Identifying people at high risk of cutaneous malignant melanoma: results from a case-control study in Western Australia

Study of Risk Factors for the Presence of Interdigital Nevi of the Feet

BACKGROUND AND OBJECTIVES

No studies focused on counting the interdigital acquired melanocytic nevi (AMN) of the foot (IDNf) have ever been conducted. Therefore, our objective was to study the relationship between the presence of IDNf and the total number of AMN in the feet and the rest of the body, the racial phenotypic characteristics, and other risk factors for melanoma.

MATERIAL AND METHODS

We conducted a cross-sectional observational study with 255 patients ≥18 years old who attended our Dermatology Unit from September 2020 through February 2021, and included all AMN ≥1mm from the feet and ≥2mm from the rest of the bod. The association between the variables was studied using univariate and multivariate logistic regression models.

RESULTS

The presence of IDNf was significantly and independently associated with the presence of plantar AMN and body counts ≥50 AMN. However, no significant differences were observed regarding sex, age, personal history of melanoma, presence of nevi on the dorsum of the foot, history of sunburn or UV rays, or racial phenotypic characteristics.

CONCLUSIONS

The presence of IDNf is associated with a higher count of plantar nevi and total AMN in the body, meaning that interdigital spaces of the foot-anatomical expansions of the sole and other possibly genetic causes-could be responsible for the number of AMN found in this location, as these regions are not photoexposed.

Inter-Rater Agreement in Assessing Risk of Bias in Melanoma Prediction Studies Using the Prediction Model Risk of Bias Assessment Tool (PROBAST): Results from a Controlled Experiment on the Effect of Specific Rater Training

Assessing the risk of bias (ROB) of studies is an important part of the conduct of systematic reviews and meta-analyses in clinical medicine. Among the many existing ROB tools, the Prediction Model Risk of Bias Assessment Tool (PROBAST) is a rather new instrument specifically designed to assess the ROB of prediction studies. In our study we analyzed the inter-rater reliability (IRR) of PROBAST and the effect of specialized training on the IRR. Six raters independently assessed the risk of bias (ROB) of all melanoma risk prediction studies published until 2021 (n = 42) using the PROBAST instrument. The raters evaluated the ROB of the first 20 studies without any guidance other than the published PROBAST literature. The remaining 22 studies were assessed after receiving customized training and guidance. Gwet's AC₁ was used as the primary measure to quantify the pairwise and multi-rater IRR. Depending on the PROBAST domain, results before training showed a slight to moderate IRR (multi-rater AC₁ ranging from 0.071 to 0.535). After training, the multi-rater AC₁ ranged from 0.294 to 0.780 with a significant improvement for the overall ROB rating and two of the four domains. The largest net gain was achieved in the overall ROB rating (difference in multi-rater AC₁: 0.405, 95%-CI 0.149-0.630). In conclusion, without targeted guidance, the IRR of PROBAST is low, questioning its use as an appropriate ROB instrument for prediction studies. Intensive training and guidance manuals with context-specific decision rules are needed to correctly apply and interpret the PROBAST instrument and to ensure consistency of ROB ratings.

Digital Educational Strategies to Teach Skin Self-examination to Individuals at Risk for Skin Cancer

Skin cancer is the most common cancer in the United States, and early detection of melanoma may lead to diagnosis of thinner and more treatable cancers, resulting in improved survival rates. This study examined the effects of message interactivity (high vs. low) and imagery (cartoon, real human character, or customized imagery preference) on accuracy of identifying abnormal skin lesions (ASL) and skin self-examination (SSE) intention. This study employed a 3 (cartoon character vs. real person vs. customization) x 2 (high interactivity vs. low interactivity) between-subjects online experimental design. Participants at risk for skin cancer were randomly assigned to one of the six conditions and completed a survey after reviewing the educational materials. Univariate analyses were conducted to detect group differences on the accuracy of identifying ASL and intention to conduct SSE in the next 3 months. Among 321 participants who completed the study, the mean age was 36.61 years, 56.7% were females, 76.1% had a college or higher degree, and over 60% self-identified as non-Hispanic White. Individuals in the high interactivity and customization group (compared to the low interactivity and cartoon group) were more likely to accurately identify ASL. Individuals in the high interactivity and customization or low interactivity and real person imagery groups (compared to the low interactivity and cartoon group) reported higher intention to conduct SSE in the next 3 months. These results suggest that customization and interactivity may be beneficial for educational programs or intervention design to improve both melanoma identification and SSE intention.

Using the Prediction Model Risk of Bias Assessment Tool (PROBAST) to Evaluate Melanoma Prediction Studies

Simple Summary

The rising incidence of cutaneous melanoma over recent decades, combined with a general interest in cancer risk prediction, has led to a high number of published melanoma risk prediction models. The aim of our work was to assess the validity of these models in order to discuss the current state of knowledge about how to predict incident cutaneous melanoma. To assess the risk of bias, we used a standardized procedure based on PROBAST (Prediction model Risk Of Bias ASsessment Tool). Only one of the 42 studies identified was rated as having a low risk of bias. However, it was encouraging to observe a recent reduction of problematic statistical methods used in the analyses. Nevertheless, the evidence base of high-quality studies that can be used to draw conclusions on the prediction of incident cutaneous melanoma is currently much weaker than the high number of studies on this topic would suggest.

Abstract

Rising incidences of cutaneous melanoma have fueled the development of statistical models that predict individual melanoma risk. Our aim was to assess the validity of published prediction models for incident cutaneous melanoma using a standardized procedure based on PROBAST (Prediction model Risk Of Bias ASsessment Tool). We included studies that were identified by a recent systematic review and updated the literature search to ensure that our PROBAST rating included all relevant studies. Six reviewers assessed the risk of bias (ROB) for each study using the published “PROBAST Assessment Form” that consists of four domains and an overall ROB rating. We further examined a temporal effect regarding changes in overall and domain-specific ROB rating distributions. Altogether, 42 studies were assessed, of which the vast majority (n = 34; 81%) was rated as having high ROB. Only one study was judged as having low ROB. The main reasons for high ROB ratings were the use of hospital controls in case-control studies and the omission of any validation of prediction models. However, our temporal analysis results showed a significant reduction in the number of studies with high ROB for the domain “analysis”. Nevertheless, the evidence base of high-quality studies that can be used to draw conclusions on the prediction of incident cutaneous melanoma is currently much weaker than the high number of studies on this topic would suggest.

Reporting Quality of Studies Developing and Validating Melanoma Prediction Models: An Assessment Based on the TRIPOD Statement

Transparent and accurate reporting is essential to evaluate the validity and applicability of risk prediction models. Our aim was to evaluate the reporting quality of studies developing and validating risk prediction models for melanoma according to the TRIPOD (Transparent Reporting of a multivariate prediction model for Individual Prognosis Or Diagnosis) checklist. We included studies that were identified by a recent systematic review and updated the literature search to ensure that our TRIPOD rating included all relevant studies. Six reviewers assessed compliance with all 37 TRIPOD components for each study using the published “TRIPOD Adherence Assessment Form”. We further examined a potential temporal effect of the reporting quality. Altogether 42 studies were assessed including 35 studies reporting the development of a prediction model and seven studies reporting both development and validation. The median adherence to TRIPOD was 57% (range 29% to 78%). Study components that were least likely to be fully reported were related to model specification, title and abstract. Although the reporting quality has slightly increased over the past 35 years, there is still much room for improvement. Adherence to reporting guidelines such as TRIPOD in the publication of study results must be adopted as a matter of course to achieve a sufficient level of reporting quality necessary to foster the use of the prediction models in applications.

Review of Wearable and Portable Sensors for Monitoring Personal Solar UV Exposure

Sunlight is one of the main environmental resources that keeps all the organisms alive on earth. The ultraviolet (UV) radiation from the sun is essential for vitamin D synthesis in the human body, which is crucial for bone and muscle health. In addition, sun exposure also helps to reduce the risk of some cardiovascular diseases and cancers. However, excessive UV exposure can lead to adverse effects, including some eye diseases, premature aging, sunburn and skin cancers. The solar UV irradiance itself depends on many environmental factors. In fact, the UV index reported in weather forecasts is an estimation under cloudless conditions. Personal UV exposure also depends on one's outdoor activities and habits. Furthermore, the UV intake depends on the skin sensitivity. Therefore, there is a need for research into monitoring the optimal daily UV exposure for health benefits, without developing potential health risks. To facilitate the monitoring of solar UV intensity and cumulative dose, a variety of UV sensors have been developed in the past few decades and many are commercially available. Examples of sensors being marketed are: portable UV dosimeter, wearable UV radiometer, personal UV monitor, and handheld Solarmeter®. Some of the UV sensors can be worn as personal health monitors, which promote solar exposure protection. The paper provides a comprehensive review of the wearable and portable UV sensors for monitoring personal UV exposure, including a discussion of their unique advantages and limitations. Proposals are also presented for possible future research into reliable and practical UV sensors for personal UV exposure monitoring.

Risk Prediction Models for Melanoma: A Systematic Review on the Heterogeneity in Model Development and Validation

The rising incidence of cutaneous melanoma over the past few decades has prompted substantial efforts to develop risk prediction models identifying people at high risk of developing melanoma to facilitate targeted screening programs. We review these models, regarding study characteristics, differences in risk factor selection and assessment, evaluation, and validation methods. Our systematic literature search revealed 40 studies comprising 46 different risk prediction models eligible for the review. Altogether, 35 different risk factors were part of the models with nevi being the most common one (n = 35, 78%); little consistency in other risk factors was observed. Results of an internal validation were reported for less than half of the studies (n = 18, 45%), and only 6 performed external validation. In terms of model performance, 29 studies assessed the discriminative ability of their models; other performance measures, e.g., regarding calibration or clinical usefulness, were rarely reported. Due to the substantial heterogeneity in risk factor selection and assessment as well as methodologic aspects of model development, direct comparisons between models are hardly possible. Uniform methodologic standards for the development and validation of risk prediction models for melanoma and reporting standards for the accompanying publications are necessary and need to be obligatory for that reason.

Factors in Early Adolescence Associated With a Mole-Prone Phenotype in Late Adolescence

Importance

Nevi are important phenotypic risk factors for melanoma in adults. Few studies have examined the constitutional and behavioral factors associated with a mole-prone phenotype in adolescents.

Objective

To identify host, behavioral, and dermoscopic factors in early adolescence (age, 14 years) that are associated with a mole-prone phenotype in late adolescence (age, 17 years).

Design, Setting, and Participants

A prospective observational cohort study from the Study of Nevi in Children was conducted from January 1, 2009, to December 31, 2014, with a 2- to 3-year follow-up. A total of 569 students from the school system in Framingham, Massachusetts, were enrolled in the 8th or 9th grade (baseline; mean [SD] age, 14.4 [0.7] years). The overall retention rate was 73.3%, and 417 students were reassessed in the 11th grade.

Main Outcome and Measures

Mole-prone phenotype in the 11th grade, defined as total nevus count of the back and 1 randomly selected leg in the top decile of the cohort or having any nevi greater than 5 mm in diameter.

Results

Of the 417 students assessed at follow-up in the 11th grade (166 females and 251 males; mean [SD] age, 17.0 [0.4] years), 111 participants (26.6%) demonstrated a mole-prone phenotype: 69 students (62.2%) with 1 nevus greater than 5 mm in diameter, 23 students (20.7%) with total nevus count in the top decile, and 19 students (17.1%) with both characteristics. On multivariate analysis, baseline total nevus count (adjusted odds ratio, 9.08; 95% CI, 4.0-23.7; P < .001) and increased variability of nevus dermoscopic pattern (adjusted odds ratio, 4.24; 95% CI, 1.36-13.25; P = .01) were associated with a mole-prone phenotype.

Conclusions and Relevance

This study found clinically recognizable factors associated with a mole-prone phenotype that may facilitate the identification of individuals at risk for melanoma. These findings could have implications for primary prevention strategies and help target at-risk adolescents for higher-intensity counseling about sun protection and skin self-examination.

Association of nevus count with prevention attitudes and behaviors before melanoma diagnosis

Although melanoma risk factors are commonly known to healthcare professionals, the extent to which the at-risk public is either aware of these factors or perceives their risk accordingly has rarely been studied. We sought to investigate whether the presence of known melanoma risk factors, such as high total nevus and atypical nevus counts, was associated with increased prevention attitudes and behaviors, such as skin self-examinations and physician skin examinations. This was a retrospective study of 566 individuals recently diagnosed with melanoma in two large academic centers. Most prevention attitudes and behaviors did not vary on the basis of total nevi or atypical nevi counts. However, younger patients (<60 years) with many total nevi (>50) were more likely than those with fewer nevi (<20) to believe that they were at-risk for melanoma (42 vs. 23%; P<0.05), and more likely to state that they had been instructed on the signs of melanoma (36 vs. 21%; P<0.05). Patient and health provider recognition of the impact of nevus count on melanoma risk presents a unique and mostly untapped opportunity for earlier detection.

Independent validation of six melanoma risk prediction models

Identifying people at high risk of melanoma is important for targeted prevention activities and surveillance. Several tools have been developed to classify melanoma risk, but few have been independently validated. We assessed the discriminatory performance of six melanoma prediction tools by applying them to individuals from two independent data sets, one comprising 762 melanoma cases and the second a population-based sample of 42,116 people without melanoma. We compared the model predictions with actual melanoma status to measure sensitivity and specificity. The performance of the models was variable with sensitivity ranging from 97.7 to 10.5% and specificity from 99.6 to 1.3%. The ability of all the models to discriminate between cases and controls, however, was generally high. The model developed by MacKie et al. (1989) had higher sensitivity and specificity for men (0.89 and 0.88) than women (0.79 and 0.72). The tool developed by Cho et al. (2005) was highly specific (men, 0.92; women, 0.99) but considerably less sensitive (men, 0.64; women, 0.37). Other models were either highly specific but lacked sensitivity or had low to very low specificity and higher sensitivity. Poor performance was partly attributable to the use of non-standardized assessment items and various differing interpretations of what constitutes "high risk".

Predicting melanoma risk: theory, practice and future challenges

The incidence of melanoma continues to rise in most fair-skinned populations. Strategies to curb the toll from melanoma include targeting the patients who are at highest risk with the aim of either preventing the onset of cancer or intervening early in order to improve survival. The challenge has been to synthesize the available information on risk factors into prediction tools with clinical utility, such that 'high-risk' patients can be identified with accuracy. While a number of risk prediction tools for melanoma have been developed, few have undergone rigorous evaluation of their performance in order to assess calibration or discrimination, and even fewer have been validated in independent populations. Future research should assess the validity of existing tools and seek to integrate the increasing volumes of data being generated by genomic studies.

Melanoma: A new strategy to reduce morbidity and mortality

BACKGROUND

Public awareness campaigns could address risk factors for melanoma to reinforce their sun protection message. The objective of this study is to prioritise risk factors associated with malignant melanoma (MM) to improve public awareness.

METHOD

DESIGN

A cross-sectional study with retrospective data analysis from 2004 to 2010.

SETTING

Western Australian Melanoma Advisory Service (WAMAS), a tertiary referral multidisciplinary organisation providing MM management advice. WAMAS data files were analysed with histologically confirmed cutaneous MM. Forty- seven patients had two or more melanomas, but the patient file was counted only once. Six MM data files with missing or incomplete information were excluded.

MAIN OUTCOME MEASURES

The number of naevi, blood relatives with MM, and previous sunburns were the primary variables collected.

RESULTS

The results showed that 70.9 per cent (268/378) had previous sunburn; 40.2 per cent (152/378) had multiple naevi; and 22.5 per cent (85/378) had a positive family history. In the 110 MM data files not associated with sunburn, multiple naevi and a positive family history represented 34.5 per cent (38/110) and 20.0 per cent (22/110), respectively.

CONCLUSION

The results confirm the findings of previous studies that multiple naevi and a positive family history are important risk factors associated with MM. We suggest that MM can be detected earlier and its mortality decreased by focusing on these high-risk groups who are not targeted by current public awareness campaigns.

Identifying risk factors using a skin cancer screening program

BACKGROUND

The incidence of melanoma and nonmelanoma skin cancer continues to increase. To detect lesions at an earlier phase in their progression, skin cancer screening programs have been advocated by some. However, the effectiveness of skin cancer screening and the ideal population that these screenings should target have yet to be firmly established. This study details the relationship of a group of well-known risk factors with presumptive diagnoses in a large series of individuals self-referred for free skin cancer screening.

METHODS

Data obtained during 2007 to 2010 from a descriptive cross-sectional study skin cancer screening program are presented. Participant history was recorded using standardized medical history forms prior to skin examination. Screeners conducted a skin examination varying from whole-body to limited areas (per participant preference) and recorded diagnoses. Diagnoses were assigned to the nonmelanoma cancer (NMC) or suspicious pigmented lesion group for analysis.

RESULTS

A presumptive diagnosis of NMC was associated with male sex, age ≥ 50 years, personal history of skin cancer, lower skin phototype, increased sunscreen use, and increased chronic sun exposure (all P values ≤ .0001). After controlling for skin phototype, increased sunscreen use was not associated with a presumptive diagnosis of NMC (P = .96). Presumptive diagnosis of a suspicious pigmented lesion was associated with a reported history of "changing mole" (P < .0001) and negatively associated with age ≥ 50 years (P < .0001) and a personal history of skin cancer (P = .0119).

CONCLUSIONS

Several known risk factors for nonmelanoma skin cancer correlated with a presumptive diagnosis of NMC. The yield of presumptive atypical pigmented lesions was increased in participants aged < 50 years, supporting the notion that this population may benefit from screening.

Risk prediction models for melanoma: a systematic review

Melanoma incidence is increasing rapidly worldwide among white-skinned populations. Earlier diagnosis is the principal factor that can improve prognosis. Defining high-risk populations using risk prediction models may help targeted screening and early detection approaches. In this systematic review, we searched Medline, EMBASE, and the Cochrane Library for primary research studies reporting or validating models to predict risk of developing cutaneous melanoma. A total of 4,141 articles were identified from the literature search and six through citation searching. Twenty-five risk models were included. Between them, the models considered 144 possible risk factors, including 18 measures of number of nevi and 26 of sun/UV exposure. Those most frequently included in final risk models were number of nevi, presence of freckles, history of sunburn, hair color, and skin color. Despite the different factors included and different cutoff values for sensitivity and specificity, almost all models yielded sensitivities and specificities that fit along a summary ROC with area under the ROC (AUROC) of 0.755, suggesting that most models had similar discrimination. Only two models have been validated in separate populations and both also showed good discrimination with AUROC values of 0.79 (0.70-0.86) and 0.70 (0.64-0.77). Further research should focus on validating existing models rather than developing new ones.

MC1R genotype as a predictor of early-onset melanoma, compared with self-reported and physician-measured traditional risk factors: an Australian case-control-family study

Background

Melanocortin-1 receptor (MC1R) gene variants are very common and are associated with melanoma risk, but their contribution to melanoma risk prediction compared with traditional risk factors is unknown. We aimed to 1) evaluate the separate and incremental contribution of MC1R genotype to prediction of early-onset melanoma, and compare this with the contributions of physician-measured and self-reported traditional risk factors, and 2) develop risk prediction models that include MC1R, and externally validate these models using an independent dataset from a genetically similar melanoma population.

Methods

Using data from an Australian population-based, case-control-family study, we included 413 case and 263 control participants with sequenced MC1R genotype, clinical skin examination and detailed questionnaire. We used unconditional logistic regression to estimate predicted probabilities of melanoma. Results were externally validated using data from a similar study in England.

Results

When added to a base multivariate model containing only demographic factors, MC1R genotype improved the area under the receiver operating characteristic curve (AUC) by 6% (from 0.67 to 0.73; P < 0.001) and improved the quartile classification by a net 26% of participants. In a more extensive multivariate model, the factors that contributed significantly to the AUC were MC1R genotype, number of nevi and previous non-melanoma skin cancer; the AUC was 0.78 (95% CI 0.75-0.82) for the model with self-reported nevi and 0.83 (95% CI 0.80-0.86) for the model with physician-counted nevi. Factors that did not further contribute were sun and sunbed exposure and pigmentation characteristics. Adding MC1R to a model containing pigmentation characteristics and other self-reported risk factors increased the AUC by 2.1% (P = 0.01) and improved the quartile classification by a net 10% (95% CI 1-18%, P = 0.03).

Conclusions

Although MC1R genotype is strongly associated with skin and hair phenotype, it was a better predictor of early-onset melanoma than was pigmentation characteristics. Physician-measured nevi and previous non-melanoma skin cancer were also strong predictors. There might be modest benefit to measuring MC1R genotype for risk prediction even if information about traditional self-reported or clinically measured pigmentation characteristics and nevi is already available.

Identifying Persons at Highest Risk of Melanoma Using Self-Assessed Risk Factors

OBJECTIVE: To develop a self-assessed melanoma risk score to identify high-risk persons for screening METHODS: We used data from a 1997 melanoma case-control study from Washington State, USA, where 386 cases with invasive cutaneous melanoma and 727 controls were interviewed by telephone. A logistic regression prediction model was developed on 75% of the data and validated in the remaining 25% by calculating the area under the receiver operating characteristic curve (AUC), a measure of predictive accuracy from 0.5-1 (higher scores indicating better prediction). A risk score was calculated for each individual, and sensitivities for various risk cutoffs were calculated. RESULTS: The final model included sex, age, hair color, density of freckles, number of severe sunburns in childhood and adolescence, number of raised moles on the arms, and history of non-melanoma skin cancer. The area under the receiver operating characteristic curve(AUC) was 0.70 (95% CI: 0.64, 0.77). The top 15% risk group included 50% of melanomas (sensitivity 50%). CONCLUSIONS: This self-assessed score could be used as part of a comprehensive melanoma screening and public education program to identify high-risk individuals in the general population. This study suggests it may be possible to capture a large proportion of melanomas by screening a small high-risk group. Further study is needed to determine the costs, feasibility, and risks of this approach.

Familial melanoma: a meta-analysis and estimates of attributable fraction

Melanoma commonly clusters in families, and the recent identification of numerous genotypes predicting higher risks of melanoma has led to the widespread perception that this cancer is predominantly a genetic disease. We conducted a systematic review of the literature and meta-analysis to quantify the contribution of familial factors to melanoma, estimated by the population attributable fraction (PAF). Eligible studies were those that permitted quantitative assessment of the association between histologically confirmed melanoma and family history of the disease; we identified 22 such studies using citation databases, followed by manual review of retrieved references. We calculated summary RRs using weighted averages of the log RR, taking into account random effects, and used these to estimate the PAF. Overall, family history was associated with a significant 2-fold increased risk of melanoma (odds ratio, 2.06; 95% confidence interval, 1.72-2.45); however, there was significant heterogeneity (P = 0.01). The pooled estimate for population-based studies (n = 11) was 2.03 (1.70-2.43), and 2.51 (1.55-4.07) for clinic/hospital-based studies (n = 11), both with significant heterogeneity (P = 0.049 and P = 0.013, respectively). Two studies used record linkage to verify family history in relatives; the pooled risk estimate from these two studies was 2.52 (2.11-3.00) with no evidence of heterogeneity (P = 0.258). Estimates of PAF associated with a positive family history ranged from 0.007 for Northern Europe to 0.064 for Australia (0.040 for all regions combined). Our findings suggest that only a small percentage of melanoma cases (always <7%) are attributable to familial risk; the majority of melanomas are presumably attributable to other factors.

Sun exposure and risk of melanoma

BACKGROUND

As skin cancer education programmes directed to children and adolescents continue to expand, an epidemiological basis for these programmes is necessary to target efforts and plan for further evaluation.

AIMS

To summarise the epidemiological evidence on sun exposure during childhood and adolescence and melanoma risk.

METHODS

A literature review was conducted using Medline (1966 to December 2004) to identify articles relating to sun exposure and melanoma. The review was restricted to studies that included sun exposure information on subjects 18 years of age or younger.

RESULTS

Migrant studies generally indicate an increased melanoma risk in individuals who spent childhood in sunny geographical locations, and decreasing melanoma risk with older age at arrival. Individuals who resided in geographical locations close to the equator or close to the coast during childhood and/or adolescence have an increased melanoma risk compared to those who lived at higher latitudes or never lived near the coast. The intermittent exposure hypothesis remains controversial; some studies indicate that children and adolescents who received intermittent sun exposure during vacation, recreation, or occupation are at increased melanoma risk as adults, but more recent studies suggest intermittent exposure to have a protective effect. The majority of sunburn studies suggest a positive association between early age sunburn and subsequent risk of melanoma.

CONCLUSION

Future research efforts should focus on: (1) clarifying the relation between sun exposure and melanoma; (2) conducting prospective studies; (3) assessing sun exposure during different time periods of life using a reliable and quantitative method; (4) obtaining information on protective measures; and (5) examining the interrelations between ability to tan, propensity to burn, skin type, history of sunburns, timing and pattern of sun exposure, number of nevi, and other host factors in the child and adolescent populations.

Eruptive nevi of the palms and soles

The sudden eruption of atypical and benign melanocytic nevi has been associated with a number of disease states and primary skin conditions. Most case reports and series of patients have linked eruptive nevi with blistering skin disease or immunosuppression. Subsets of patients in the immunosuppressed category have remarkably increased numbers of nevi on the palms and soles. We describe a case of multiple eruptive nevi of the palms and soles in association with immunosuppression, and the potential underlying mechanisms promoting such nevogenesis are explored. Although both the absolute number of nevi and presence of dysplastic nevi have been correlated with an increased relative risk of melanoma, actual risk of melanoma in patients with eruptive nevi is unknown.

Modifiable risk factors for cancer

Over 6 million people around the world die from cancer each year. Modifiable risk factors have been linked to a wide range of malignancies, including cancers of the oropharynx, oesophagus, larynx, lung, kidney, bladder, pancreas, skin, stomach, ovary, breast, cervix, uterus, prostate, and colon. Research indicates that over half of all cancers in developed countries could be prevented if we implemented population-wide measures to promote the following behaviours: reduce tobacco use, increase physical activity, control weight, improve diet, limit alcohol, utilise safer sex practices, get routine cancer screening tests, and avoid excess sun exposure.

Validity of an unsupervised self-administered questionnaire for self-assessment of melanoma risk

Mass screening for cutaneous melanoma is impracticable because of its low yield and high costs. The validity of self-selection of high-risk individuals through self-assessment of melanoma risk factors is not known. The aim of this study was to assess the validity of an unsupervised self-administered questionnaire for the self-assessment of melanoma risk. In a case-control study, melanoma cases (n = 202) and controls (n = 202) matched for age and gender filled in a questionnaire about melanoma risk factors. After filling in the questionnaire, all participants were interviewed and examined by a dermatologist in order to compare self-assessment with physician-assessment. The number of naevi, skin phototype and ultraviolet damage to the skin were identified as independent risk factors for melanoma on both self-assessment and physician-assessment. Receiver operating characteristics analysis showed no statistically significant difference between the accuracy of the self-assessment-based model and the model based on physician-assessment. While excluding 90% of the controls, the self-assessment-based high-risk group included 39% (95% confidence interval 31-48%) of the melanoma patients and the physician-assessment-based high-risk group included 42% (95% confidence interval 33-52%) of the melanoma patients. In conclusion, an unsupervised self-administered questionnaire is, to some extent, useful for the identification of individuals at high risk for melanoma. The moderate accuracy of self-assessment and physician-assessment to identify individuals at high risk for melanoma is a limitation for the practicability of targeted melanoma screening in general.

Acquired melanocytic nevi as risk factor for melanoma development. A comprehensive review of epidemiological data

Acquired melanocytic nevi (MN) in Caucasian populations are important markers for the risk of melanoma development. The total number of MN on the whole body is the most important independent risk factor for melanoma and the risk of melanoma development increases almost linearly with rising numbers of MN. Additionally, the presence of atypical MN and of actinic lentigines are likewise independent risk factors for melanoma. Atypical mole syndrome should be defined by the presence of many acquired MN and a threshold number of atypical MN. Acquired MN develops mainly during childhood and adolescence in the first two decades of life. The number of acquired nevi seems to be related to hereditary factors and nevus-prone families exist. The amount of sun exposure is the most important environmental risk factor for nevus development, particularly in early childhood. Interestingly, sunburns may play a role in nevus development, but seem not to be required, and even moderate sun exposure promotes the process. Therefore, preventive measures for nevus and melanoma development should target young children and adolescents.

Screening for skin cancer

CONTEXT

Malignant melanoma is often lethal, and its incidence in the United States has increased rapidly over the past 2 decades. Nonmelanoma skin cancer is seldom lethal, but, if advanced, can cause severe disfigurement and morbidity. Early detection and treatment of melanoma might reduce mortality, while early detection and treatment of nonmelanoma skin cancer might prevent major disfigurement and to a lesser extent prevent mortality. Current recommendations from professional societies regarding screening for skin cancer vary.

OBJECTIVE

To examine published data on the effectiveness of routine screening for skin cancer by a primary care provider, as part of an assessment for the U.S. Preventive Services Task Force.

DATA SOURCES

We searched the MEDLINE database for papers published between 1994 and June 1999, using search terms for screening, physical examination, morbidity, and skin neoplasms. For information on accuracy of screening tests, we used the search terms sensitivity and specificity. We identified the most important studies from before 1994 from the Guide to Clinical Preventive Services, second edition, and from high-quality reviews. We used reference lists and expert recommendations to locate additional articles.

STUDY SELECTION

Two reviewers independently reviewed a subset of 500 abstracts. Once consistency was established, the remainder were reviewed by one reviewer. We included studies if they contained data on yield of screening, screening tests, risk factors, risk assessment, effectiveness of early detection, or cost effectiveness.

DATA EXTRACTION

We abstracted the following descriptive information from full-text published studies of screening and recorded it in an electronic database: type of screening study, study design, setting, population, patient recruitment, screening test description, examiner, advertising targeted at high-risk groups or not targeted, reported risk factors of participants, and procedure for referrals. We also abstracted the yield of screening data including probabilities and numbers of referrals, types of suspected skin cancers, biopsies, confirmed skin cancers, and stages and thickness of skin cancers. For studies that reported test performance, we recorded the definition of a suspicious lesion, the "gold-standard" determination of disease, and the number of true positive, false positive, true negative, and false negative test results. When possible, positive predictive values, likelihood ratios, sensitivity, and specificity were recorded.

DATA SYNTHESIS

No randomized or case-control studies have been done that demonstrate that routine screening for melanoma by primary care providers reduces morbidity or mortality. Basal cell carcinoma and squamous cell carcinoma are very common, but detection and treatment in the absence of formal screening are almost always curative. No controlled studies have shown that formal screening programs will improve this already high cure rate. While the efficacy of screening has not been established, the screening procedures themselves are noninvasive, and the follow-up test, skin biopsy, has low morbidity. Five studies from mass screening programs reported the accuracy of skin examination as a screening test. One of these, a prospective study, tracked patients with negative results to determine the number of patients with false-negative results. In this study, the sensitivity of screening for skin cancer was 94% and specificity was 98%. Several recent case-control studies confirm earlier evidence that risk of melanoma rises with the presence of atypical moles and/or many common moles. One well-done prospective study demonstrated that risk assessment by limited physical exam identified a relatively small (<10%) group of primary care patients for more thorough evaluation.

CONCLUSIONS

The quality of the evidence addressing the accuracy of routine screening by primary care providers for early detection of melanoma or nonmelanoma skin cancer ranged from poor to fair. We found no studies that assessed the effectiveness of periodic skin examination by a clinician in reducing melanoma mortality. Both self-assessment of risk factors or clinician examination can classify a small proportion of patients as at highest risk for melanoma. Skin cancer screening, perhaps using a risk-assessment technique to identify high-risk patients who are seeing a physician for other reasons, merits additional study as a strategy to address the excess burden of disease in older adults.

Risk factors for cutaneous melanoma: a case-control study in Argentina

BACKGROUND

Although cutaneous malignant melanoma (CMM) is still a relatively rare neoplasm, incidence rates are increasing in many white populations worldwide. A case-control study was performed in Argentina to estimate the risk factors for CMM.

METHODS

The study group comprised 101 hospital cases with histologically verified melanoma and 246 controls, frequency matched by age, sex, and hospital. Individuals were interviewed about demographic and constitutional factors and sun exposure history.

RESULTS

The following risk factors were significant in the logistic analysis: nevi on arms (odds ratio (OR) = 6.3 for 20 or more), skin phototype (OR = 4.1 for type l or ll), holidays spent at the beach (OR = 4 for more than 6 weeks lifelong), fair skin tone (OR = 3.4), light eye color (OR = 2.8), sunburn before the age of 15 years (OR = 2.4), and participation in outdoor sports (OR = 3.2 for more than 5790 h accumulated in a lifetime). Occupational sun exposure was not related to CMM risk. Educational level, hair color, and the presence of freckles were not independent risk factors for CMM.

CONCLUSIONS

The risk factors found for the studied population, with nearly 90% of the individuals born in Argentina and with nearly 50% with four southern European grandparents, were consistent with those described for other countries. This investigation has resulted in findings that may be of use in preparing actions to prevent CMM in Argentina; these should be directed at those individuals who present the above mentioned risk factors. These actions should include instructions to avoid excessive sun exposure, with the aim to reduce melanoma incidence.

Sun awareness in school teachers

School children are important targets for sun awareness education, but the knowledge, attitudes and behaviour of school teachers with respect to sun awareness are poorly understood. A questionnaire-based survey of 76 school teachers was undertaken. Twenty-four per cent of teachers indicated previous experience in teaching sun awareness, but 93% of teachers had no classroom resources for teaching sun awareness. Sun awareness was perceived by respondents as unimportant relative to other health education issues. There was considerable scope for improvement in attitudes and behaviour of teachers with respect to sun awareness. Teachers need more information about environmental factors which affect strength of sunlight, individual risk factors for sunburn and sunscreen strength. Intervention strategies involving school teachers need simple messages, emphasizing the importance of shade, clothing and hats in sun avoidance.

Teaching children about skin cancer prevention: why wait for adolescence?

The baseline knowledge about skin cancer prevention of 983 children aged 8 to 12 years was assessed by a pretest questionnaire. After the pretest, half were given a formal presentation about skin cancer prevention. The other half participated in an informal, question-and-answer session, which covered all material from the formal presentation. Two weeks later, all students completed an identical post-test. The students had a high baseline level of knowledge about skin cancer prevention. Knowledge increased for most items in the post-test questionnaire. In all age groups there was no difference in results between the formal and interactive teaching sessions, except among eight-year-olds, for whom the formal presentation was more effective. As much solar skin damage occurs before adolescence, the younger age group is the important target for skin cancer prevention programs.

Multiple primary melanomas: implications for screening and follow-up programs for melanoma

BACKGROUND

Once individuals are diagnosed with malignant melanoma, they are at an increased risk of developing another melanoma when compared with the normal population.

METHODS

To determine the impact of an intensive follow-up protocol on the stage of disease at diagnosis of subsequent primary melanomas, a retrospective query was performed of an electronic medical record database of 2,600 consecutively registered melanoma patients.

RESULTS

Sixty-seven patients (2.6%) had another melanoma diagnosed at the time of presentation to the clinic or within 2 months (synchronous) and another 44 patients (1.7%) developed a second primary melanoma during the follow-up period (metachronous). For the 44 patients diagnosed with metachronous lesions, the Breslow mean tumor thickness for the first invasive melanoma was 2.27 mm compared with 0.90 mm for the second melanoma. The first melanomas diagnosed are thicker by an average of 3.8 mm (p = 0.008). The mean Clark level for the initial melanoma was greater than the mean level for subsequently diagnosed melanomas (p = 0.002). Twenty-three percent of the initial melanomas were ulcerated, whereas only one of the second primary lesions showed this adverse prognostic factor (p = 0.002).

CONCLUSIONS

Once individuals are diagnosed with melanoma, they are in a high-risk population for having other primary site melanomas diagnosed and should be placed in an intensive follow-up protocol consisting of a complete skin examination.

Naevi and pigmentary characteristics as risk factors for melanoma in a high-risk population: a case-control study in New South Wales, Australia

The relationship between risk of cutaneous malignant melanoma and total body and site-specific naevus counts and other host factors was investigated in a Caucasian population aged 15-84 years in New South Wales, Australia. The study sample comprised 244 cases with melanoma diagnosed in 1989-1993, and 276 controls. The strongest relationship was with total body naevus count. Risk of melanoma was raised 12 times in those with more than 100 naevi compared with those with less than 10. There were also strong risks, with odds ratios of 5 or more, associated with having multiple atypical naevi, multiple large naevi, high naevus counts in sun-exposed or sun-protected areas and being unable to tan on repeated sun exposure. The effect of inability to tan was stronger at younger than older ages. Lesser risks, with odds ratios of 2-3, were associated with being prone to burn on sun exposure, having many freckles as a child and having red hair. The site distribution of naevi in males compared with females resembled the distribution of melanoma by sex. Risk of melanoma of the back was significantly more closely related to back naevus count than naevus count for the remainder of the body. For other anatomical sites, naevus count was non-significantly more closely related to naevus counts at that site than counts over the remainder of the body. Naevus count declined with age in both cases and controls. In those aged under 40, having 100 or more naevi was associated with an aetiological fraction (AF) of 41%. In those aged 60 and over, however, the AF associated with this number of naevi was only 5%.

Number and distribution of melanocytic nevi in individuals with a history of childhood leukemia

BACKGROUND

An increased number of melanocytic nevi at the termination of chemotherapy has been documented in children with hematologic malignancies. The persistence of the increased number of nevi over time and the relationship with personal (e.g. phenotype) and disease related variables remain to be explored.

METHODS

One hundred Italian patients diagnosed as having acute lymphatic or myeloid leukemia, after 1975, were recruited and compared with a group of 100 control individuals drawn from friend of the enrolled patients. Information regarding lifetime sun exposure, phenotypic characteristics, and number of nevi was collected by experienced dermatologists. Counts of nevi were expressed both as totals and as counts per unit of body surface area ("density"). Multiple linear regression analysis was employed to control for potentially confounding factors when comparing patients and controls.

RESULTS

The patients and controls were fairly comparable in terms of constitutional characteristics, but the patients had a significantly higher number and density of nevi > or = 2 mm or larger in diameter. In addition, patients had a greater number of large nevi ( > or = 6 mm in greatest dimension), and of nevi in unusual areas, such as the palms and soles. Differences in nevus density between patients and controls were notably maintained in the older age group ( > 12 years). None of the disease-related factors analyzed (e.g. treatment protocol and radiotherapy), appeared to be significantly correlated with nevus density.

CONCLUSIONS

Patients with a history of childhood leukemia have a sustained increase in their nevus density. A fairly convincing body of evidence indicates that a large number of melanocytic nevi is the strongest risk factor for melanoma. Therefore, the utility of periodic skin examination of these should be considered.

Research note: the Lions Cancer Institute and the Western Australian Society of Plastic Surgeons skin cancer screening programme

BACKGROUND

The Lions Cancer Institute, Perth, and the Western Australian Society of Plastic Surgeons have been investigating the feasibility of community based skin cancer screening. Members of the community responded to newspaper advertisements to attend free skin cancer screening events. This report presents preliminary results obtained from the methods development programme.

METHODS

Seventeen screening clinics were conducted in Perth (4) and country towns (14) in Western Australia between January 1991 and October 1993. The participants were interviewed and given promotional literature and their personal profiles were determined. A total body skin examination was performed by a specialist plastic surgeon and any suspicious lesions were recorded and, if necessary, recommendations for further treatment was documented.

RESULTS

The number of individuals screened was 3397. Of these, 572 patients were referred to general practitioners for further medical attention of suspicious lesions, 79 patients were clinically diagnosed as having suspicious pigmented skin lesions (13.8% of total lesions and 2.3% of total sample screened). Of these, 53 individual patient pathology reports were obtained. Four invasive malignant melanomas and two in situ melanomas arising in Hutchinson's melanotic freckles were detected.

CONCLUSIONS

Debates concerning the efficacy of screening for skin cancer have recently received great attention from many medical disciplines. However, as yet the effectiveness of population based skin cancer screening programmes have not been adequately evaluated with randomized controlled studies. The study reported here provides some findings that may be used to enhance future screening studies.

Malignant melanoma in Italy: risks associated with common and clinically atypical melanocytic nevi

BACKGROUND

Most epidemiologic studies on risk factors for cutaneous melanoma have been performed in predominantly fair-skinned populations.

OBJECTIVE

Our purpose was to assess by means of a case-control study the importance of common melanocytic nevi (CMN) and clinically atypical nevi (CAN) as risk factors for cutaneous melanoma in a Mediterranean population.

METHODS

One hundred six patients with invasive cutaneous melanoma and 109 population control subjects were included in the study. All subjects were younger than 70 years of age and were residents of the Florence area.

RESULTS

The adjusted odds ratios obtained by exact conditional analysis, accounting for age, sex, place of birth, and residence, were 2.6 (95 confidence interval [CI], 1.0 to 6.7) for 10 to 30 CMN, and 22.3 (CI, 4.8 to 215) for more than 30 CMN (chi 2 for trend, 25.41; p < 0.001), 2.9 (CI, 1.2 to 7.5) for large nevi, and 8.4 (CI, 2.2 to 31.4) for CAN. Tendency to freckle resulted in a twofold increase in risk (odds ratio, 2.2) (CI, 1.0 to 5.2). The relative risk associated with a large number of CMN was statistically significant after adjustment for all other variables. When adjusted for the number of CMN, none of the other variables showed a statistically significant increased risk.

CONCLUSION

A large number of CMN represents the most important risk factor for cutaneous melanoma in the Italian population. The presence of large nevi and CAN did not result in an increased risk when the number of CMN was considered.

Self screening for risk of melanoma: validity of self mole counting by patients in a single general practice

OBJECTIVE

To validate self screening by patients of high mole counts, assess the within family association of sun protection behaviour and mole counts, and estimate prevalence of risk factors for melanoma.

SETTING AND SUBJECTS

Systematic sample of families from a single affluent general practice population in Wessex.

DESIGN

Subjects completed a questionnaire about risk factors for melanoma and counted their moles. Subsequently a mole count was done by a general practitioner trained at dermatology clinics.

MAIN OUTCOME MEASURES

Validation of self counts by observer's count. Within family association of sun protection behaviour and mole counts; self reported risk factors.

RESULTS

199/237 subjects (84%) returned the questionnaire; 212/237 (89%) were examined. High counts by patients on the front of the trunk (> 7 moles of > or = 2 mm) were reasonably sensitive (79%), predictive (75%), and specific (97%) of the observer's mole counts (kappa = 0.74), unlike arm or total body counts. Sun protection behaviour correlated between individuals and other family members (Spearman's coefficient r = 0.50, P < 0.01). In the past three months 15/114 adults (13.2%, 95% confidence interval 7.0% to 19.4%) reported any change in a mole and 6/114 (5.3%, 2.0% to 11.1%) "major" changes; 6/109 adults (5.5%, 2.1% to 11.6%) had both high mole counts and freckling.

CONCLUSIONS

Asking patients to count trunk moles could be a feasible way of identifying patients at high risk of melanoma. Concentrating on reported major changes in moles should avoid considerable workload in general practice. The generalisability of these findings and the adverse effects, net benefit in earlier diagnosis and prevention, and workload implications of such self screening need further research.

Does intermittent sun exposure cause basal cell carcinoma? a case-control study in Western Australia

Our report deals with the relationship of pattern and timing of sun exposure to basal cell carcinoma (BCC) in a population-based case-control study conducted in Western Australia in 1988. The main measure of intermittent exposure was based on the amount of exposure on non-working days relative to that over the whole week. Outdoor recreational activities, holidays and sunburn were also considered to be markers of intermittent exposure. We observed a statistically significant increase in risk of BCC with increasing proportion of weekly sun exposure obtained at the weekend, especially in late teenage (OR = 3.9, 95% CI 1.9-7.8 for maximum intermittency of exposure), exposure of the site of skin cancer during holidays (OR = 1.9, 95% CI 1.1-3.1 for the highest exposure quarter) and sunburn to the site (ORs of 1.8 for 3-10 and 1.5 for 11+ sunburns in a lifetime). Risk of BCC increased substantially with increasing intermittency in poor tanners but not at all in good tanners. Our data suggest that a particular amount of sun exposure delivered in infrequent, probably intense increments will increase risk of BCC more than a similar dose delivered more continuously over the same total period of time.

Enhancing the early detection of melanoma within current guidelines

Queensland has the highest reported incidence of malignant melanoma in the world, and early detection offers the possibility of reducing the burden of this cancer in the short term. We report on a survey of 995 residents of the Gold Coast, Queensland, regarding behavioural aspects of the early detection of skin cancer. Survey results suggest that although many people report some form of skin examination behaviour, by either checking their own skin, having another nonmedical person check their skin, or by going to their general practitioner for a skin check, much of this activity may be inadequate. They indicate that current early detection could be enhanced by encouraging individuals and general practitioners to extend the coverage of the examinations they already conduct.

Reliability of naevus counts in identifying individuals at high risk of malignant melanoma

The majority of deaths from malignant melanoma could be prevented by regular screening of at-risk individuals. However, the feasibility of introducing active screening programmes depends on the reliability of criteria for identifying those individuals who are at increased risk. Several case-control studies indicate that one of the most important risk factors is the number of benign pigmented naevi. This criterion might constitute a practical means of identifying individuals suitable for inclusion in an active screening programme. The aim of this study was to assess the reliability of using naevus counts as an indicator of risk. Two possible methods of assessment were compared: assessment by trained interviewers, and assessment by experienced dermatologists. The results suggest that this criterion may not be as practical or reliable as originally anticipated. Interviewer naevus counts correlated poorly with dermatologists' assessments (kappa = 0.19). Counts by dermatologists of the number of naevi on the left arm differed by up to nine naevi, although most counts were within four naevi of each other. There was reasonable correlation between naevus counts on the left arm and those on the whole body (r = 0.71). However, the relationship was not perfect. Selection of individuals for screening solely based on the number of naevi on the left arm may exclude many people with high total body counts but relatively low left arm counts.

Screening for melanoma and options for its evaluation [see comment]

A review of the published evidence presented here argues that screening for melanoma is recommended and practised at present, but with wide diversity of opinions about its value; there is evidence that screening has considerable potential for benefit, but the evidence of actual benefit is limited; and there are substantial costs and potential hazards from screening. On this basis the evaluation of screening procedures for melanoma is important, and options for this are discussed. The ideal study design to assess the efficacy of melanoma screening in reducing mortality is a large scale randomised trial. This may need a well coordinated proposal involving several centres in one or more countries, and the cost would be substantial. Without such a trial, however, it is most likely that increasing resources will be put into poorly designed screening programmes of unknown value. The simplest and strongest designs use individual randomisation, but group randomisation designs may have practical advantages, though they require a greater sample size. Designs based on general population screening, and on screening only high risk groups, are both considered. They answer different questions. In countries with high incidence the value of general population screening is probably the more critical. Not enough is known to specify the type and frequency of screening precisely; both screening by doctors and self screening require evaluation, and annual screening should probably be tested. The age range at risk will depend on the local incidence, but is likely to be quite wide-for example, 45-69, and both sexes need inclusion. Thus a suggested design for a moderate to high incidence area would be a trial, randomised by individual or group, assessing at least two annual rounds of both screening by doctor and self screening (ideally by a factorial design), for adults aged 45-69, with mortality over several years' follow up as the critical outcome. In an area with good data systems such a study could compare screening offered to some 260,000 subjects with 10 times that number of controls passively followed up, with 90% power to detect a one third reduction in mortality. A general assessment of costs over five years gave estimates of $8.3 million for the screening programme and $2.4 million for the evaluation. The much weaker designs, area based cohort studies using individual data or a simpler ecological comparison, and case-control studies, are also considered. If well designed with attention to their methodological limitations they may be valuable but are unlikely to be as definitive as a randomised trial.

Malignant melanoma in different ethnic groups in Israel. Incidence and biologic behavior

BACKGROUND

The Jewish population of Israel is divided into two ethnic groups: Ashkenazic Jews (AJ) who immigrated from Europe and are fair-skinned, and Sephardic Jews (SJ) who immigrated from the Orient and Africa and who are dark-skinned. The biologic behavior of malignant melanoma (MM) in these two groups has not been investigated.

METHODS

Three hundred forty-eight of 380 patients with MM, who could be accurately grouped ethnically, constitute this study group. The gender, site and depth of primary tumor, metastatic involvement and survival analysis, including univariate analysis for level of invasion, were examined.

RESULTS

Of 348 patients with MM, 285 were AJ and 63 were SJ. The female:male ratio was 2:1 and 0.9:1, for AJ and SJ, respectively (P < 0.05). Lesion site distribution was similar. The lesions were more invasive in SJ, 53% Clark level 4-5 versus 41% in AJ (P < 0.05). The 5-year survival was worse in SJ relative to AJ--50% versus 71% for female patients and 30% versus 62% for male patients--but did not reach statistical significance (NS). The actuarial 10-year survival showed poorer survival for female SJ: 27% versus 67% in female AJ (P < 0.05) and male SJ; 32% versus 65% in male AJ (P < 0.01). For all stage I MM, the actuarial 10-year survival was in male patients 32% versus 79% (P < 0.05), and in female patients, 27% versus 72% (P < 0.05) in SJ and AJ, respectively. For the more invasive lesions (Clark levels 4 and 5), the actuarial 10-year survival was for male patients 19% versus 75% (P < 0.05) and for female patients, 65% versus 67% (NS) in SJ and AJ, respectively.

CONCLUSIONS

The dark-skinned SJ tend to have MM less than the fair-skinned AJ, but once MM occurs in SJ, it appears to have a more virulent nature.