among men and women diagnosed with malignant melanoma

Early care seeking is important for prognosis of malignant melanoma. Coping styles in decision-making to seek care can relate to prognosis since avoidant strategies could delay care seeking. The aim of this study was to compare self-reported coping styles in decision-making between men and women diagnosed with malignant melanoma. We used the Swedish version of the Melbourne Decision-Making Questionnaire to assess coping styles. Men generally scored higher in buck-passing while women and those living without a partner scored higher in hypervigilance. This knowledge could be used in the development of preventive programmes with intention to reach those who delay care seeking.

Examining the pathways linking lower socioeconomic status and advanced melanoma

BACKGROUND

Low socioeconomic status (SES) is associated with more advanced melanoma at diagnosis and decreased survival. Exploring the pathways linking lower SES and thicker melanoma will help guide public and professional strategies to reduce deaths.

METHODS

The authors surveyed 566 newly diagnosed patients at Stanford University Medical Center, Veterans Affairs Palo Alto Health Care System, and University of Michigan. SES was assessed by education level (high school/general education degree or less [HS], associate/technical school degree, or ≥college graduate). All data was obtained by self-report among patients within three months of their diagnosis.

RESULTS

HS-educated individuals were significantly more likely than college graduates to believe that melanoma was not very serious (odds ratio [OR], 2.90; 95% confidence interval [CI], 1.79-4.71) and were less likely to know the asymmetry, borders (irregular), color (variegated), and diameter (>6 mm) (ABCD) melanoma rule or the difference between melanoma and ordinary skin growths (OR, 0.34 [95% CI, 0.23-0.52] and 0.26 [95% CI, 0.16-0.41] respectively). Physicians were less likely to have ever told HS-educated versus college-educated individuals they were at risk for skin cancer (OR, 0.46; 95% CI, 0.31-0.71) or instructed them on how to examine their skin for signs of melanoma (OR, 0.40; 95% CI, 0.25-0.63). HS-educated individuals were less likely to have received a physician skin examination within the year before diagnosis (OR, 0.54; 95% CI, 0.37-0.80).

CONCLUSIONS

Decreased melanoma risk perception and knowledge among low-SES individuals and decreased physician communication regarding skin examinations of these individuals may be key components of the consistently observed socioeconomic gradient in mortality. The current findings suggest the need to raise melanoma awareness among lower-SES patients and to increase physician awareness of socioeconomic disparities in clinical communication and care.

Behavioral determinants of successful early melanoma detection: role of self and physician skin examination

BACKGROUND

Reduced melanoma mortality should result from an improved understanding of modifiable factors related to early detection. The authors of this report surveyed newly diagnosed patients to identify differences in prediagnosis behavioral and medical care factors associated with thinner versus thicker melanoma.

METHODS

In total, 566 adults with invasive melanoma completed questionnaires within 3 months of diagnosis on demographics, health care access, skin self-examination (SSE), and physician skin examination (PSE) practices in the year before diagnosis. SSE was measured by us e of a melanoma picture aid and routine examination of some/all body sites versus none. Patient-reported partial or full-body PSE also was assessed. Melanoma thickness was dichotomized at 1 mm.

RESULTS

Patient ranged in age from 18 years to 99 years, and 61% were men. The median tumor thickness was 1.25 mm, and 321 tumors (57%) were >1 mm thick. Thinner tumors (≤1 mm) were associated with age ≤60 years (P = .0002), women (P = .0127), higher education level (P = .0122), and physician discovery (P ≤ .0001). Patients who used a melanoma picture aid and performed routine SSE were more likely to have thinner tumors than those who did not (odds ratio [OR], 2.66; 95% confidence interval [CI], 1.48-4.80). Full-body PSE was associated with thinner tumors (OR, 2.51; 95% CI, 1.62-3.87), largely because of the effect of PSE in men aged >60 years (OR, 4.09 95% CI, 1.88-8.89).

CONCLUSIONS

SSE and PSE were identified as complementary early detection strategies, particularly in men aged >60 years, in whom both partial and full-body PSE were associated with thinner tumors. Given the high rates of physician access, PSE may be a more practical approach for successful early detection in this subgroup with highest mortality.

Malignant melanoma: gender patterns in care seeking for suspect marks

AIMS AND OBJECTIVES

Gender patterns in self-detection of melanoma are not sufficiently highlighted in the literature. The aim of the study was to identify specific patterns in the decision-making process to seek care for suspect melanoma, as narrated by women and men.

BACKGROUND

Females have a more favourable prognosis than males and also a higher level of perceived susceptibility and a higher level of knowledge about melanoma. Women are, furthermore, more prone to participate in screening.

METHOD

Thirty patients (15 women and 15 men) with a mean age of 55.5 years and diagnosed with malignant melanoma were interviewed about their decisions to seek care for suspect skin marks. The interviews were transcribed and analysed with qualitative content analysis.

RESULTS

Care-seeking behaviour for suspect melanoma was influenced by gender constructions. Men seldom or never acknowledged interest in attention to bodily changes, but when they became aware of changes, they often took a quick decision and sought an expert's assessment. Men were compliant with wives' and relatives' advice about seeking care. All women reported that they paid attention to bodily changes, but they often delayed care seeking, due to family responsibilities and emotional struggles. The women also attempted self-care remedies, such as applying ointment, before seeking professional care.

CONCLUSIONS

There are gender-specific patterns that may influence decision making in the care-seeking process. Such patterns are important to identify, since health care professionals must take these factors into account in communicating with men and women.

RELEVANCE TO CLINICAL PRACTICE

Nurses and in particular those working in telephone counselling, are often at the frontlines, deciding who can have access to health services. They are ideally placed to tackle the issue of gender constructions in the development of effective health care services.

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.

Development of a practical guide for the early recognition for malignant melanoma of the foot and nail unit

Background

Malignant melanoma is a rare but potentially lethal form of cancer which may arise on the foot. Evidence suggests that due to misdiagnosis and later recognition, foot melanoma has a poorer prognosis than cutaneous melanoma elsewhere.

Methods

A panel of experts representing podiatry and dermatologists with a special interest in skin oncology was assembled to review the literature and clinical evidence to develop a clinical guide for the early recognition of plantar and nail unit melanoma.

Results

A systematic review of the literature revealed little high quality data to inform the guide. However a significant number of case reports and series were available for analysis. From these, the salient features were collated and summarised into the guide. Based on these features a new acronym "CUBED" for foot melanoma was drafted and incorporated in the guide.

Conclusions

The use of this guide may help clinicians in their assessment of suspicious lesions on the foot (including the nail unit). Earlier detection of suspicious pedal lesions may facilitate earlier referral for expert assessment and definitive diagnosis. The guide is currently being field tested amongst practitioners.

Defining the patient at high risk for melanoma

In this practical review, we aim to help clinicians identify patients who are at significant risk of developing malignant melanoma. Universal screening is challenging, thus it is important to effectively single out patients who have a high risk of developing the disease. We provide a summary of pertinent questions to review when taking the patient's history, point out the phenotypic features to note during skin examination, and suggest risk stratification as a means to plan initial and long-term surveillance strategy. We mention personal and family history of melanoma as prime risk factors for melanoma, yet the review also focuses on the patient who has no history of melanoma, either in himself or his family, and the proper ways to evaluate his likelihood of developing the disease.

Time trends in tumour thickness vary in subgroups: analysis of 6475 patients by age, tumour site and melanoma subtype

An elevated tumour thickness is strongly associated with an increased risk of mortality in melanoma patients. In the last few decades, an overall decrease of the tumour thickness to prognostically more favourable levels has been observed in several countries. Nevertheless, it is not clear whether this positive time trend occurred uniformly in specific subgroups of melanoma patients. Therefore, we aimed to assess time trends of tumour thickness by age group, tumour site and melanoma subtype. The study population consisted of 6475 patients with histologically proven primary invasive cutaneous melanomas seen at the Department of Dermatology and Allergology at the Ludwig-Maximilian-University Munich between 1977 and 2000. Age-adjusted time trends were assessed using linear and logistic regression analysis. Overall, a positive time trend with a decreasing tumour thickness was observed during the observation period in most subgroups. However, no significant time trend was observed in patients with a melanoma on the feet or with a nodular or acrolentiginous melanoma. The almost constant high tumour thickness of these patients might be caused by underaddressing the specific traits of these melanomas in earlier prevention campaigns. An important goal for the upcoming years should consist of a positive time trend with a decreasing tumour thickness in these subgroups.

COX-2 expression in malignant melanoma: a novel prognostic marker?

Several studies illustrated considerably elevated levels of cyclooxygenase-2 (COX-2) protein in various types of human cancer including malignant melanoma. Recently, it was reported that COX-2 is strongly expressed in malignant melanoma and may be correlated with the development and progression of disease. In contrast, other groups did not detect COX-2 protein in primary melanoma cells but did in infiltrating inflammatory cells or metastases. However, there are no reports about patterns or alterations of COX-2 expression in melanoma cells during disease progression or of a correlation between COX-2 expression and overall survival. The aim of this study was to investigate whether there is a correlation between expression of COX-2 protein and disease prognosis in malignant melanoma. We therefore analyzed the expression of COX-2 protein by immunohistochemistry in 101 primary malignant melanomas and 28 metastases and correlated our data with Breslow tumor thickness, Clark levels, different melanoma subtypes, metastases, and overall survival. We detected a strong COX-2 expression in 95% of all primary melanomas, primarily restricted to melanoma cells as shown by various immunohistochemical methods. Levels of COX-2 expression in primary melanoma and corresponding metastases remained stable. A significant correlation between immunohistochemical staining intensity and tumor thickness was demonstrated. Furthermore, Kaplan-Meier curves illustrated a significant correlation between staining intensity and disease-specific survival. Our findings emphasize that the COX-2 protein might be a novel prognostic marker. Owing to its strong expression in melanoma cells it might also be a reasonable therapeutic target.

Dermoscopy as a technique for the early identification of foot melanoma

Malignant melanoma is the most common primary malignant tumour arising on the foot. Where improvements in the prognosis have been observed for patients with melanoma elsewhere on the skin, pedal lesions are still frequently delayed in presentation through neglect or misdiagnosis. Detection of foot melanoma relies on the health care practitioner's skills and observations in recognising early changes. Recent publications have documented the use a dermoscopy as a tool to improve recognition of such suspicious lesions. This paper reviews current literature with a special emphasis of its potential applications on plantar and nail unit melanoma. Data from these studies suggest that the technique is a useful and significant adjunct to clinical examination, which ultimately may lead to earlier recognition of this aggressive tumour.

Changes in the presentation of nodular and superficial spreading melanomas over 35 years

BACKGROUND

Nodular melanoma (NM) may be biologically aggressive compared with the more common superficial spreading melanoma (SSM), with recent data suggesting underlying genetic differences between these 2 subtypes. To better define the clinical behavior of NMs, the authors compared their clinical and histopathologic features to those of SSMs at their institution, a tertiary referral center, over 3 decades.

METHODS

A total of 1,684 patients diagnosed with 1,734 melanomas were prospectively enrolled. Of these, 1,143 patients (69% SSM, 11% NM, 20% other) were diagnosed between 1972 and 1982; 541 patients (54% SSM, 23% NM, 23% other) were diagnosed between 2002 and the present. Differences between the features of NM and SSM within each time period as well as changes over time were analyzed.

RESULTS

The authors found that SSMs are now diagnosed as thinner lesions (P < .0001) with a low incidence of histologic ulceration (P < .0001), whereas there was no significant change in the median tumor thickness or ulceration status of NMs over time (P = .10, P = .30, respectively). The median age at diagnosis of NM, however, did significantly increase over time (51 years to 63 years, P < .01). The median duration of NMs was reported to be only 5 months compared with 9 months in SSM patients.

CONCLUSIONS

The authors' data suggest that improvements have been made in the early detection of SSM but not NM. Modifications of current screening practices, including increased surveillance of high-risk patients with an emphasis on the "E" for "evolution" criterion of the ABCDE acronym used for early detection of melanoma, are thus warranted.

[Skin cancer: what's new in clinical research?]

Every year skin cancer is the subject of many publications. In this review of the recent literature, we selected epidemiological, clinical, and therapeutic data published between October 2006 and September 2007. Some of the studies presented in conferences in 2007 are also mentioned. New epidemiological data have been provided regarding the incidence of different types of skin cancers, the effect of certain risk factors or drug or food protective factors, the overall improvement of survival in melanoma, the epidemiological, clinical, and/or therapeutic particularities of rapidely growing melanomas and thick melanomas, and the relations between sun exposure, skin cancers, and other solid tumors. New prognostic studies in melanoma have improved the evaluation of prognosis in specific situations such as thin melanoma, acrolentiginous melanoma, and melanoma with positive sentinel lymph nodes (depending on the type of positivity) or negative sentinel lymph nodes. Important results on adjuvant interferon in melanoma have been presented. Clinical trials evaluating new therapeutic approaches in stage III and IV melanoma are going on. Several studies confirmed the clinical benefit of adjuvant irradiation on the tumor site in Merkel cell carcinoma. New treatments are being studied or have been approved in refractory forms of cutaneous T-cell lymphoma and in inoperable forms of squamous cell carcinoma and dermatofibrosarcoma protuberans.