Enhancing the early detection of melanoma within current guidelines

Screening for reducing morbidity and mortality in malignant melanoma

BACKGROUND

Screening for malignant melanoma has the potential to reduce morbidity and mortality from the disease through earlier detection, as prognosis is closely associated with the thickness of the lesion at the time of diagnosis. However, there are also potential harms from screening people without skin lesion concerns, such as overdiagnosis of lesions that would never have caused symptoms if they had remained undetected. Overdiagnosis results in harm through unnecessary treatment and the psychosocial consequences of being labelled with a cancer diagnosis. For any type of screening, the benefits must outweigh the harms. Screening for malignant melanoma is currently practised in many countries, and the incidence of the disease is rising sharply, while mortality remains largely unchanged.

OBJECTIVES

To assess the effects on morbidity and mortality of screening for malignant melanoma in the general population.

SEARCH METHODS

We searched the following databases up to May 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registries, checked the reference lists of included and other relevant studies for further references to randomised controlled trials (RCTs), used citation tracking (Web of Science) for key articles, and asked trialists about additional studies and study reports.

SELECTION CRITERIA

RCTs, including cluster-randomised trials, of screening for malignant melanoma compared with no screening, regardless of screening modality or setting, in any type of population and in any age group where people were not suspected of having malignant melanoma. We excluded studies in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome) and studies performed exclusively in people with previous melanomas.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcomes of this review were total mortality, overdiagnosis of malignant melanoma, and quality of life/psychosocial consequences.

MAIN RESULTS

We included two studies with 64,391 participants. The first study was a randomised trial of an intervention developed to increase the rate of performance of thorough skin self-examination. The intervention group received instructional materials, including cues and aids, a 14-minute instruction video, and a brief counselling session, and at three weeks a brief follow-up telephone call from a health educator, aimed at increasing performance of thorough skin self-examination. The control group received a diet intervention with similar follow-up. The trial included 1356 people, who were recruited from 11 primary care practices in the US between 2000 and 2001. Participant mean age was 53.2 years and 41.7% were men. This study did not report on any of our primary outcomes or the following secondary outcomes: mortality specific to malignant melanoma, false-positive rates (skin biopsies/excisions with benign outcome), or false-negative rates (malignant melanomas diagnosed between screening rounds and up to one year after the last round). All participants were asked to complete follow-up telephone interviews at 2, 6, and 12 months after randomisation.The second study was a pilot study for a cluster-RCT of population-based screening for malignant melanoma in Australia. This pilot trial included 63,035 adults aged over 30 years. The three-year programme involved community education, an education and support component for medical practitioners, and the provision of free skin screening services. The mean age of people attending the skin screening clinics (which were held by primary care physicians in workplaces, community venues, and local hospitals, and included day and evening sessions) was 46.5 years, and 51.5% were men. The study included whole communities, targeting participants over 30 years of age, but information on age and gender of the whole study population was not reported. Study duration was three years (1998 to 2001), and outcomes were measured at the screening clinics during these three years. There was no further follow-up for any outcomes. The control group received no programme. The ensuing, planned cluster randomised trial in 560,000 adults was never carried out due to lack of funding. At the time of this review, there are no published or unpublished data on our prespecified outcomes available, and no results for mortality outcomes from the pilot study are to be expected.The risk of bias in these studies was high for performance bias (blinding study personnel and participants) and high or unclear for detection bias (blinding of outcome assessment). Risk of bias in the other domains was either unclear or low. We were unable to assess the certainty of the evidence for our primary outcomes as planned due to lack of data.

AUTHORS' CONCLUSIONS

Adult general population screening for malignant melanoma is not supported or refuted by current evidence from RCTs. It therefore does not fulfil accepted criteria for implementation of population screening programmes. This review did not investigate the effects of screening people with a history of malignant melanoma or in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome). To determine the benefits and harms of screening for malignant melanoma, a rigorously conducted randomised trial is needed, which assesses overall mortality, overdiagnosis, psychosocial consequences, and resource use.

Skin cancer-related prevention and screening behaviors: a review of the literature

Primary prevention and early detection continue to be of paramount importance in addressing the public health threat of skin cancer. The aim of this systematic review was to provide a comprehensive overview of the prevalence and correlates of skin cancer-related health behaviors in the general population. To achieve this aim, 91 studies published in international peer-reviewed journals over the past three decades were reviewed and synthesized. Reported estimates of sunscreen use varied considerably across studies, ranging from 7 to 90%. According to self-report, between 23 and 61% of individuals engage in skin self-examination at least once per year, and the documented prevalence of annual clinical skin examination ranges from 8 to 21%. Adherence to sun protection and screening recommendations is associated with a range of factors, including: female gender, sun-sensitive phenotype, greater perceived risk of skin cancer, greater perceived benefits of sun protection or screening, and doctor recommendation for screening. The literature suggests that a large proportion of the general population engage in suboptimal levels of sun protection, although there is substantial variability in findings. The strongest recommendation to emerge from this review is a call for the development and widespread use of standardized measurement scales in future research, in addition to more studies with a population-based, multivariate design. It is also recommended that specific targeted interventions are developed to increase the prevalence of preventative and early intervention behaviors for the control of skin cancer.

Factors associated with thorough skin self-examination for the early detection of melanoma

BACKGROUND

Regular thorough skin self-examination (TSSE) has potential for detecting melanoma early and reducing melanoma mortality.

OBJECTIVES

We sought to model factors associated with skin self-examination (SSE) and test whether efficacy and attitudes about SSE mediated these relationships.

PATIENTS/METHODS

The Check-It-Out project is a randomized trial of an intervention to encourage TSSE; 2126 participants were recruited from the practices of primary care physicians. Correlates predicting baseline TSSE included demographic variables, skin cancer risk, physician advice to examine skin, and appropriate conditions for conducting SSE (availability of partner to assist with self-examination, availability of a wall mirror, and use of contact lenses/glasses).

RESULTS

Those who were given physician advice, had a wall mirror, and had a partner available were more likely to perform TSSE.

LIMITATIONS

We identified the factors associated with concurrent TSSE practices. Further research is needed to determine if these same factors predict future behaviour. Our findings may not be applicable in geographical areas other than our recruitment area.

CONCLUSIONS

Primary care providers can recommend SSE and provide materials to increase ability to recognize skin problems. Providing instructions and aids for conducting TSSE may increase self-efficacy.

Community perceptions of adequate levels and reasons for skin protection

In this study the authors addressed whether or not community members use relevant risk factors to determine an appropriate level of skin protection behavior in the prevention of skin cancer. The authors conducted a postal survey with a community sample of 3,600 Queensland residents that they randomly selected from the Commonwealth electoral roll. The predictors of "perceptions of doing enough skin protection" included intrapersonal, social, and attitudinal influences. People protected themselves from the sun primarily out of a desire for future good health and on other occasions did not protect themselves from the sun because they were not out there long enough to get burnt. The predictors of perceptions of doing enough skin protection indicated that participants were aware of relevant risk factors. The main reasons that people protect themselves from the sun suggest that they are acting on many health promotion messages. However, skin cancer prevention programs need to move beyond increasing awareness and knowledge of the disease to providing a supportive environment and enhancing individual skills. Health promotion campaigns could reinforce appropriate risk assessment and shape an individual's decision about how much sun protection is needed.

Strategies to improve the frequency and coverage of skin self examination conducted in small communities

A three group randomised control trial assessed the impact of a self‐help booklet and a community skin check competition on the frequency and coverage of skin examinations conducted upon Queenslanders who already report that they check their skin. Attitudinal and behavioural measures were collected in pre‐test and post‐test postal surveys.

Skin cancer screening among U.S. adults from 1992, 1998, and 2000 National Health Interview Surveys

BACKGROUND

Relatively little is known about the prevalence of skin cancer screening in the context of inconsistent skin cancer screening recommendations.

METHODS

To determine the prevalence and predictors of skin cancer screening rates in the U.S. adult population, we used self-reported data from the 1992, 1998, and 2000 National Health Interview Surveys, a nationally representative survey of civilian noninstitutionalized adults.

RESULTS

The percentage of the U.S. adult population who had ever had a skin examination conducted by a doctor was 20.6% in 1992, 20.9% in 1998, and 14.5% in 2000. The percentage with a recent skin examination was 10.3% in 1992, 11.0% in 1998, and 8.0% in 2000. White non-Hispanics reported being screened more frequently than persons in other racial or ethnic groups. Recent skin cancer screening exams were more common among white persons who had a family history of melanoma, had higher education, had usual place of care, and were older (> or =50 years). Frequent use of sunscreen and hats was associated with a recent skin cancer exam.

CONCLUSIONS

In the past decade, skin cancer screening rates have been consistently low. Continued monitoring of skin cancer examination is important given conflicting current research results and potentially evolving science.

Attitudes and intentions in relation to skin checks for early signs of skin cancer

BACKGROUND

Screening for melanoma by whole-body clinical skin examination or skin self-examination may improve early diagnosis of melanoma. As part of the first phase of a community-based randomised controlled trial of screening for melanoma, this study examined the prevalence of skin screening intentions and associated factors in a population at high risk for skin cancer.

METHODS

A telephone survey stratified by gender reached 3,110 participants > or = 30 years representative for the population.

RESULTS

Overall, 45% intended to have a clinical skin check, and 72% intended to examine their own skin within the next 12 months. In multivariate analysis, a history of a clinical skin examination was most strongly related to intention to screen. Concern about skin cancer or a personal history of skin cancer and high susceptibility towards skin cancer were further important determinants of screening intention. Men were less likely than women to intend participation.

CONCLUSIONS

Given that skin screening is not recommended by health authorities in absence of scientific evidence of benefit, the intention to participate in screening for melanoma in this Australian sample was high. Except for the lower intention among men, screening intention appears to be highest in those at highest risk of melanoma.

Reliability of assessment and circumstances of performance of thorough skin self-examination for the early detection of melanoma in the Check-It-Out Project

BACKGROUND

Thorough skin self-examination (TSSE) has substantial potential to reduce melanoma mortality by early detection.

METHODS

We interviewed 2,126 patients before a scheduled routine visit with a primary care physician, at which participation in a randomized trial was offered as part of the Check-It-Out Project. We asked about skin examination behavior and related issues.

RESULTS

By our a priori definition of TSSE, 18% of participants performed this activity, but other definitions led to widely varying estimates of 12% to 38%. Using a partner to assist in the examination was strongly associated with TSSE. That partner was generally the spouse, and wives were more likely to assist their husbands in these examinations than the reverse. The availability of a wall mirror was a particularly important predictor of TSSE performance. Visual impairment also affected performance.

CONCLUSIONS

Estimates of TSSE performance vary substantially with the questions used to elicit this information. Partners, particularly spouses, appear to play a critical role in the conduct of TSSE, and wives appear more often and more effectively engaged in this process. Appropriate circumstances, such as availability of a wall mirror, are also important factors. These findings can be used to design interventions to increase TSSE performance with the ultimate aim of reducing melanoma mortality.

Prevalence of skin screening by general practitioners in regional Queensland

OBJECTIVE

To establish the prevalence and predictors of skin screening by general practitioners in regional Queensland.

DESIGN

Questionnaire administered to participants by professional interviewers via telephone.

PARTICIPANTS AND SETTING

Participants were 3100 adults aged > or = 30 years (66.9% overall response rate), selected from residents of 18 regional Queensland communities with populations of between 2000 and 10 000 (as recorded in the 1996 Australian census). Within the last 10 communities surveyed, an additional telephone survey of 727 participants evaluated mole density. The survey was conducted between January and October 1998.

MAIN OUTCOME MEASURE

Prevalence of whole-body skin examinations by GPs.

RESULTS

11% of participants reported a whole-body skin examination by a GP during the previous 12 months, and 20% during the previous 3 years. Men and women reported a similar prevalence of whole-body skin examinations. Factors associated with a significantly increased likelihood of having had a whole-body skin examination within the previous 3 years included a positive attitude towards skin screening, a personal history of non-melanoma skin cancer, a tendency to burn, and having more than four moles on the right upper arm.

CONCLUSIONS

A substantial proportion of Queenslanders undergo skin screening. Those at highest risk for skin cancer are more likely to be screened.

Skin cancer screening and prevention in the primary care setting: national ambulatory medical care survey 1997

OBJECTIVE

To describe skin cancer prevention and screening activities in the primary care setting and to compare these findings to other cancer screening and prevention activities.

DESIGN

Descriptive study.

SETTING/PATIENTS

National Ambulatory Medical Care Survey 1997 data on office-based physician visits to family practitioners and internists.

MEASUREMENTS AND MAIN RESULTS

Data were obtained on 784 primary care visits to 109 family practitioners and 61 internists. We observed that the frequency of skin cancer prevention and screening activities in the primary care setting was much lower than other cancer screening and prevention activities. Skin examination was reported at only 15.8% of all visits (17.4% for family practitioners vs 13.6% for internists, P >.1). For other cancer screening, the frequencies were as follows: breast examination, 30.3%; Papanicolaou test, 25.3%; pelvic examination, 27.6%; and rectal examination, 17.9%. Skin cancer prevention in the form of education and counseling was reported at 2.3% of these visits (2.9% for family practitioners vs 1.5% for internists, P >.1), while education on breast self-examination, diet and nutrition, tobacco use, and exercise was 13.0%, 25.3%, 5.7%, and 17.9%, respectively.

CONCLUSIONS

The results of this study indicate that the proportion of primary care visits in which skin cancer screening and prevention occurs is low. Strategies to increase skin cancer prevention and screening by family practitioners and internists need to be considered.

Thorough skin examination for the early detection of melanoma

BACKGROUND

Melanoma is a major public health problem for which early detection may reduce mortality. Since melanoma is generally asymptomatic, this requires skin examination. We sought to evaluate the extent to which the general public has their skin examined by themselves, their partners, or health care providers and the frequency of these examinations.

METHODS

Random-digit-dial survey of adult Rhode Islanders.

RESULTS

Only 9% performed a thorough skin examination (TSE) at least once every few months, although over half of the sample reported conducting skin self-examination "deliberately and systematically." Participants were more likely to perform TSE if they were women and if their health care provider had asked them to examine their skin. Most participants reported that their health care provider never or rarely looked at the areas of their skin in which melanoma is most likely to arise.

CONCLUSIONS

The reported frequency of skin self-examination depends critically on the manner of inquiry. TSE by self or a partner is uncommon, and health care providers do not routinely examine the areas of the skin on which melanomas commonly arise.

Are young adults checking their skin for melanoma?

This study examined the prevalence and predictors of self screening for melanoma in a large sample of young New Zealanders. A self-report questionnaire was administered to a sample of 909, 21-year-olds to investigate if young adults check their skin for changes in lesions which could be melanoma, and to identify the factors which influence this behaviour and any subsequent help seeking. Fifty-three per cent reported checking their skin in the past year, with 20% noticing a change in a mole or freckle. Forty-five per cent of those who noticed a change sought medical advice. The most common reason for not seeking advice was cost. Women were more likely that men to have checked their skin, to have noticed a change and to have sought medical advice. In addition to gender, tendency to self check was also associated with knowledge of melanoma and perceived risk of melanoma. These results are discussed in light of the current debate regarding skin cancer screening. This study fills a gap in the literature regarding self screening for melanoma in young adults and identifies ways in which future prevention campaigns might be modified to address the concerns of this age group.

Community perceptions about the important signs of early melanoma

BACKGROUND

Detecting melanoma early often relies on patient concern about a particular pigmented lesion. However, it is not clear what specific features the public views as being important.

OBJECTIVE

Our purpose was to explore the importance persons place on various features of skin lesions when looking for early signs of melanoma.

METHODS

This study comprised 1148 respondents (participation rate, 78%) from 60 rural communities in Queensland, Australia, who participated in a telephone interview.

RESULTS

The following features were considered important and are listed in order of importance: change in the lesion (clearly identified as the most important), more than one color, uneven edges, elevation, large size (the last three of equal importance), and hairiness of the lesion. Age, sex, education, self-efficacy, perceived knowledge, and recent self-examination influenced importance levels, but having a recent skin examination by a family physician did not.

CONCLUSION

To increase the skin self-examination skills of the community, guidelines may have to become more specific and all opportunities fully utilized to educate the public.

Effect of a public awareness campaign on the appropriateness of patient-initiated skin examination in general practice

The aim of the study was to describe the appropriateness of patient-initiated skin examinations, and assess whether an awareness program leads to a greater proportion of inappropriate patient-initiated skin examinations. General practitioners (n = 27, response rate 71 per cent) from a regional town in Queensland recorded details of consultations involving a skin examination over a five-week period straddling the 1991 National Skin Cancer Awareness Week. The outcome measure was the clinical impression (benign, suspicious or malignant) of the most serious skin lesion presented by each general practice patient (n = 1183). Thirty-six per cent of patient-presented lesions were clinically suspicious or malignant. Lesions were more likely to be clinically suspicious or malignant if they were presented as the primary reason for the consultation (odds ratio OR = 1,219.95 per cent confidence interval (CI) 1.01 to 1.48); if the patient was aged over 35 years (OR = 5.594, CI 1.08 to 7.66); or male (OR = 1.634, CI 1.35 to 2.00). Following a public skin cancer awareness campaign, there was a slight nonsignificant decrease (OR 0.938, CI 0.91 or 1.25) in the proportion of clinically suspicious and malignant lesions detected. An increase in the number of skin examinations following an awareness campaign did not result in an increase in the proportion of inappropriate skin examinations. Patient-initiated skin examinations have an important role to play in the early detection of skin cancer.