Race-, Age-, and Anatomic Site-Specific Gender Differences in Cutaneous Melanoma Suggest Differential Mechanisms of Early- and Late-Onset Melanoma

Establishment and Validation of Prognostic Nomograms for Nonmetastatic Melanoma of the Limbs-A SEER-Based Study

BACKGROUND

Malignant melanoma, a highly aggressive skin cancer, has remarkable incidence and mortality nowadays. This study aims to explore prognostic factors associated with nonmetastatic cutaneous melanoma of the limbs and to develop nomograms for predicting overall survival (OS) and cancer-specific survival (CSS).

METHODS

The study cohort was derived from the Surveillance, Epidemiology, and End Results database. Univariate Cox regression, Lasso regression, and multivariate Cox regression analyses were conducted to identify prognostic factors and construct nomograms. The receiver operating characteristic (ROC) curve, time-dependent C-index, calibration curve, decision curve analysis (DCA) and Kaplan-Meier method were used to evaluate the accuracy and clinical applicability of the nomograms.

RESULTS

A total of 15,606 patients were enrolled. Multivariate analysis identified several prognostic factors for OS and CSS including age, sex, histologic type, N stage, tumor thickness, depth of invasion, mitotic rate, ulceration, surgery of primary site, systemic therapy, race, and number of lymph nodes examined. A nomogram incorporating 12 independent predictors for OS was developed, with a C-index of 0.866 (95% confidence interval [CI]: 0.858-0.874) in the training cohort and 0.853 (95% CI: 0.839-0.867) in validation. For CSS, 10 independent predictors and one related factor were included, yielding a C-index of 0.913 (95% CI: 0.903-0.923) in the training cohort and 0.922 (95% CI: 0.908-0.936) in validation. The ROC curve, time-dependent C-index, calibration curve, DCA, and K-M plot demonstrated favorable discrimination, calibration, and clinical utility.

CONCLUSION

The developed nomograms provide a precise and personalized predictive tool for risk management of patients with nonmetastatic limb melanoma.

Incidence and mortality trends of primary cutaneous melanoma: A 50-year Rochester Epidemiologic Project study

Background

National cancer reporting-based registry data, although robust, lacks granularity for incidence trends. Expert opinion remains conflicted regarding the possibility of melanoma overdiagnosis in the context of rising incidence without a corresponding rise in mortality.

Objective

To characterize 10- and 50-year trends in melanoma incidence and mortality.

Methods

Multicenter, population-based epidemiologic study utilizing the Rochester Epidemiology Project for Olmsted County, Minnesota residents diagnosed with melanoma from 01/01/1970 to 12/21/2020. Age- and sex-adjusted incidence and disease-specific mortality are calculated.

Results

Two thousand three hundred ten primary cutaneous melanomas were identified. Current age- and sex-adjusted incidence rates increased 11.1-fold since 1970s (P < .001). Over the last decade, there is an overall 1.21-fold (P < .002) increase, with a 1.36-fold increase (P < .002) among females and no significant increase among males (1.09-fold increase, P < .329). Melanoma-specific mortality decreased from 26.7% in 1970s to 1.5% in 2010s, with a hazard ratio (HR) reduction of 0.73 (P < .001) per 5-year period. Increased mortality was associated with Breslow thickness (HR 1.35, P < .001), age at diagnosis (HR 1.13, P = .001) left anatomic site (HR 1.98, P = .016), and nodular histogenic subtype (HR 3.08, P < .001).

Limitations

Retrospective nature and focused geographic investigation.

Conclusion

Melanoma incidence has continued to increase over the past decade, most significantly in females aged 40+. Trend variations among age and sex cohorts suggests external factors beyond overdiagnosis may be responsible. Disease-specific mortality of melanoma continues to decrease over the last 50 years.

Radiomic and deep learning analysis of dermoscopic images for skin lesion pattern decoding

This study aims to explore the efficacy of a hybrid deep learning and radiomics approach, supplemented with patient metadata, in the noninvasive dermoscopic imaging-based diagnosis of skin lesions. We analyzed dermoscopic images from the International Skin Imaging Collaboration (ISIC) dataset, spanning 2016-2020, encompassing a variety of skin lesions. Our approach integrates deep learning with a comprehensive radiomics analysis, utilizing a vast array of quantitative image features to precisely quantify skin lesion patterns. The dataset includes cases of three, four, and eight different skin lesion types. Our methodology was benchmarked against seven classification methods from the ISIC 2020 challenge and prior research using a binary decision framework. The proposed hybrid model demonstrated superior performance in distinguishing benign from malignant lesions, achieving area under the receiver operating characteristic curve (AUROC) scores of 99%, 95%, and 96%, and multiclass decoding AUROCs of 98.5%, 94.9%, and 96.4%, with sensitivities of 97.6%, 93.9%, and 96.0% and specificities of 98.4%, 96.7%, and 96.9% in the internal ISIC 2018 challenge, as well as in the external Jinan and Longhua datasets, respectively. Our findings suggest that the integration of radiomics and deep learning, utilizing dermoscopic images, effectively captures the heterogeneity and pattern expression of skin lesions.

Melanoma in Pregnancy-Diagnosis, Treatment, and Consequences for Fetal Development and the Maintenance of Pregnancy

Cutaneous malignant melanoma is one of the most common neoplasms among pregnancy-associated cancers (PACs). Risk factors include excessive exposure to ultraviolet radiation, the presence of benign and dysplastic nevi, and a patient or family history of melanoma. Self-examination and careful inspection of nevi are crucial, especially in the context of their progression over time. Physiological changes that occur during pregnancy, such as the darkening and enlargement of the nevi, delay the diagnosis of CMM. In the fetus, metastases are very rare, and if they do occur, they concern the placenta or fetal tissues. The choice of treatment is influenced by the cancer stage, symptoms, the time of termination of pregnancy, and the patient's decision. Essential procedures which are safe for the fetus are diagnostic biopsy, ultrasound, and the therapeutic excision of the lesion and the affected lymph nodes. Other imaging methods can be used with a safe radiation dose limit of 100 mGy. Immunotherapy and targeted treatments must be carefully considered, because of their possible adverse effects on the fetus. An interdisciplinary approach to the problem of melanoma during pregnancy is necessary, involving doctors of various specialties.

Systemic Inflammation, the Peripheral Blood Transcriptome, and Primary Melanoma

Peripheral blood transcriptomes from 383 patients with newly diagnosed melanoma were subjected to differential gene expression analysis. The hypotheses were that impaired systemic immunity is associated with poorer prognosis (thicker tumors and fewer tumor-infiltrating lymphocytes) and evidence of systemic inflammation (high-sensitivity CRP and fibrinogen levels). Higher fibrinogen levels were associated with thicker primary tumors. In single-gene analysis, high-sensitivity CRP levels were significantly associated with higher blood CD274 expression (coding for PD-L1), but each was independently prognostic, with high-sensitivity CRP associated with increased mortality and higher CD274 protective, independent of age. Pathway analysis identified downregulation of immune cell signaling pathways in the blood of people with thicker tumors and notable upregulation of signal transducer and activator of transcription 1 gene STAT1 in people with brisk tumor-infiltrating lymphocytes. Transcriptomic data provided evidence for increased NF-kB signaling with higher inflammatory markers but with reduction in expression of HLA class II molecules and higher CD274, suggesting that aberrant systemic inflammation is a significant mediator of reduced immune function in melanoma. In summary, transcriptomic data revealed evidence of reduced immune function in patients with thicker tumors and fewer tumor-infiltrating lymphocytes at diagnosis. Inflammatory markers were associated with thicker primaries and independently with death from melanoma, suggesting that systemic inflammation contributes to that reduced immune function.

Increasing Incidence and Decreasing Mortality of Melanoma in Elderly Adults: An Epidemiologic Study in Olmsted County, Minnesota

BACKGROUND AND OBJECTIVE

Primary cutaneous melanoma incidence is increasing in elderly individuals. This population-based cohort examines incidence and mortality rates among adults aged 61 years and older with cutaneous melanoma.

MATERIALS AND METHODS

Using the Rochester Epidemiology Project, patients aged 61 years of age or older with a first lifetime diagnosis of cutaneous melanoma between January 1, 1970 and December 31, 2020 were identified.

RESULTS

The age- and sex-adjusted incidence rate increased from 16.4 (95% CI, 8.2-24.6) per 100,000 person-years in 1970 to 1979 to 201.5 (95% CI, 185.1-217.8) per 100,000 person-years in 2011 to 2020 (12.3-fold increase). There was a 16.0x increase in males and an 8.5× increase in females. Melanoma incidence has stabilized in males (1.2-fold increase, p = .11) and continues to significantly increase in females (2.7-fold increase, p < .001). Older age at diagnosis was significantly associated with an increased risk of death (HR 1.23 per 5-year increase in age at diagnosis, 95% CI, 1.02-1.47).

CONCLUSION

Melanoma incidence continues to increase since 1970. The incidence has risen in elderly females, but has stabilized in males. Mortality has decreased throughout this period.

A Narrative Review of Current Knowledge on Cutaneous Melanoma

Cutaneous melanoma is a public health problem. Efforts to reduce its incidence have failed, as it continues to increase. In recent years, many risk factors have been identified. Numerous diagnostic systems exist that greatly assist in early clinical diagnosis. The histopathological aspect illustrates the grim nature of these cancers. Currently, pathogenic pathways and the tumor microclimate are key to the development of therapeutic methods. Revolutionary therapies like targeted therapy and immune checkpoint inhibitors are starting to replace traditional therapeutic methods. Targeted therapy aims at a specific molecule in the pathogenic chain to block it, stopping cell growth and dissemination. The main function of immune checkpoint inhibitors is to boost cellular immunity in order to combat cancer cells. Unfortunately, these therapies have different rates of effectiveness and side effects, and cannot be applied to all patients. These shortcomings are the basis of increased incidence and mortality rates. This study covers all stages of the evolutionary sequence of melanoma. With all these data in front of us, we see the need for new research efforts directed at therapies that will bring greater benefits in terms of patient survival and prognosis, with fewer adverse effects.

Distinctive lower incidence rates of cutaneous melanoma on the hips and lower extremities of men

BACKGROUND

Cutaneous melanomas (CMs) are more frequently found on the trunk in men, and on the hip and lower extremities (legs) in women. This discrepancy has been attributed to greater exposure to ultraviolet (UV) radiation of women's legs due to their dressing habits.

OBJECTIVES

To understand the sex difference in the bodily distribution of CMs, especially those on the legs.

METHODS

This was a cancer registry-based cohort study. CM incidences, relative tumour density and tumour mutational burdens (TMBs) were compared among different body sites in different sex and racial groups using the SEER (Surveillance, Epidemiology, and End Results) and TCGA SKCM (The Cancer Genome Atlas skin cutaneous melanoma) databases.

RESULTS

White men had lower rates and lower relative tumour density (RTD) of CMs on their legs compared with the rest of their body sites, or compared with White women. Men classified by SEER into racial groups other than White did not show such a trend. White women had comparable RTDs among different body sites. The ratios between the 'White' and the 'other' groups were used to evaluate the approximate effect of sun exposure at different body sites, which further validated a distinct protective effect of men's legs in melanoma. TMB on leg melanomas was lower than on other sites in both sexes.

CONCLUSIONS

The legs of both sexes in White patients show lower RTDs and lower levels of TMB, suggesting a weaker association with UV exposure. Furthermore, White men are especially protected against CM on their legs, suggesting an unknown intrinsic protective factor as compared with women.

The journey from melanocytes to melanoma

Over the past decade, melanoma has led the field in new cancer treatments, with impressive gains in on-treatment survival but more modest improvements in overall survival. Melanoma presents heterogeneity and transcriptional plasticity that recapitulates distinct melanocyte developmental states and phenotypes, allowing it to adapt to and eventually escape even the most advanced treatments. Despite remarkable advances in our understanding of melanoma biology and genetics, the melanoma cell of origin is still fiercely debated because both melanocyte stem cells and mature melanocytes can be transformed. Animal models and high-throughput single-cell sequencing approaches have opened new opportunities to address this question. Here, we discuss the melanocytic journey from the neural crest, where they emerge as melanoblasts, to the fully mature pigmented melanocytes resident in several tissues. We describe a new understanding of melanocyte biology and the different melanocyte subpopulations and microenvironments they inhabit, and how this provides unique insights into melanoma initiation and progression. We highlight recent findings on melanoma heterogeneity and transcriptional plasticity and their implications for exciting new research areas and treatment opportunities. The lessons from melanocyte biology reveal how cells that are present to protect us from the damaging effects of ultraviolet radiation reach back to their origins to become a potentially deadly cancer.

Melanoma survival by age group: Population-based disparities for adolescent and young adult patients by stage, tumor thickness, and insurance type

BACKGROUND

Melanoma survival literature predominantly represents patients >65 years of age. Study of younger patients may reveal potential age-group-specific differences in survival outcome.

OBJECTIVE

Identify factors associated with differences in melanoma survival in 2 age groups, adolescents and young adults (AYAs; ages 15-39) and older adults (ages 40-64).

METHODS

This population-based registry study included all cases (n = 81,597) of cutaneous melanoma diagnosed at ages 15 to 64 from 2004 to 2015 in California. Age-group-specific multivariable Cox hazard regressions were used.

RESULTS

In the adjusted, age-group-specific models, AYA patients with stage IV melanoma had worse survival (hazard ratio: 20.39, 95% CI: 13.30-31.20) than was observed among older adults (hazard ratio: 10.79, 95% CI: 9.33-12.48). Thicker tumors and public insurance were also associated with worse survival for AYAs than observed in models for older adults. AYAs experienced better survival when detected at earlier stages.

LIMITATIONS

Registry data do not routinely collect behavioral information or family history of melanoma.

CONCLUSIONS

Survival was much worse for AYAs with stage IV melanoma than observed among older adults. To improve AYA survival, early melanoma detection is critical. Greater awareness, suspicion, and screening for AYA melanoma may disrupt delays in diagnosis and reduce the excess burden of mortality from stage IV melanoma in young patients.

Anatomic Region of Cutaneous Melanoma Impacts Survival and Clinical Outcomes: A Population-Based Analysis

PURPOSE

The objective was to determine the effects of the anatomic site of a cutaneous melanoma on the survival outcomes of diagnosed individuals.

METHODS

We conducted a cross-sectional study using data from the Surveillance, Epidemiology, and End Results Program (SEER) Database from 2004-2014 and included 178,892 cases of individuals diagnosed with cutaneous melanoma. Overall survival (OS) for each anatomic site as well as associated demographics, primary site, stage, and pathologic prognostic factors (Breslow's depth of invasion (DOI), level of mitoses, and ulceration), were analyzed.

RESULTS

Lower extremity melanoma (LEM) was the most likely to have locoregional nodal spread, yet head and neck melanoma (HNM) was the most likely to present at the most advanced stage of disease (IV). Independent of other factors, HNM was associated with the greatest risk of death (HR 1.90 [95% CI, 1.85-1.96]) compared to other sites, and males experienced worse overall survival (OS) (HR 1.74 [95% CI, 1.70-1.78]) compared to females. The last and greatest risk of death is associated with LEM and HNM, respectively.

CONCLUSION

Given these survival differences, consideration should be given to incorporating the primary site of melanoma into staging to ensure treatment is efficacious as possible.

Primary cutaneous melanoma in Black patients: An analysis of 2464 cases from the National Cancer Database 2004-2018

Melanoma in Black patients carries a poor prognosis. Due to its rarity, melanoma in this population has not been well characterized. This study evaluates survival predictors in Black patients with melanoma. This was a retrospective cohort study of Black patients with cutaneous melanoma from the National Cancer Database 2004-2018. Of the 2464 cases, melanoma was more common among females than males (57.1% vs. 42.9%, p < .001). Median Breslow depth was 1.8 mm (interquartile range 0.4-4.4). Lower extremities were the most common location (52.8%), followed by upper extremities (13.1%) along with otherwise specified/overlapping/other (13.1%), then by trunk (11.8%), and lastly head and neck (9.2%). Stage at diagnosis was I (30.7%), II (27.5%), III (24.1%), and IV (17.7%). Ulceration was observed in 41.4% of lesions. Acral lentiginous melanoma (ALM) was the most common specific histologic subtype (20.3%), followed by superficial spreading melanoma (9.4%). After adjusting for confounders, higher stages and primary site on the head and neck were the strongest independent predictors of worse overall survival. Melanoma in Black patients is most likely to appear on the lower extremities. A large portion (41.8%) presented with stage III or IV disease. ALM was the most common specific histologic subtype.

Variations in genetics, biology, and phenotype of cutaneous disorders in skin of color. Part II: Differences in clinical presentation and disparities in cutaneous disorders in skin of color

Skin of color (SOC) patients are projected to comprise the majority of the population by 2044, yet knowledge gaps in the clinical presentation and treatment of both common and uncommon dermatologic conditions in skin of color persist. Improved awareness of disparities that disproportionately impact SOC patients is necessary to address health inequity in the field of dermatology. The first part of this CME discussed structural, genetic, and immunophenotypic differences in SOC in common inflammatory disorders as well as cutaneous malignancies. The second part of this CME highlights clinical differences in the phenotypic presentation of the inflammatory disorders of atopic dermatitis, psoriasis, and hidradenitis suppurativa as well as the cutaneous malignancies of melanoma, basal cell carcinoma, and cutaneous T-cell lymphoma. Health disparities associated with each of these conditions are also discussed.

Oral mucosal melanoma - A systematic review

Oral mucosal melanoma (OMM) is the subject of few studies, resulting in a lack of understanding. The aim of this study is to review the current literature on OMM. The term searched was "oral mucosal melanoma" between 01/01/2000 and 03/15/2021 in the PubMed Database (MEDLINE). Patients presenting with OMM and treated in our center between January 2009 and January 2020 were included in a case series. Demographics, location, risk factors, genetic mutations, treatment performed, and overall survival (OS) rates were evaluated. The PubMed database search yielded a total of 513 results, thirty-eight articles were finally included, which amounted to 2230 cases of OMM. 13 patients were included in the case series. A male-to-female ratio of 1.28:1.00 was found with a mean age at first diagnosis of 58.2 years old. Hard palate (1060 cases) and then gingiva (794 cases) were the two main locations. No risk factors could be identified. OMM were staged III or IV at diagnosis. Mutations were described as such: KIT in 14.6% of cases, BRAF in 7%, and NRAS in 5.6%. Treatment protocols varied but radical surgery was the cornerstone treatment associated with adjuvant therapies. Immunotherapy has not been evaluated for OMM. OS rates were 43.4% at 3 years, 33.1% at 5 year and 15.4% at 10 years. OMM show distinct features from cutaneous melanoma (CM): typical locations, no identified risk factors, different mutations profile, worse prognosis with advanced stage at diagnosis. Targeted therapies are still underused compared to CM.

"Location of cutaneous malignant melanoma in Sweden 2004-2018 - mortality and sex differences"

BACKGROUND

Cutaneous malignant melanoma (CMM) is one of the most common causes of cancer-related death in Sweden. There is increasing evidence that localisation of the primary CMM lesion differs between sexes and is associated with different outcomes. However, definitive convincing data is lacking.

AIMS

To describe changes in the distribution of CMM anatomical location over time according to sex and determine differences in mortality by location.

METHOD

This is a retrospective nation-wide cohort study of all patients diagnosed with CMM in Sweden between 2004 and 2018. Hazard ratios (HRs) were calculated using a multivariate cox regression model adjusting for age, sex, T-stage, multiple melanomas and comorbidities.

RESULTS

A total of 68,666 patients were included. In males, trunk CMM was the most common location (51% of all male CMM), with an increasing proportion over time. In females, lower extremity CMM had the largest proportion in 2004 (33%) followed by trunk CMM (27%). By 2018, trunk CMM became more common than lower extremity CMM in females. Upper and lower extremity CMMs had lower HR for all-cause mortality compared with trunk CMM (0.896 and 0.887, respectively, p<0.001), while head and neck CMM had higher HR compared with trunk CMM (1.090, p<0.001). Males had greater risk than females (HR 1.352, p<0.001).

CONCLUSIONS

Head and neck CMMs were associated with increased risk of all-cause mortality, while both upper and lower extremity CMMs were associated with decreased risk. Both sexes had increasing proportions of trunk and upper extremity CMM over time, with corresponding decreases in lower extremity and, head and neck CMM.

An Examination of Melanoma Detection and Characteristics at a Nova Scotia Tertiary Care Centre, From 2015-2019

BACKGROUND

Melanoma is one of the most common cancers in Canada,1 with the highest incidence in Nova Scotia (NS).

OBJECTIVES

To describe the demographics, lesion characteristics, and diagnostic accuracy of suspected melanomas excised at the largest center in NS.

METHODS

The dermatopathology database was interrogated for cases of possible melanoma from 2015 through 2019. Age, gender, site of lesion, pathologic diagnosis, Breslow depth, and equivocal pathology were assessed.

RESULTS

984 lesions had a clinical diagnosis of possible melanoma, identifying 301 melanomas. Of these, 142 (47%) were melanoma in situ (MIS) which in females occurred mostly on the extremities, while in males the head predominated. For invasive melanoma (IM), the extremities remained predominant for women, while the back was most common in men. Lower extremity lesions were more likely to be invasive and female patients were more likely to present with them at a younger age compared to males. The pathology was challenging for 23.94% of MIS, and 16.18% of IM. A mean of 3.1 lesions were excised for every melanoma identified.

CONCLUSIONS

Early diagnosis of melanoma is challenging clinically and pathologically. Our melanoma detection rate was 31%, with an increasing trend in the proportion of MIS, and decreasing trend in the proportion of IM over the years. Almost 50% of melanomas were detected in early stages, supporting positive outcomes. Melanomas were more common on extremities in females and the back in males. Melanomas on the lower limbs were more likely to be invasive regardless of gender.

The role of immune checkpoint inhibitors in clinical practice: an analysis of the treatment patterns, survival and toxicity rates by sex

PURPOSE

Our aim is to describe the role of immune checkpoint inhibitors (ICI) in clinical practice by providing the patient and tumor characteristics as well as survival and toxicity rates by sex.

METHODS

We used electronic health records to identify patients treated at the Cancer Center of the University Hospital Bern, Switzerland between January 1, 2017 and June 16, 2021.

RESULTS

We identified 5109 patients, 689 of whom (13.5%) received at least one dose of ICI. The fraction of patients who were prescribed ICI increased from 8.6% in 2017 to 22.9% in 2021. ICI represented 13.2% of the anticancer treatments in 2017 and increased to 28.2% in 2021. The majority of patients were male (68.7%), who were older than the female patients (median age 67 vs. 61 years). Over time, adjuvant and first line treatments increased for both sexes. Lung cancer and melanoma were the most common cancer types in males and females. The incidence of irAEs was higher among females (38.4% vs. 28.1%) and lead more often to treatment discontination in females than in males (21.1% vs. 16.8%). Independent of sex, the occurrence of irAEs was associated with greater median overall survival (OS, not reached vs. 1.1 years). Female patients had a longer median OS than males (1.9 vs. 1.5 years).

CONCLUSIONS

ICI play an increasingly important role in oncology. irAEs are more frequent in female patients and are associated with a longer OS. More research is needed to understand the association between patient sex and toxicity and survival.

Characteristics, Treatments, and Survival of Uveal Melanoma: A Comparison between Chinese and American Cohorts

Simple Summary

This retrospective comparative cohort study aimed to determine whether there were racial or national differences in UM, by comparing the demographic and clinical characteristics, such as tumor size, onset age, trend and proportion of treatment modalities, and overall survival. In the two cohorts, we found that Chinese patients have a younger onset age and a better survival rate. The survival advantage was likely secondary to younger onset age. In addition, a greater proportion of Chinese patients received brachytherapy as opposed to enucleation compared with American patients. This study was the first time comparing patients from different countries and races, which may help ophthalmologists better understand the clinical characteristics of the disease and suggests the importance of early diagnosis and treatment.

Abstract

Uveal melanoma (UM) is the most common intraocular malignant carcinoma. This study aimed to compare the clinical features, treatment modalities, and prognosis of UM patients in China with those in America over a 15-year period. In the study, 4088 American patients with primary UM from the Surveillance, Epidemiology, and End Results (SEER) database and 1508 Chinese patients from Tongren-ophthalmology Research Association of Clinical Evaluation (TRACE) were included. Univariable and multivariable analyses were performed to determine prognostic factors and propensity score matching (PSM) and sensitivity analyses were applied to adjust for confounders and identify independent prognostic factors. Chinese patients were diagnosed at a younger age (mean ± SD, 47.3 ± 12.5 years vs. 59.7 ± 14.8 years) and tumors at diagnosis were larger (diameter: 12.0 ± 3.54 mm vs. 11.3 ± 8.27 mm; thickness: 7.13 ± 3.28 mm vs. 4.91 ± 3.01 mm). Chinese patients were more likely to undergo brachytherapy than American patients. Chinese patients had better overall survival than American patients while no significant differences exhibited after adjusting for age through PSM. In conclusion, compared with American patients, Chinese patients had younger onset age, larger tumors at diagnosis and better prognosis, mainly because of their younger age.

Safety of combining dabrafenib plus trametinib in elderly BRAF V600 mutation-positive advanced melanoma patients: real-world data analysis of Spanish patients (ELDERLYMEL)

Efficacy and safety of dabrafenib and trametinib in metastatic melanoma have been demonstrated in two-phase III and one-phase I/II clinical trials. However, patients at least 75 years old (y.o.) were largely underrepresented. Additionally, the safety profile of dabrafenib and trametinib based on age is unknown. ELDERLYMEL is a retrospective noninterventional multicenter study, describing the effectiveness and safety of at least 75 y.o. patients compared with less than 75 y.o. patients with advanced BRAF V600-mutated melanoma treated with dabrafenib plus trametinib or dabrafenib monotherapy. A total of 159 patients were included, 130 less than 75 y.o. and 29 at least 75 y.o. Clinical features were similar between the groups, except in the number of comorbidities, number of metastatic sites, Eastern Cooperative Oncology Group (ECOG) performance status, and BRAF V600-mutation type. Five patients per group received dabrafenib monotherapy. There were no differences in adverse events (AEs) rate or grade between the groups. However, AE profiles were different between the groups, being pyrexia infrequent in patients at least 75 y.o. (13.8% vs. 42.3%; P = 0.005). Dabrafenib and trametinib dose intensities were lower in at least 75 y.o. patients (P = 0.018 and P = 0.020), but there were no differences in effectiveness between the groups. Finally, in a multivariate analysis, sex (female) was the only variable independently associated with an increased risk of AE grade ≥3. Data from the ELDERLYMEL study demonstrate that dabrafenib plus trametinib is safe and effective in at least 75 y.o. patients with advanced BRAF V600-mutated melanoma without increasing toxicity. Additionally, we describe a different safety profile depending on age and sex.

Cutaneous Melanoma in Alpine Population: Incidence Trends and Clinicopathological Profile

Previous studies associated high-level exposure to ultraviolet radiation with a greater risk of cutaneous malignant melanoma (CMM). This study focuses on the changing incidence of CMM over time (from 1990 to 2017) in the Veneto region of Northeast Italy, and its Alpine area (the province of Belluno). The clinicopathological profile of CMM by residence is also considered. A joinpoint regression analysis was performed to identify significant changes in the yearly incidence of CMM by sex and age. For each trend, the average annual percent change (AAPC) was also calculated. In the 2017 CMM cohort, the study includes a descriptive analysis of the disease's categorical clinicopathological variables. In the population investigated, the incidence of CMM has increased significantly over the last 30 years. The AAPC in the incidence of CMM was significantly higher among Alpine residents aged 0-49 than for the rest of the region's population (males: 6.9 versus 2.4; females 7.7 versus 2.7, respectively). Among the Alpine residents, the AAPC was 3.35 times greater for females aged 0-49 than for people aged 50+. The clinicopathological profile of CMM was significantly associated with the place of residence. Over three decades, the Veneto population has observed a significant increase in the incidence of CMM, and its AAPC. Both trends have been markedly more pronounced among Alpine residents, particularly younger females. While epidemiology and clinicopathological profiles support the role of UV radiation in CMM, the young age of this CMM-affected female population points to other possible host-related etiological factors. These findings also confirm the importance of primary and secondary prevention strategies.

Skin Cancer in People of Color: A Systematic Review

BACKGROUND

People of African, Asian, Hispanic or Latino, Pacific Islander, and Native Indian descent are considered people of color by the Skin of Color Society (SOCS).

OBJECTIVES

In this study, we assess incidence, risk factors, clinical characteristics, histopathology, treatment, and survival for skin malignancies in people of color as defined by the SOCS, by systematically reviewing the literature.

METHODS

An electronic literature search of the PubMed, EMBASE, and MEDLINE databases was performed. Articles published from 1 January 1990 through 12 December 2020 were included in the search.

RESULTS

We identified 2666 publications potentially meeting the study criteria. Titles and abstracts of these studies were reviewed and 2353 were excluded. The full text of 313 articles were evaluated and 251 were included in this review.

CONCLUSION

Differences in incidence, patterns, treatment, and survival exist among people of color for cutaneous malignancies. Further research and initiatives are needed to account for and mitigate these differences.

Ambient UVR and Environmental Arsenic Exposure in Relation to Cutaneous Melanoma in Iowa

Intermittent sun exposure is the major environmental risk factor for cutaneous melanoma (CM). Cumulative sun exposure and other environmental agents, such as environmental arsenic exposure, have not shown consistent associations. Ambient ultraviolet radiation (UVR) was used to measure individual total sun exposure as this is thought to be less prone to misclassification and recall bias. Data were analyzed from 1096 CM cases and 1033 controls in the Iowa Study of Skin Cancer and Its Causes, a population-based, case-control study. Self-reported residential histories were linked to satellite-derived ambient UVR, spatially derived environmental soil arsenic concentration, and drinking water arsenic concentrations. In men and women, ambient UVR during childhood and adolescence was not associated with CM but was positively associated during adulthood. Lifetime ambient UVR was positively associated with CM in men (OR for highest vs. lowest quartile: 6.09, 95% confidence interval (CI) 2.21–16.8), but this association was not as strong among women (OR for highest vs. lowest quartile: 2.15, 95% CI 0.84–5.54). No association was detected for environmental soil or drinking water arsenic concentrations and CM. Our findings suggest that lifetime and adulthood sun exposures may be important risk factors for CM.

Analysis of Demographics and Outcomes of Surgical Resection in the Central Nervous System of Patients With Metastatic Melanoma

Background

Patients with melanoma frequently develop central nervous system metastases. Oligometastatic disease is often treated either by surgical resection or by stereotactic radiotherapy. This study investigates the trends and clinical outcomes of patients with melanoma who have undergone surgical procedures on the central nervous system during their hospitalization.

Methods

A retrospective study was performed based on admissions of adult patients who underwent craniotomy for metastatic melanoma from 2000 to 2014 using the Nationwide Inpatient Sample database. The primary outcome measure was all-cause in-hospital mortality. Secondary outcomes included hospital length of stay (LOS) and discharge disposition (home/home with health care and skilled nursing facilities/long-term acute care (SNFs/LTAC)). Factors associated with in-hospital mortality were examined by multivariable logistic regression. We adjusted for patient and hospital characteristics, payer, and comorbid conditions. We also examined trends of mortality for the study years.

Results

There were an estimated 1,216 discharges of patients with melanoma undergoing craniotomy during the study period. Patients undergoing surgical interventions were typically males (69%) and whites (79%). Ninety-eight percent of procedures were performed at teaching hospitals. Unadjusted all-cause in-hospital mortality was 3.1%. There was no significant difference in mortality over 13 years. Age, gender, and race were not associated with increased in-hospital mortality. LOS was longer in elderly and those with higher Charlson Comorbidity Index. Of the survivors, 76% were discharged to home or with home healthcare while 24% were discharged to SNFs/LTAC. Patients with age > 65 (odds ratio (OR): 2.9; 95% confidence interval (CI): 2.2 - 3.9, P < 0.001) and those with higher Charlson Comorbidity Index (OR: 1.2; 95% CI: 1.1 - 1.3) had higher odds for being discharged to SNFs/LTAC.

Conclusions

Patients who undergo craniotomy for metastatic melanoma have a low in-hospital mortality rate. One quarter of patients were discharged to SNFs/LTAC.

Changing epidemiology and age-specific incidence of cutaneous malignant melanoma in Lithuania: an analysis of national cancer registration data by gender and anatomical site, 1991-2015

Introduction

The purpose of this study was to investigate the gender-specific and anatomical site-specific incidence of cutaneous melanoma.

Material and methods

All cases of primary skin melanoma reported to the Lithuanian Cancer Registry during the period 1991-2015 were included. For the analyses, patients were categorized by sex and melanoma site.

Results

Overall age-standardized rate (ASR) of melanoma in the trunk increased 0.8-3.3, while in limbs the ASR increased 1.0-3.4. The highest increase in new cases per 100,000 population (in both sexes) was detected in limbs and it increased over time (from 2.01 per 100,000 in 1991 to 3.65 per 100,000 in 2015). The highest increase in the number of new cases was in limbs with ASR, with a more than 3-fold increase from 1991-2015 (1.4-4.6). A statistically significant increase was observed in mortality of skin melanoma between 1991 and 2015, with the highest annual percentage change (APC) of 5.5 in the trunks of men (95% CI: 5.2-5.9; p < 0.05) and women with APC 3.9 (95% CI: 3.5-4.4, p < 0.05).

Conclusions

In our study, we found higher incidence rates of skin melanoma in females. Melanoma was more commonly diagnosed in the trunk of males and limbs of females, with the highest mortality increase in trunk melanoma in both genders.

ZooME: Efficient Melanoma Detection Using Zoom-in Attention and Metadata Embedding Deep Neural Network

Melanoma detection is a crucial yet hard task for both dermatologists and computer-aided diagnosis (CAD). Many traditional machine learning algorithms including deep learning-based methods are employed for melanoma classification. However, more and more complex network architectures do not harvest a leap in model performance. In this paper, we aim to enhance the credibility of CAD approach for melanoma by paying more attention to clinically important information. We propose a Zoom-in Attention and Metadata Embedding (ZooME) melanoma detection network by: 1) introducing a Zoom-in Attention model to better extract and utilize unique pathological information of dermoscopy images; 2) embedding patients' demographic information including age, gender, and anatomic body site, to provide well-rounded information for better prediction. We apply a ten-fold cross-validation on the latest ISIC-2020 dataset with 33,126 dermoscopy images. The proposed ZooME achieved state-of-the-art results with 92.23% in AUC score, 84.59% in accuracy, 85.95% in sensitivity, and 84.63% in specialty, respectively.

Towards gender equity in artificial intelligence and machine learning applications in dermatology

There has been increased excitement around the use of machine learning (ML) and artificial intelligence (AI) in dermatology for the diagnosis of skin cancers and assessment of other dermatologic conditions. As these technologies continue to expand, it is essential to ensure they do not create or widen sex- and gender-based disparities in care. While desirable bias may result from the explicit inclusion of sex or gender in diagnostic criteria of diseases with gender-based differences, undesirable biases can result from usage of datasets with an underrepresentation of certain groups. We believe that sex and gender differences should be taken into consideration in ML/AI algorithms in dermatology because there are important differences in the epidemiology and clinical presentation of dermatologic conditions including skin cancers, sex-specific cancers, and autoimmune conditions. We present recommendations for ensuring sex and gender equity in the development of ML/AI tools in dermatology to increase desirable bias and avoid undesirable bias.

Sex disparity in skin carcinogenesis and potential influence of sex hormones

Background

Sex or gender disparity in skin cancer has been documented for a long time at the population level. UV radiation (UVR) is a common environmental risk for all three major types of skin cancer: cutaneous melanoma (CM), basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC). The underlying mechanism for sex disparity has been largely attributed to sex‐differentiated behaviour patterns related to UVR. Non‐UVR factors such as intrinsic physiological differences have been suggested but remain understudied.

Aims, Materials and Methods

This review summarizes and compares the known sex differences in three skin cancer types with regard to body site distribution and age influence.

Results

We found a similar age‐dependent sex difference pattern in CM and BCC. Specifically, CM and BCC tend to show higher incidence in young women and old men, with a switching age around menopause. The switching age suggests involvement of sex hormones, which has shown controversial influence on skin cancers at epidemiological level. Literatures regarding sex hormone receptors for oestrogen, androgen and progesterone are summarized for potential explanations at molecular level.

Discussion

Overall, more and more evidence suggests non‐UVR factors such as sex hormones play critical roles in skin cancer (especially CM and BCC), yet solid population and molecular evidence are required. Incidences of skin cancer are increasing which suggests limited effect for the current UVR‐avoidance prevention methods.

Conclusion

Fully understanding the causes of sex disparities in incidence is necessary for developing a comprehensive prevention strategy.

A Review of Epidemiology and Cancer Biology of Malignant Melanoma

Malignant melanoma is a neoplasm originating in the melanocytes in the skin. Although malignant melanoma is the third most common cutaneous cancer, it is recognized as the main cause of skin cancer-related mortality, and its incidence is rising. The natural history of malignant melanoma involves an inconsistent and insidious skin cancer with great metastatic potential. Increased ultra-violet (UV) skin exposure is undoubtedly the greatest risk factor for developing cutaneous melanoma; however, a plethora of risk factors are now recognized as causative. Moreover, modern oncology now considers melanoma proliferation a complex, multifactorial process with a combination of genetic, epigenetic, and environmental factors all known to be contributory to tumorgenesis. Herein, we wish to outline the epidemiological, molecular, and biological processes responsible for driving malignant melanoma proliferation.

Effect of hypoxia factors gene silencing on ROS production and metabolic status of A375 malignant melanoma cells

The innate response of melanocytes to exogenous or endogenous stress stimuli like extreme pH and temperature, metabolite and oxygen deficiency or a high UV dose initiates a cellular stress response. This process activates adaptive processes to minimize the negative impact of the stressor on the pigment cell. Under physiological conditions, a non-cancer cell is directed to apoptosis if the stressor persists. However, malignant melanoma cells will survive persistent stress thanks to distinct "cancerous" signaling pathways (e.g. MEK) and transcription factors that regulate the expression of so-called "survival genes" (e.g. HIF, MITF). In this survival response of cancer cells, MEK pathway directs melanoma cells to deregulate mitochondrial metabolism, to accumulate reduced species (NADH), and to centralize metabolism in the cytosol. The aim of this work was to study the effect of gene silencing in malignant melanoma A375 cells on metabolic processes in cytosol and mitochondria. Gene silencing of HIF-1α, and miR-210 in normoxia and pseudohypoxia, and analysis of its effect on MITF-M, and PDHA1 expression. Detection of cytosolic NADH by Peredox-mCherry Assay. Detection of OCR, and ECAR using Seahorse XF96. Measurement of produced O₂^•- with MitoTracker Red CMXRos. ¹H NMR analysis of metabolites present in cell suspension, and medium. By gene silencing of HIF-1α and miR-210 the expression of PDHA1 was upregulated while that of MITF-M was downregulated, yielding acceleration of mitochondrial respiratory activity and thus elimination of ROS. Hence, we detected a significantly reduced A375 cell viability, an increase in alanine, inositol, nucleotides, and other metabolites that together define apoptosis. Based on the results of measurements of mitochondrial resipiratory activity, ROS production, and changes in the metabolites obtained in cells under the observed conditions, we concluded that silencing of HIF-1α and miR-210 yields apoptosis and, ultimately, apoptotic cell death in A375 melanoma cells.

Bullous Pemphigoid Associated with Anti-programmed Cell Death Protein 1 and Anti-programmed Cell Death Ligand 1 Therapy: A Review of the Literature

Bullous pemphigoid constitutes a rare dermatological immune-related adverse event of programmed cell death protein 1 (PD-1)/programmed cell death ligand 1 (PD-L1) inhibitors. Herein, we review all published cases of anti-PD-1/PD-L1 related bullous pemphigoid and discuss current knowledge on this condition. Clinical and diagnostic findings were found to resemble those of classic bullous pemphigoid. A delayed onset of bullous pemphigoid after commencement of immunotherapy as well as a frequent precendence of a refractory pruritic eruption prior to blister development was oberved, both posing diagnostic challenges. In addition to topical and systemic treatment, most patients required either discontinuation or permanent interruption of immunotherapy. Assessment of tumour outcome did not reveal improved survival in patients developing bullous pemphigoid during immunotherapy, as suggested for other types of skin toxicity, including vitiligo. Better understanding of the pathogenetic mechanism and prognostic implications of this increasingly-reported adverse event is essential in order to establish optimal diagnostic and therapeutic management of these patients.

Evaluation of Sex-Specific Incidence of Melanoma

Importance

Men and women develop melanoma at different rates on different body sites, with variation across countries, but explanations for these disparities remain elusive.

Objective

To test whether observed differences in melanoma incidence between men and women vary by population, age, or anatomic site.

Design

Cross-sectional analysis of sex- and site-specific temporal trends in melanoma incidence over 3 decades was conducted for men and women diagnosed with invasive melanoma in the US (limited to white race), Canada, Australia, New Zealand, the UK, Sweden, Norway, and Denmark. Using cancer registry data, male to female incidence rate ratios (IRRs) were calculated overall and by anatomic site, and Joinpoint regression models were used to estimate the annual percentage rate changes in sex- and site-specific incidence in each population. Incidence rates were standardized to the US 2000 population. Data on the incidence between January 1, 1982, and December 31, 2015, were obtained; analysis was conducted from March 1 to October 15, 2019.

Main Outcomes and Measures

Male to female IRRs and annual percentage change in rates.

Results

Total melanoma incidence was higher in men than women in US individuals (limited to white race), Canada, Australia, and New Zealand, but not in Denmark, the UK, Norway, and Sweden. In all populations, men had higher rates of melanoma of the head and neck and trunk than women (male to female IRR >1), but lower melanoma rates on the lower limbs (ie, male to female IRR approximately 0.5). The male to female IRR increased log linearly with age, with excess melanomas in women younger than 45 years in all populations (eg, IRR for 20-24 y age group, 0.3 in Denmark and 0.7 in Australia), and excess melanomas in men older than 69 years (eg, IRR for 70-74 y age group, 1.1 in Denmark and 2.1 in the US white population). The age at which the melanoma incidence in men exceeded the melanoma incidence in women differed by population, being achieved the earliest in Australia (45-49 years) and latest in Denmark (65-69 years).

Conclusions and Relevance

In predominantly fair-skinned populations, melanoma incidence appears to differ systematically and consistently between men and women by age and anatomic site.

Epidemiology and Survival Outcomes for Eyelid Primary Malignant Melanoma: An Analysis of 1397 Cases in the SEER Database

Purpose

There has not been a recent population-based study regarding the epidemiological trend and survival of eyelid primary malignant melanoma (PMM). Our study aims to evaluate the updated incidence trends and discuss the factors affecting the survival outcomes of eyelid PMM.

Methods

A total of 1397 eyelid PMM cases diagnosed between 1975 and 2016 were retrospectively identified from the Surveillance, Epidemiology, and End Results (SEER) database. Age-adjusted incidence rates and annual percent changes (APC) were calculated. Kaplan-Meier and Cox proportional hazards regression models were used to calculate survival outcomes and identify potential prognostic factors.

Results

The overall age-adjusted incidence of eyelid PMM rose from 0.039 (95% confidence interval [CI], 0.012–0.088) in 1975 to 0.103 (95% CI, 0.070–0.143) per 100 000 population in 2016, with significant APC of 1.313% (p < 0.001). Male subjects showed a higher average age-adjusted incidence rate than female subjects (p < 0.001). Survival analyses showed that 5-year accumulative overall survival (OS) and disease-specific survival (DSS) for patients with eyelid PMM were 70.5% and 90.6%. Additionally, 10-year OS and DSS were 51.8% and 86.1%, respectively. Analyses of Kaplan-Meier survival curves with the log-rank test revealed that older age, White race, nodular melanoma, higher American Joint Committee on Cancer (AJCC) stage (II to IV), advanced stage, distant metastasis, and no-surgery treatment were associated with lower OS and DSS rates. Age, histology, AJCC stage, and stage at diagnosis were found to be independent predictors of OS and DSS in multivariate models.

Conclusion

The incidence of eyelid PMM increased with significant APC and male predominance. Age, histology, AJCC stage, and stage at diagnosis might be independent predictors of prognosis, emphasizing the importance of improved diagnosis of eyelid PMM.

Recent advances in the management of cutaneous malignant melanoma: our case cohort

Decades of research into the management of cutaneous malignant melanoma have proven it to be a 'tough nut to crack', and its incidence has continued to increase over the last 30 years. Surgery remains a gold standard for early-stage melanoma with five-year survival of 98% for stage I disease, and 90% for stage II. Nonetheless, patients with stage III disease are at a higher risk, resulting in local recurrence as well as distant metastasis. Research regarding the control of metastatic malignant melanoma of the head and neck has evolved. Currently the search is on to understand metastatic malignant melanoma as a heterogeneous disease both at the molecular and clinical level. This paper focuses on the latest systemic therapy for metastatic disease of the head and neck, including cytotoxic chemotherapy, immunotherapy, and target therapy. The new eighth edition of tumour staging, and the sequelae for malignant melanoma, sentinel lymph node biopsy (SLNB), surgical intervention, and its benefits and shortfalls, are discussed. Also, the outcome of our cohort series of patients with metastatic cutaneous malignant melanoma who were treated with systemic combination therapy in Dorset is presented.

A Novel Nomogram and Risk Classification System Predicting the Cancer-Specific Mortality of Patients with Initially Diagnosed Metastatic Cutaneous Melanoma

BACKGROUND

Cutaneous melanoma and distant organ metastasis has varying outcomes. Considering all prognostic indicators in a prediction model might assist in selecting cases who could benefit from a personalized therapy strategy.

OBJECTIVE

This study aimed to develop and validate a prognostic model for patients with metastatic melanoma.

METHODS

A total of 1535 cases diagnosed with metastatic cutaneous melanoma (stage IV) were identified from the Surveillance, Epidemiology, and End Results database. Patients were randomly divided into the training (n = 1023) and validation (n = 512) cohorts. A prognostic nomogram was established based predominantly on results from the competing-risk regression model for predicting cancer-specific death (CSD). The area under the time-dependent receiver operating characteristic curve (AUC), calibration curves, and decision curve analyses (DCAs) were used to evaluate the nomogram.

RESULTS

No significant differences were observed in the clinical characteristics between the training and validation cohorts. In the training cohort, patient-, tumor-, and treatment-related predictors of CSD for metastatic melanoma included age, sex, race, marital status, insurance, American Joint Committee on Cancer T and N stage, number of metastatic organs, surgical treatment, and chemotherapy. All these factors were used for nomogram construction. The time-dependent AUC values of the training and validation cohorts suggested a favorable performance and discrimination of the nomogram. The 6-, 12-, and 18-month AUC values were 0.706, 0.700, and 0.706 in the training cohort, and 0.702, 0.670, and 0.656 in the validation cohort, respectively. The calibration curves for the probability of death at 6, 12, and 18 months showed acceptable agreement between the values predicted by the nomogram and the observed outcomes in both cohorts. DCA curves showed good positive net benefits in the prognostic model among most of the threshold probabilities at different time points (death at 6, 12, and 18 months). Based on the total nomogram scores of each case, all patients were divided into the low-risk (n = 511), intermediate-risk (n = 512), and high-risk (n = 512) groups, and the risk classification could identify cases with a high risk of death in both cohorts.

CONCLUSIONS

A predictive nomogram and a corresponding risk classification system for CSD in patients with metastatic melanoma were developed in this study, which may assist in patient counseling and in guiding clinical decision making for cases with metastatic melanoma.

A Possible Link of Genetic Variations in ER/IGF1R Pathway and Risk of Melanoma

The mechanism of gender disparity in cutaneous melanoma incidence remains unclear. Steroid hormones including estrogens have long been implicated in the course of melanoma, but the conclusion is controversial. Estrogen receptors (ERs) and insulin-like growth factor 1 receptor (IGF1R) show extensive crosstalk in cancer development, but how the ER/IGF1R network impacts melanoma is currently unclear. Here we studied the melanoma associations of selected SNPs from the ER/IGF1R network. Part of the International Genes, Environment, and Melanoma (GEM) cohort was used as a discovery set, and the Gene Environment Association Studies Initiative (GENEVA) dataset served as a validation set. Based on the associations with other malignant disease conditions, thirteen single nucleotide polymorphism (SNP) variants in ESR1, ESR2, IGF1, and IGF1R were selected for candidate gene association analyses. The rs1520220 in IGF1 and rs2229765 in IGF1R variants were significantly associated with melanoma risk in the GEM dataset after Benjamini-Hochberg multiple comparison correction, although they were not validated in the GENEVA set. The discrepancy may be caused by the multiple melanoma characteristics in the GEM patients. Further analysis of gender disparity was carried out for IGF1 and IGF1R SNPs in the GEM dataset. The GG phenotype in IGF1 rs1520220 (recessive model) presented an increased risk of melanoma (OR = 8.11, 95% CI: 2.20, 52.5, p = 0.006) in men but a significant opposite effect in women (OR = 0.15, 95% CI: 0.018, 0.86, p = 0.045). The AA genotype in IGF1R rs2229765 (recessive model) showed a significant protective effect in men (OR = 0.24, 95% CI: 0.07, 0.64, p = 0.008) and no effect in women. Results from the current study are warranted for further validation.

Epidemiology of Skin Cancer: Update 2019

Melanoma and keratinocyte skin cancer (KSC) are the most common types of cancer in White-skinned populations. Both tumor entities showed increasing incidence rates worldwide but stable or decreasing mortality rates. Rising incidence rates of cutaneous melanoma (CM) and KSC are largely attributed to increasing exposure to ultraviolet (UV) radiation, the main causal risk factor for skin cancer.Incidence rates of KSC, comprising of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are much higher than that of melanoma. BCC development is mainly the cause of an intensive UV exposure in childhood and adolescence, while SCC development is related to chronic, cumulative UV exposure over decades. Although mortality is relatively low, KSC is an increasing problem for health care services causing significant morbidity.Cutaneous melanoma is rapidly increasing in White populations, with an estimated annual increase of around 3-7% over the past decades. In contrast to SCC, melanoma risk is associated with intermittent and chronic exposure to sunlight. The frequency of its occurrence is closely associated with the constitutive color of the skin and the geographical zone. Changes in outdoor activities and exposure to sunlight during the past 70 years are an important factor for the increasing incidence of melanoma. Mortality rates of melanoma show stabilization in the USA, Australia, and in European countries. In the USA even dropping numbers of death cases were recently reported, probably reflecting efficacy of the new systemic treatments.Among younger cohorts in some populations (e.g., Australia and New Zealand,), stabilizing or declining incidence rates of CM are observed, potentially caused by primary prevention campaigns aimed at reducing UV exposure. In contrast, incidence rates of CM are still rising in most European countries and in the USA. Ongoing trends towards thinner melanoma are largely ascribed to earlier detection.