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Validation of the Self-Assessment of Melanoma Risk Score for a melanoma-targeted screening
Abstract
Melanoma is nowadays a major public health problem because of its increasing incidence. Targeted screening for patients at a high risk for melanoma is being promoted. The aim of our study was to assess the effectiveness of a targeted screening on the basis of the self-selection of high-risk individuals with the Self-Assessment of Melanoma Risk Score (SAMScore). Our main objective was to prove that this score allows the selection of a group of patients who are at a higher risk and in whom more melanomas may be detected. This prospective study was carried out in France in 2009. Consecutive patients, while visiting their doctor's office, filled out a melanoma risk factor questionnaire. Patients were assessed as being at high risk or not according to the SAMScore, and patients at a high risk were examined both by their general practitioner and by a dermatologist. The efficiency of the selection tool corresponded to the ratio of the prevalence of melanoma in a population selected with the SAMScore to the prevalence in the general population. A logistic model with a random effect was used. A total of 7977 patients filled out the questionnaire. Among the 2404 patients at high risk, histologically proven melanoma was screened in 10 cases: two in-situ and eight invasive melanomas. The SAMScore efficiency assessed was equal to 11.54 (P=0.0016). In conclusion, in this strategy, to detect a new case of melanoma, it is necessary to screen 11 times fewer patients than with a nontargeted screening. This is the first study to confirm the efficiency of a targeted screening on the basis of self-selection of high-risk individuals.
... Copies of the validated survey, Self-Assessment of Melanoma Risk Score (SAMScore), were provided to participating PCPs [24,25]. Quéreux et al. assessed the efficiency of the SAMScore and found that targeted screening using this score allows for 11 times fewer patient screenings than with a nontargeted screening [26]. This would allow non-dermatologists to screen primarily those that are identified as high-risk patients by the SAMScore questionnaire. ...
... (A) Presence of at least three risk factors among the seven following risk factors: (1) skin type I (very fair skin, blonde or red hair, light eyes -blue or green, never tan, and always sunburn after sun exposure) or skin type II (fair skin, blonde or light brown hair, light eyes -blue or green, and usually sunburn), (2) freckling tendency, (3) number of melanocytic nevi > 20 on both arms, (4) severe sunburn during childhood or teenage years, (5) life in a country at low latitude, (6) a history of previous melanoma, (7) a history of melanoma in a first-degree relative, (B) A subject under 60 years of age and a number of melanocytic nevi > 20 on both arms, (C) A subject of 60 years old or over and a freckling tendency [26]. ...
... Anecdotal responses from patients indicated that a photo with an example of the skin type may make skin-type identification easier. SAMScore risk survey provides six different skin type options for patients with no visual aids: skin type I -very fair skin, blonde or red hair, light eyes (blue or green), never tan, and always sunburn after sun exposure; skin type II -fair skin, blonde or light brown hair, light eyes (blue or green), and usually sunburn; skin type III -dark skin, brown hair, and light to medium eye color; skin type IV -olive skin, dark brown hair, and brown eyes; skin type V -brown skin black hair, and black eyes; skin type VI -black skin, back hair, and black eyes [26]. Answering these questions correctly helps their providers identify if they are at high risk for melanoma. ...
Introduction
Melanoma incidence rates are rising faster than the rates of any other malignancy. As a major global public health concern, melanoma can be identified by a visual exam not requiring expensive invasive procedures. However, non-dermatologists lack specialized training and skills to identify high-risk patients and implement melanoma skin screenings during regular exams. Most patients from rural and underserved areas have inadequate access to specialty dermatologic care, which can potentially lead to later-stage melanomas and poor patient outcomes. The objective of this study was to identify facilitators and barriers to the implementation of risk surveys and melanoma skin screenings in primary care settings through live interactive education and the telementoring project - Melanoma ECHO (Extension for Community Healthcare Outcomes).
Methods
This cross-sectional study was designed with theoretical concepts from dissemination and implementation research. Monthly Melanoma ECHO sessions were integrated into an ongoing Dermatology ECHO at the University of Missouri, Columbia, Missouri, USA, from April 2018 to February 2019. Ten primary care providers, medical doctors/doctors of osteopathic medicine (MDs/DOs), nurse practitioners (NPs), and physician assistants (PAs), from across Missouri participated. Eleven virtual monthly melanoma-related didactics and case-based discussions were provided to participants. Information regarding risk factors, risk surveys, and screening techniques was provided. Ongoing telementoring and guidance were also provided for de-identified real-life patient cases. The main outcomes and measures of the study were to identify the facilitators and barriers of risk survey and melanoma skin screenings in primary care settings and to quantify the number of high-risk patients identified by participating providers and the number of new melanomas detected by visual exams during the study period.
Results
The primary reason why six out of 10 providers reported participation in Melanoma ECHO was that implementing melanoma skin screenings in their practice was made easier as it increased their confidence. Nine providers reported increased knowledge, and eight cited professional networking as other facilitators. The main perceived barrier to melanoma skin screening was lack of administrative and nursing support, and six providers indicated that lack of time to incorporate skin exams was also a barrier. Combined, ten participants reported identifying 976 high-risk patients during the study period and detecting 36 new melanomas.
Discussion and conclusion
Our findings indicate that primary care providers may benefit from attending regularly scheduled and focused specialized telementoring sessions, such as Melanoma ECHO. Ongoing support from specialists may help providers practicing in rural and isolated areas with the successful integration of risk surveys and melanoma skin screenings in primary care settings. Further Melanoma ECHO sessions with a more diverse group of primary care providers are needed to better understand the generalizability of the results.
... 29 On the basis of these findings, our team has developed a targeted melanoma screening procedure grounded in primary care, using the Self-Assessment of Melanoma Risk Score (SAMScore). This score is based on a 7-item self-administered questionnaire (figure 1) that a patient can answer without specific medical knowledge (30)(31)(32) and allows for the selection of a population at high risk of melanoma during primary care consultations. [30][31][32][33] The SAMScore algorithm allows for the expression of risk in a dichotomous format (either at elevated risk or not for melanoma; figure 1). ...
... This score is based on a 7-item self-administered questionnaire (figure 1) that a patient can answer without specific medical knowledge (30)(31)(32) and allows for the selection of a population at high risk of melanoma during primary care consultations. [30][31][32][33] The SAMScore algorithm allows for the expression of risk in a dichotomous format (either at elevated risk or not for melanoma; figure 1). According to the SAMScore, a patient is considered at elevated risk for melanoma if at least one of the following three criteria is met: (1) the presence of at least three risk factors among the following seven risk factors: phenotype I or II, a freckling tendency, >20 melanocytic naevus on both arms, experienced severe sunburn during the childhood or teenage years, resides in a country at low latitude, a history of previous melanoma and a history of melanoma in a first-degree relative; (2) under 60 years of age and >20 melanocytic naevus on both arms; and (3) 60 years of age or older with a freckling tendency. ...
... Previous research based on a literature review has suggested a relative risk of 13.77 in the selected high-risk population. 31 32 The SAMScore has been used to create a cohort of patients at high risk of melanoma (COPARIME) who were then asked to participate in a pilot targeted screening for melanoma (NCT01610531). 33 The targeted melanoma screening procedure comprised the following three steps: (1) identifying high-risk patients using the SAMScore; (2) asking GPs to perform a total skin examination on these highrisk patients; and (3) referring patients to a dermatologist if needed (for patients requiring a specialist opinion according to the GP). ...
Objective To evaluate the efficacy of a targeted screening for melanoma in high-risk patients following the receipt of a mailed invitation to an annual skin examination by a general practitioner (GP).
Methods A prospective cohort study was conducted in a primary care setting in western France. A total of 3897 patients at elevated risk of melanoma (identified using the Self-Assessment of Melanoma Risk Score) consented to participate in a targeted melanoma screening project in 2011. One year later, the participants were invited by mail to consult their GP for an annual skin examination. Efficacy of the procedure was evaluated according to patient participation and the number of melanomas detected. The consultation dates and results were collected during the 12 months postreminder and were analysed using SAS. Analyses of whether participation decreased compared with that during the year of inclusion and whether populations at risk for thick melanoma showed reduced participation in the screening were performed.
Results Of the 3745 patients who received the mailed invitation, 61% underwent a skin examination. The participation of patients at risk for thick melanoma (any patient over 60 years of age and men over 50 years of age) was significantly greater than that of the patients in the other subgroups (72.4% vs 49.6%, p<0.001; and 66% vs 52.4%, p<0.001, respectively). The patients referred to the dermatologist after 1 year were more compliant compared with those referred during the first year (68.8% vs 59.1%, p=0.003). Six melanomas were detected within 1 year postreminder; therefore, the incidence of melanoma in the study population was 160/100 000.
Conclusions This study confirms the benefits of developing a targeted screening strategy in primary care. In particular, after the annual reminder, patient participation and the diagnosis of melanoma remained high in the patients at elevated risk of thick melanomas.
Trial registration number NCT01610531.
... Moreover, the reduction failed to reach statistical significance, a result which could indicate chance oscillation. On the other hand, in a previously described targeted screening setting based on self-selection of high-risk individuals, the number of patients needed to screen to find one more melanoma case was estimated to be 11 times lower than using a non-targeted strategy [35], and relative melanoma risk was assessed to rise roughly 14-fold relative to individuals not at high risk [36]. Similarly, in our analysis, the hazard of an invasive melanoma diagnosis was increased 18.5-fold in the VHM-Skin relative to the VHM-Health Exam cohort during the screening period 1989-1994. ...
Simple Summary
To date, it remains unclear whether population-based skin cancer screening lowers melanoma-specific mortality. We herein evaluated a population-based skin cancer program that followed a pragmatic targeted screening approach conducted in the Austrian province Vorarlberg in 1989–1994 and examined possible effects on melanoma mortality in the general population during follow-up until 2019. Relative to the general population and participants of a health examination program, invasive and in situ melanoma incidences, as well as melanoma mortality, were increased. In the general population of Vorarlberg, however, melanoma mortality declined until 2004, though statistically non-significantly. Arguments for and against a contribution of the program are considered. Given the uncertain effectiveness of expensive population-wide mass screening programs, targeted risk-based skin cancer screening could be considered a viable cost-effective alternative strategy to prevent melanoma deaths.
Abstract
Background: whether screening for skin cancer affects melanoma-specific mortality in a population-based setting remains unclear. Methods: in this population-based cohort study, we characterized and evaluated a skin cancer prevention program following a targeted screening approach conducted in 1989–1994 in the Austrian province Vorarlberg, with follow-up until 2019. The general population and attendees of a health examination program served for comparison. Results: in the screening program including full follow-up until 2019, 207 invasive and 187 in situ melanomas were identified in 8997 individuals. Incidences of invasive and in situ melanomas were elevated compared to the general population (IRR 2.92, 95%-CI 2.49–3.41, and IRR 4.13, 95%-CI 3.53–4.83, respectively) and the health examination program (HR 3.02, 95%-CI 2.59–3.52, and HR 3.90, 95%-CI 3.30–4.61, respectively). Breslow thickness and Clark’s level at time of invasive diagnosis were significantly lower in 1989–2019, but the tumor characteristics of the melanomas diagnosed during 1989–1994 did not differ from the comparison groups. Moreover, melanoma mortality was significantly elevated in the screening program (IRR 1.66, 95%-CI 1.00–2.75 vs. the general population, HR 2.12, 95%-CI 1.25–3.61 vs. the health examination cohort). Melanoma mortality in Vorarlberg declined until 2004, though statistically non-significantly. Conclusions: given the uncertain effectiveness and high public expenditures of population-wide mass screening programs, primary prevention and targeted risk-based skin cancer screening might be promising alternatives.
... 37 38 In our study, we did not find any influence of education level on adherence, whereas other authors have reported lower adherence in populations with lower education levels. 8 39 40 This study has many strengths. Participation in the survey was high (more than 70%), and the proportions of adherent and non-adherent patients among the patients who completed the questionnaires were consistent with the figures published as part of the general monitoring of the entire cohort 9 10 ; therefore, our results should be representative. ...
Objective
The aim of the study was to assess whether adherence to annual clinical skin monitoring is dependent on patient sociodemographic characteristics or personality traits.
Design
The study was a questionnaire survey.
Setting and participants
Data were collected between February and April 2013 in a sample of 1000 patients at high risk of melanoma who participated in a pilot-targeted screening programme in western France.
Outcome measures
Sociodemographic data, overall anxiety level (State-Trait Anxiety Inventory questionnaire), locus of control (Multidimensional Health Locus of Control scale) and levels of anxiety specifically associated with screening and melanoma were collected. Actual participation in the skin monitoring examination was reported by 78 general practitioner investigators.
Statistical analysis
Statistical analysis was performed using R statistical software. Factors associated with non-adherence were identified by multivariate analysis.
Results
Our analysis included 687 responses (526 adherent patients and 161 non-adherent patients). Non-adherence was higher in younger patients and in men (OR=0.63 (0.41–0.99)). Viewing health status as dependent on external persons (OR=0.90, 95% CI 0.83 to 0.97) or determined by chance (OR=0.89, 95% CI 0.80 to 0.98) and overall anxiety (OR=0.98, 95% CI 0.97 to 0.99) were also factors associated with non-adherence. In contrast, there was no link between anxiety specifically associated with the screening performed or melanoma and patient adherence to monitoring. Adherence was higher in married patients (OR=1.68 95% CI 1.08 to 2.60).
Conclusions
The results of this study suggest that sociodemographic and psychological characteristics should be considered when including patients at elevated risk of melanoma in a targeted screening programme.
Trial registration number
NCT01610531; Post-results.
... Although our data included a rich array of information including, skin phenotype, demographic details, and behavioural characteristics, we were unable to analyse the impact of the SSE programme on diagnosed melanoma due to the small size and duration of our panel. Skin selfexamination has been reported to increase melanoma diagnosis in selected patient samples, (Berwick et al., 1996;Carli et al., 2003;Aitken et al., 2004;Williams et al., 2011;Quereux et al., 2012;Badertscher et al., 2014). Public health initiatives that have promoted skin self-examination in Australian (Janda et al., 2009), Italian (Rossi et al., 2000), Greek (Stratigos et al., 2007) and German (Waldmann et al., 2012) populations, have also reported increased numbers of CM diagnosed., however, the results from a British study were inconclusive (Melia, 1995;Melia et al., 1995;Melia et al., 2000). ...
Background
Effective skin self-examination can enable early diagnosis and treatment of skin cancer, which otherwise could result in significant morbidity and mortality. We compare the effects of watching a DVD and reading printed materials on self skin examination.
Methods
Longitudinal data from the Randomized Skin Awareness Trial were analysed (n=984). The control group were provided with written materials describing how to conduct effective skin self-examination. The intervention group received additional instruction from a DVD. It was hypothesized that self skin examination may be confounded by unobserved variables. A recursive model was specified to control for this potential source of bias.
Results
At six months only watching the DVD had a statistically significant effect on diagnosed skin cancer. By 12 months both interventions were statistically significant; reading the printed materials was 63% as effective as watching the DVD.
Conclusion
Watching a DVD was associated with the largest increase in diagnosed skin cancer. However, reading written materials was also associated with an increase in diagnosed skin cancer. Both visual and written communication should be considered when designing an effective skin self-examination programme.
Background
Annually, 175.4 million people are infected with scabies worldwide. Although parasitic infections are important nosocomial infections, they are unrecognized compared to bacterial, fungal, and viral infections. In particular, nonspecific cutaneous manifestations of scabies lead to delayed diagnosis and frequent nosocomial transmission. Hospital-based studies on the risk factors for scabies have yet to be systematically reviewed.
Methods
The study followed the PRISMA guidelines and was prospectively registered in PROSPERO (CRD42023363278). Literature searches were conducted in three international (PubMed, Embase, and CINAHL) and four Korean (DBpia, KISS, RISS, and Science ON) databases. We included hospital-based studies with risk estimates calculated with 95% confidence intervals for risk factors for scabies infection. The quality of the studies was assessed using the Joanna Briggs Institute critical appraisal tools. Two authors independently performed the screening and assessed the quality of the studies.
Results
A total of 12 studies were included. Personal characteristics were categorized into demographic, economic, residential, and behavioral factors. The identified risk factors were low economic status and unhygienic behavioral practices. Being a patient in a long-term care facility or institution was an important factor. Frequent patient contact and lack of personal protective equipment were identified as risk factors. For clinical characteristics, factors were categorized as personal health and hospital environment. People who had contact with itchy others were at higher risk of developing scabies. Patients with higher severity and those with a large number of catheters are also at increased risk for scabies infection.
Conclusions
Factors contributing to scabies in hospitals range from personal to clinical. We emphasize the importance of performing a full skin examination when patients present with scabies symptoms and are transferred from settings such as nursing homes and assisted-living facilities, to reduce the transmission of scabies. In addition, patient education to prevent scabies and infection control systems for healthcare workers, such as wearing personal protective equipment, are needed.
Background
Musculoskeletal health problems are one of the greatest healthcare expenses in the United States but patient-driven screening procedures to detect risk factors do not exist.
Hypothesis/Purpose
The purpose was to establish the inter-rater reliability of the Symmio Self-Screen application in untrained individuals and to investigate its accuracy to detect MSK risk factors such as pain with movement, movement dysfunction, and decreased dynamic balance.
Study Design
Cross-Sectional
Methods
Eighty (42 male, 38 female) healthy individuals mean age 26.5 ± 9.4 participated in the study. The inter-rater reliability of Symmio application was established by comparing self-screen scores from untrained subjects with the results simultaneously determined by a trained healthcare provider. Each subject was evaluated for pain with movement, movement dysfunction, and deficits in dynamic balance by two trained evaluators who were blinded to the Symmio results. The validity of Symmio was determined by comparing self-screen performance dichotomized as pass or fail with the reference standard of pain with movement, failure on the Functional Movement Screen™, and asymmetry on the Y Balance Test-Lower Quarter™ using three separate 2x2 contingency tables.
Results
The mean Cohen’s kappa coefficient was 0.68 (95% CI, 0.47-0.87) and the absolute agreement was 89% between self-assessment of subjects and the observation of a trained healthcare provider. There were significant associations for the presence of pain with movement ( p =0.003), movement dysfunction ( p =0.001), and dynamic balance deficits ( p =0.003) relative to poor Symmio performance. The accuracy of Symmio to identify pain with movement, movement dysfunction, and dynamic balance deficits were 0.74 (95% CI, 0.63-0.83), 0.73 (95% CI, 0.62-0.82), and 0.69 (95% CI, 0.57-0.79), respectively.
Conclusions
The Symmio Self-Screen application is a reliable and feasible screening tool that can be used to identify MSK risk factors.
Level of Evidence
Level 2
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.
Importance: Melanoma incidence and mortality rates are increasing worldwide. While screening appears to be inefficient, targeted screening might be effective.
Objective: To assess the relative risk of developing a melanoma in a population that participated in targeted screening program compared with the general population. The secondary objective was to identify the factors related to melanoma thickness at the time of diagnosis.
Design, setting, and participants: We assessed the incidence of melanoma from 2011 to 2015 in a cohort of 3832 patients at elevated risk of melanoma living on the west coast of France. The patients were older than 20 years, selected using the Self-Assessment of Melanoma risk score, and invited each spring to undergo a complete skin examination as part of a pilot targeted screening program for melanoma.
Main Outcome, Measures: We calculated the relative risk of developing a melanoma, based on the comparison of melanoma incidence in patients who participated in the targeted screening and in the general population in the geographic area. Data collection was performed by the regional cancer registry, in accordance with international standards. Demographical variables and histological variables related to the identification of a thick melanoma (stage 2 and higher) were also analyzed.
Results: 3 169 patients developed melanomas between April 2011 and December 2015. The relative risk of developing a melanoma during the five years of follow-up was 4.33 [4.17;4.50] in patients who participated in the pilot targeted screening program compared with the general population. The following factors were associated with the identification of thick melanomas: male gender (OR = 1.40; 95% CI [1.18-1.66]), age older than 75 years (OR = 1.72; 95% CI [1.38-2.14]), and residence in a rural area (OR = 1.48; 95% CI [1.21-1.80]). The targeted screening program did not lead to a lower proportion of thick melanomas at the time of diagnosis (OR=0.48 [0.11-1.40]).
Conclusions and Relevance: Targeted screening for melanoma allows general practitioners to focus their attention, energy, and time on at-risk populations with greater efficiency. However, participation in the pilot screening program was not associated with the identification of thinner melanomas at the time of diagnosis.
Trial Registration: This trial was registered in the Clinical Trials database before study enrollment commenced (ClinicalTrials.gov; Registration number: NCT01610531).
In the Western population, 1 out of every 50 individuals will develop melanoma. The incidence of melanoma is increasing faster than any other malignancy. The development of melanoma is multifactorial arising from an interaction between genetic susceptibility and environmental exposures. Sixty to seventy percent of melanomas are thought to be caused by ultraviolet radiation. Most cutaneous melanomas are of increased risk. Prevention strategies involve mitigating the environmental risk factors and identifying individuals with phenotypic risk factors for increased surveillance.
Purpose
Melanoma represents an important public health problem, due to its high case-fatality rate. Identification of individuals at high risk would be of major interest to improve early diagnosis and ultimately survival. The aim of this study was to evaluate whether MC1R variants predicted melanoma risk independently of at-risk phenotypic characteristics.
Materials and methods
Data were collected within an international collaboration – the M-SKIP project. The present pooled analysis included data on 3,830 single, primary, sporadic, cutaneous melanoma cases and 2,619 controls from seven previously published case–control studies. All the studies had information on MC1R gene variants by sequencing analysis and on hair color, skin phototype, and freckles, ie, the phenotypic characteristics used to define the red hair phenotype.
Results
The presence of any MC1R variant was associated with melanoma risk independently of phenotypic characteristics (OR 1.60; 95% CI 1.36–1.88). Inclusion of MC1R variants in a risk prediction model increased melanoma predictive accuracy (area under the receiver-operating characteristic curve) by 0.7% over a base clinical model (P=0.002), and 24% of participants were better assessed (net reclassification index 95% CI 20%–30%). Subgroup analysis suggested a possibly stronger role of MC1R in melanoma prediction for participants without the red hair phenotype (net reclassification index: 28%) compared to paler skinned participants (15%).
Conclusion
The authors suggest that measuring the MC1R genotype might result in a benefit for melanoma prediction. The results could be a valid starting point to guide the development of scientific protocols assessing melanoma risk prediction tools incorporating the MC1R genotype.
Purpose of Review
The purpose of this paper is to review skin cancer screening guidelines from major public health/medical organizations.
Recent Findings
No consensus exists on whether or not screening to prevent skin cancer is warranted.
Summary
The best evidence of screening efficacy should come from population-based randomized trials, but is unlikely to exist due to feasibility constraints. Consequently, consensus should be built from observational/non-randomized designs, such as the SCREEN study in Germany. Current guidelines often focus on melanoma alone, while potential benefits of screening for non-melanoma skin cancers (NMSC) are largely overlooked. There may be less room for doubt regarding the value of screening, if both diseases were considered. Further, targeted approaches, i.e., screening only in high-risk populations, remain poorly defined and untested. Continuing to state that there is insufficient evidence to recommend screening leads to confusion about whether or not to screen and is unlikely to result in substantial changes to the morbidity of NMSC and significant mortality from melanoma.
Purpose of Review
This review discusses recent findings involving epidemiologic issues in melanoma, including incidence trends, potential risk factors, and recent studies of skin examination, whether by a physician or by a patient performing self-examination.
Recent Findings
Melanoma incidence rates have increased, although not in a uniform fashion throughout the population. Tanning beds have been affirmed as a risk factor for melanoma, while other potential risk factors, such as sildenafil, alcohol, and fruit juice, as well a potential protective effect of coffee, have some interesting preliminary data but have not been consistently demonstrated to be causally linked to melanoma. Further studies are needed. There are promising data from Germany that physician skin examination may have an impact, but the data are not completely clear. Skin self-examination rates are low; several authors have tried to identify methods of improving compliance.
Summary
There have been many interesting and provocative papers regarding the epidemiology of melanoma to come out in recent years. While further work is needed to understand fully the issues raised by these studies, these efforts are important elements in the path towards improving our understanding of how to best combat this deadly disease.
Objective: The study objective was to measure the rates of inclusion of populations at risk of advanced melanoma in a pilot targeted screening project involving general practitioners. Design: This cross-sectional database study compared the inclusion rates of patients who signed inclusion in a targeted screening project with those of patients who did not, during a period in which both groups of patients consulted investigators. Setting: Data were extracted from the national healthcare insurance records in western France from 11 April to 30 October 2011. Patients: Patients, older than 18, considered for the data extraction had consulted one of the 78 participating GPs during the study period, and were affiliated with the national healthcare insurance. Main outcome measures: Inclusion in the screening was the main outcome measure. Patients at risk of advanced melanoma were characterized by male gender, age over 50, low income, rural residence, farmer, and presence of chronic disease. Results: A total of 57,279 patients consulted GPs during the inclusion period and 2711 (4.73%) were included in the targeted screening. Populations at risk of advanced melanoma were less included: men (OR = 0.67; 95%CI [0.61–0.73]; p
During this year 2013, Onco-dermatology was the object of numerous publications, especially in the field of metastatic melanoma. Previous results concerning anti PD-1 have been consolidated. Studies concerning Mek inhibitors have been published with promising results in uveal melanoma. In metastatic melanoma two combinations showed great results: combination of ipilimumab and nivolumab and combination of B-RAF and MEK inhibitors. Some studies demonstrated efficacy of these new therapeutics (ipilimumab, vemurafenib and dabrafenib) in brain metastasis. Moreover, the year 2013 was marked by the increasing knowledge in the management of adverse events induced by these new treatments. In the field of basal cell carcinoma, after the publication of large scale studies, vismodegib, the inhibitor of the hedgehog signalling pathway, was approved by the European Medicines Agency.
El melanoma es un tumor maligno desarrollado a expensas de los melanocitos. Su incidencia aumenta constantemente en todos los países desarrollados. La exposición solar representa un factor de riesgo importante, pero no explica, por sí sola, todas las formas clínicas de melanoma. Un fototipo claro y la presencia de un gran número de nevus son factores de riesgo reconocidos. Las formas familiares son raras e implican a varios genes de susceptibilidad. La exéresis quirúrgica es esencial, permite el diagnóstico y asegura el único tratamiento potencialmente curativo del melanoma. En estadio metastásico visceral, los tratamientos actuales todavía son insuficientes, a pesar de que se han obtenido avances importantes con las terapias dirigidas y las nuevas inmunoterapias. El pronóstico está condicionado por el índice de Breslow. La prevención se basa en la modificación de los comportamientos de riesgo, la detección precoz y la exéresis de las lesiones sospechosas.
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.
Background: Early diagnosis of melanoma can save lives. However, mass screening is not recommended, and few studies have addressed targeted screening. Objective: To evaluate a targeted melanoma screening intervention by measuring the cumulative melanoma incidence and patient compliance with the screening. Methods: This was a prospective one-year follow-up of a cohort of 3923 French patients at elevated risk of melanoma who were recruited from April to October 2011 by 78 GPs using the Self-assessment of melanoma risk score. Following standard practice, based on the GPs’ opinions, a subset of these patients was referred to dermatologists. The dermatologists scheduled excisions when required. Melanomas were confirmed using pathology reports. Patient compliance with the clinical pathway was assessed retrospectively. The cohort was followed prospectively using three data sources (GPs, dermatologists and patients). Analyses of factors associated with compliance were performed using multiple logistic regression. Results: GPs examined the skin of 3923 high-risk patients, 1506 of whom were referred to dermatologists. Nine cases of melanoma were diagnosed, corresponding to a cumulative incidence of 229.4/100 000. Of the referred patients, 57.9% attended the dermatologist consultation. Patient attendance was better when the GPs provided a dermatologist's name (OR = 2.15, 95% CI: 1.51–3.09). A delay before consulting a dermatologist was inversely associated with the estimated lesion malignancy. Conclusion: Performing this targeted screening in a high-risk population resulted in a high melanoma detection rate, despite moderate compliance. Observations suggest that naming a dermatologist is a simple, inexpensive means of increasing patient compliance with the screening.
A high number of melanocytic naevi is one of the major risk factors for cutaneous melanoma. Therefore, counting the number of acquired naevi could be a useful strategy to identify individuals at an increased risk for targeted skin cancer screening. The aim of this study was to assess agreement between naevus self-counts and counts of trained examiners as well as to analyse potential determinants of the magnitude of agreement. In a large cross-sectional survey (n=1772), university students counted their naevi on both arms and were additionally examined by specifically trained examiners in a mutually blinded manner. Further data on other melanoma risk factors such as skin phototype, hair colour or freckling were collected by a questionnaire. The relative difference between the two naevus counts and the ratio of the counts were calculated to quantify agreement. Regression modelling was performed to identify independent determinants of agreement. The overall agreement was moderate, with participants counting on average 14% more naevi than the examiners. In terms of the potential determinants associated with agreement, skin type and medical education showed a strong effect. The difference in naevus counts was significantly larger for individuals with lighter skin types compared with those with a dark skin (Fitzpatrick type IV), and medical students yielded a naevus count more similar to the examiner's count than nonmedical students. Naevus self-counts can only provide a rough estimate of the number of naevi, but may not be accurate enough to reliably identify a high-risk group for melanoma screening, especially in individuals with light skin types.
Although melanoma is a deadly cancer that is rising in incidence, the USA does not have uniform guidelines for melanoma screening. Screening for melanoma requires no specialized equipment and has little associated morbidity. However, screening has the greatest impact when performed among patients with the highest risk for melanoma incidence and mortality. Screening lower-risk patients may result in prohibitively high costs, unnecessary biopsies of benign lesions, and decreased access to a dermatologic specialist for patients who are actually at a higher risk. We advocate targeting melanoma screening efforts toward those patients at high risk of developing and dying from melanoma, as well as toward those at-risk patients who are least likely to detect their own melanoma.
To assess whether patients at elevated risk of melanoma attended a dermatologist consultation after a GP referral and to determine individual predictors of non-compliance.
This survey included 1506 high-risk French patients (selected using the Self-Assessment Melanoma Risk Score) referred to a dermatologist between April and October 2011. Compliance was evaluated from January to April 2012, based on attendance at a dermatologist consultation (or scheduling an appointment). Demographic data and factors mapping the Health Belief Model were tested as correlates using a multivariate logistic regression.
Compliance with referral was 58.4%. The top seven factors associated with non-compliance were as follows: GP advice to consult was unclear (OR=13.22;[7.66-23.56]); no previous participation in cancer screenings, including smear tests (OR=5.03;[2.23-11.83]) and prostate screening (OR=2.04;[1.06-3.97]); lack of knowledge that melanoma was a type of cancer (OR=1.94;[1.29-2.92]); and reporting no time to make an appointment (OR=2.08;[1.82-2.38]), forgetting to make an appointment (OR=1.26;[1.08-1.46]), long delays in accessing an appointment (OR=1.25;[1.12-1.41]), not being afraid of detecting something abnormal (OR=1.54;[1.35-1.78]), no need to consult a dermatologist to feel secure (OR=1.28;[1.09-1.51]).
Physicians should be aware of the factors predicting patient compliance with referrals for dermatologist consultations; better GP counseling might enhance compliance in high-risk populations.
Importance
Currently, there is no comprehensive assessment of melanoma risk prediction models.
Objective
To systematically review published studies reporting multivariable risk prediction models for incident primary cutaneous melanoma for adults.
Evidence Review
EMBASE, MEDLINE, PREMEDLINE, and Cochrane databases were searched to April 30, 2013. Eligible studies were hand searched and citation tracked. Two independent reviewers extracted information.
Findings
Nineteen studies reporting 28 melanoma prediction models were included. The number of predictors in the final models ranged from 2 to 13; the most common were nevi, skin type, freckle density, age, hair color, and sunburn history. There was limited reporting and substantial variation among the studies in model development and performance. Discrimination (the ability of the model to differentiate between patients with and without melanoma) was reported in 9 studies and ranged from fair to very good (area under the receiver operating characteristic curve, 0.62-0.86). Few studies assessed internal or external validity of the models or their use in clinical and public health practice. Of the published melanoma risk prediction models, the risk prediction tool developed by Fears and colleagues, which was designed for the US population, appears to be the most clinically useful and may also assist in identifying high-risk groups for melanoma prevention strategies.
Conclusions and Relevance
Few melanoma risk prediction models have been comprehensively developed and assessed. More external validation and prospective evaluation will help translate melanoma risk prediction models into useful tools for clinical and public health practice.
Purpose:
Targeted interventions to reduce the risk and increase the early detection of melanoma have the potential to save lives. We aimed to assess the effect of such an intervention on patient prevention behavior.
Methods:
We conducted a pilot clustered randomized controlled trial, comparing a targeted screening and education intervention with a conventional information-based campaign in 20 private surgeries in western France. In the intervention group, 10 general practitioners identified patients at elevated risk for melanoma with a validated assessment tool, the Self-Assessment Melanoma Risk Score (SAMScore), examined their skin, and counseled them using information leaflets. In the control group, 10 general practitioners displayed a poster and the leaflets in their waiting room and examined patients' skin at their own discretion. The main outcome measures were sunbathing and skin self-examinations among patients at elevated risk, assessed 5 months later with a questionnaire.
Results:
Analyses were based on 173 patients. Compared with control patients, intervention patients were more likely to remember the campaign (81.4% vs 50.0%, P = .0001) and to correctly identify their elevated risk of melanoma (71.1% vs 42.1%, P = .001). Furthermore, intervention patients had higher levels of prevention behaviors: they were less likely to sunbathe in the summer (24.7% vs 40.8%, P = .048) and more likely to have performed skin self-examinations in the past year (52.6% vs 36.8%, P = .029). The intervention was not associated with any clear adverse effects, although there were trends whereby intervention patients were more likely to worry about melanoma and to consult their general practitioner again about the disease.
Conclusions:
The combination of use of the SAMScore and general practitioner examination and counseling during consultations is an efficient way to promote patient behaviors that may reduce melanoma risk. Extending the duration of follow-up and demonstrating an impact on morbidity and mortality remain major issues for further research.
During this year 2013, Onco-dermatology was the object of numerous publications, especially in the field of metastatic melanoma. Previous results concerning anti PD-1 have been consolidated. Studies concerning Mek inhibitors have been published with promising results in uveal melanoma. In metastatic melanoma two combinations showed great results: combination of ipilimumab and nivolumab and combination of B-RAF and MEK inhibitors. Some studies demonstrated efficacy of these new therapeutics (ipilimumab, vemurafenib and dabrafenib) in brain metastasis. Moreover, the year 2013 was marked by the increasing knowledge in the management of adverse events induced by these new treatments. In the field of basal cell carcinoma, after the publication of large scale studies, vismodegib, the inhibitor of the hedgehog signalling pathway, was approved by the European Medicines Agency.
Copyright © 2013 Elsevier Masson SAS. All rights reserved.
Rituximab is an anti-CD20 monoclonal antibody increasingly used in haematology and rheumatology, but also in internal medicine and dermatology. It has a good tolerance profile without known increased risk of cancer. We report a case of nodular melanoma with a 4.8 mm Breslow thickness that appeared after 2 years of rituximab in a 45-year-old patient with non-Hodgkin lymphoma. Fifteen additional rituximab-associated melanoma cases in 13 patients have been identified in the literature and in the EudraVigilance database. These patients were treated for various indications and had melanomas, often aggressive, initially diagnosed at a metastatic stage in 31% of cases. Our work raises the question of rituximab accountability in melanoma onset in these immunosuppressed patients. A dermatological monitoring seems necessary in patients treated with rituximab, especially in case of risk factors for melanoma. In case of individual melanoma history, the benefit/risk ratio of initiating rituximab therapy should be carefully assessed. © 2013 S. Karger AG, Basel.
To calculate pooled risk estimates of the association between pigmentary characteristics and basal cell carcinoma (BCC) of the skin.
We searched three electronic databases and reviewed the reference lists of the retrieved articles until July 2012 to identify eligible epidemiologic studies. Eligible studies were those published in between 1965 and July 2012 that permitted quantitative assessment of the association between histologically-confirmed BCC and any of the following characteristics: hair colour, eye colour, skin colour, skin phototype, tanning and burning ability, and presence of freckling or melanocytic nevi. We included 29 studies from 2236 initially identified. We calculated summary odds ratios (ORs) using weighted averages of the log OR, using random effects models.
We found strongest associations with red hair (OR 2.02; 95% CI: 1.68, 2.44), fair skin colour (OR 2.11; 95% CI: 1.56, 2.86), and having skin that burns and never tans (OR 2.03; 95% CI: 1.73, 2.38). All other factors had weaker but positive associations with BCC, with the exception of freckling of the face in adulthood which showed no association.
Although most studies report risk estimates that are in the same direction, there is significant heterogeneity in the size of the estimates. The associations were quite modest and remarkably similar, with ORs between about 1.5 and 2.5 for the highest risk level for each factor. Given the public health impact of BCC, this meta-analysis will make a valuable contribution to our understanding of BCC.
To compare melanomas diagnosed in patients included in follow-up programs with melanomas diagnosed in patients referred to a melanoma unit.
Retrospective analysis of 215 consecutive melanomas diagnosed between 2007 and 2008.
Melanoma Unit, Hospital Clinic of Barcelona, Barcelona, Spain.
The study included 201 patients (105 men and 96 women), 40 of whom were included in a follow-up program in our unit and 161 of whom were referred for evaluation.
Clinical (ABCD algorithm), dermoscopic (ABCD rule of dermoscopy), and main histologic characteristics were evaluated in both groups.
Most melanomas diagnosed in follow-up did not fulfill some of the ABCD criteria, and only 12.0% fulfilled all 4 ABCD criteria, in contrast with 63.6% of the melanomas referred for evaluation (P < .001). The total dermoscopy score was lower in melanomas diagnosed in follow-up (5.04 vs. 6.39, P < .01), and 36% were misclassified as benign in this group according to the total dermoscopy score. Seventy percent of melanomas diagnosed in follow-up were in situ; among invasive melanomas, the Breslow index was significantly lower in the group of melanomas diagnosed in follow-up, with a mean (range) of 0.55 (0.25-0.90) mm vs 1.72 (0.25-13.00) mm (P < .001).
The inclusion of patients who are at high risk for melanoma in follow-up programs allows the detection of melanomas in early stages, with good prognosis, even in the absence of clinical and dermoscopic features of melanoma. In the general population without specific surveillance, melanoma continues to be diagnosed at more advanced stages.
To assess whether the proportion of primary care physicians implementing full body skin examination (FBSE) to screen for melanoma changed over time.
Meta-regression analyses of available data. Data Sources: MEDLINE, ISI, Cochrane Central Register of Controlled Trials.
Fifteen studies surveying 10,336 physicians were included in the analyses. Overall, 15%-82% of them reported to perform FBSE to screen for melanoma. The proportion of physicians using FBSE screening tended to decrease by 1.72% per year (P =0.086). Corresponding annual changes in European, North American, and Australian settings were -0.68% (P =0.494), -2.02% (P =0.044), and +2.59% (P =0.010), respectively. Changes were not influenced by national guide-lines.
Considering the increasing incidence of melanoma and other skin malignancies, as well as their relative potential consequences, the FBSE implementation time-trend we retrieved should be considered a worrisome phenomenon.
It is controversial whether worldwide increases in melanoma incidence represent a true epidemic. Dramatic increases in incidence in the setting of relatively stable mortality trends have also been attributed to expanded skin screening and detection of biologically indolent tumors with low metastatic potential. To better understand how melanoma incidence trends varied by severity at diagnosis and factors relevant to screening access, we assessed recent United States incidence and mortality trends by histologic type, tumor thickness, and area-level socioeconomic status (SES). We obtained population-based data regarding diagnoses of invasive melanoma among non-Hispanic whites from nearly 291 million person-years of observation by the Surveillance Epidemiology and End Results (SEER) program (1992-2004). Age-adjusted incidence and mortality rates were calculated for SEER and a subset (California) for which small-area SES measure was available. Overall, melanoma incidence increased at 3.1% (P<0.001) per year. Statistically significant rises occurred for tumors of all histologic subtypes and thicknesses, including those >4 mm. Melanoma incidence rates doubled in all SES groups over a 10-year period whereas melanoma mortality rates did not increase significantly. We conclude that screening-associated diagnosis of thinner melanomas cannot explain the increasing rates of thicker melanomas among low SES populations with poorer access to screening.
Many epidemiologic studies report the odds ratio as a measure of association for cross-sectional studies with common outcomes. In such cases, the prevalence ratios may not be inferred from the estimated odds ratios. This paper overviews the most commonly used procedures to obtain adjusted prevalence ratios and extends the discussion to the analysis of clustered cross-sectional studies.
Prevalence ratios(PR) were estimated using logistic models with random effects. Their 95% confidence intervals were obtained using delta method and clustered bootstrap. The performance of these approaches was evaluated through simulation studies. Using data from two studies with health-related outcomes in children, we discuss the interpretation of the measures of association and their implications.
The results from data analysis highlighted major differences between estimated OR and PR. Results from simulation studies indicate an improved performance of delta method compared to bootstrap when there are small number of clusters.
We recommend the use of logistic model with random effects for analysis of clustered data. The choice of method to estimate confidence intervals for PR (delta or bootstrap method) should be based on study design.
Education campaigns to encourage self-examination coupled with rapid access to specialized dermatological clinics is considered the key strategy in the realization of early detection of cutaneous melanoma and non-melanoma skin cancer (NMSC). An alternative to an initial visit to the family doctor is open access to a skin cancer clinic at the decision of the individual. This approach has been followed mainly in countries with high melanoma incidence where the majority of the population is of northern European origin. However, the efficacy of this system has not been well established because there are few studies involving systematic follow up of individuals with positive screening through pathological confirmation of the diagnosis. We report the follow up data focussed on melanoma and NMSC detection rates in more than 1,000 subjects examined at numerous 1-day, open access clinics on the occasion of the Italian nation-wide "Skin Cancer Day" campaign promoted by the Federation of Italian Dermatological Societies. Total body skin examination was performed on all subjects, and surgical excision of a lesion was recommended in 41 of the 1042 subjects (3.9 %). Histologic diagnosis, available for 39/41 lesions, evidenced 3 superficial spreading melanomas (1 in situ, one "thin" lesion, ie. 0.30 mm in thickness, and one "thick" lesion, with a thickness of 4.53 mm) and 6 NMSC (5 BCC and 1 SCC). Thus, the prevalence of skin cancer (melanoma and NMSC) in this group was 0.8 % (9/1042), and the prevalence of melanoma was 3/1042, 0.2 %, rather similar to that found in populations of northern European origin. Open access to skin cancer clinics may represent an alternative approach to melanoma prevention also in southern European populations. Increased public awareness regarding skin cancer probably represents the main effect of this type of campaign.
A systematic revision of the literature was conducted in order to undertake a comprehensive meta-analysis of all published observational studies on melanoma. An extensive analysis of the inconsistencies and variability in the estimates was performed to provide some clues about its Epidemiology. Following a systematic literature search, relative risks (RRs) for sun exposure were extracted from 57 studies published before September 2002. Intermittent sun exposure and sunburn history were shown to play considerable roles as risk factors for melanoma, whereas a high occupational sun exposure seemed to be inversely associated to melanoma. The country of study and adjustment of the estimates adjuste for phenotype and photo-type were significantly associated with the variability of the intermittent sun exposure estimates (P = 0.024, 0.003 and 0.030, respectively). For chronic sun exposure, inclusion of controls with dermatological diseases and latitude resulted in significantly different data (P = 0.05 and 0.031, respectively). Latitude was also shown to be important (P = 0.031) for a history of sunburn; studies conducted at higher latitudes presented higher risks for a history of sunburns. Role of country, inclusion of controls with dermatological diseases and other study features seemed to suggest that "well conducted" studies supported the intermittent sun exposure hypothesis: a positive association for intermittent sun exposure and an inverse association with a high continuous pattern of sun exposure.
A systematic meta-analysis of observational studies of melanoma and one of the most important risk factors, the number of naevi, was conducted in order to clarify aspects of the aetiology of this disease. Following a systematic literature search, relative risks (RRs) were extracted from 46 studies published before September 2002. Dose-response random effects models were used to obtain pooled estimates. Sub-group analysis and meta-regression were carried out to explore sources of between-study variation and bias. Sensitivity analyses investigated the reliability of the results and any publication bias. Number of common naevi was confirmed an important risk factor with a substantially increased risk associated with the presence of 101-120 naevi compared with <15 (pooled Relative Risk (RR) = 6.89; 95% Confidential Interval (CI): 4.63, 10.25) as was the number of atypical naevi (RR = 6.36 95%; CI: 3.80, 10.33; for 5 versus 0). The type of study and source of cases and controls were two study characteristics that significantly influenced the estimates. Case-control studies, in particular when the hospital was the source for cases or controls, appeared to present much lower and more precise estimates than cohort studies.
We analyzed the value of digital epiluminescence microscopy (DELM) for the long-term follow-up of atypical nevi. Patients (n=530) were prospectively categorized into defined melanoma risk groups and followed by clinical and epiluminescence microscopy (ELM) examinations. Atypical nevi (n=7001) were additionally followed by DELM. During follow-up (median 32.2 months), we detected 53 melanomas among 637 excised lesions (8.3% overall chance of success). The chance of success for melanoma detection among lesions suspicious by ELM criteria was increased to 17% when additional DELM-documented changes were present. Moreover, 18 of the 53 melanomas were exclusively identified by DELM-documented changes, indicating that DELM increased the sensitivity of the ELM analysis by identifying additional melanomas. However, for lesions exclusively excised due to DELM changes, the chance of success was lower than for ELM (5.2 vs 11.8%). Excisions due to mere DELM changes detected 66.7% of melanomas in familial atypical mole and multiple melanoma (FAMMM) and 32.5% of melanomas in atypical mole syndrome (AMS) patients. We conclude that DELM is a valuable tool for the long-term follow-up of atypical nevi, especially in the high-risk groups of FAMMM and AMS patients. Randomized controlled trials are needed to validate the data from this clinical trial.
To examine the role of sequential dermoscopy imaging in detecting incipient melanoma and to elucidate the impact of length of follow-up on the relevance of observed changes.
Baseline and follow-up images of melanomas and melanocytic nevi excised only because of changes across time were inspected on a computer screen and assessed according to prospectively defined criteria. Lesions were stratified into 3 groups according to the length of follow-up.
Three hospital-based referral centers in Europe and Australia. Patients Four hundred sixty-one patients selected for digital dermoscopy monitoring.
Description and comparison of dermoscopy features and changes in melanomas and melanocytic nevi at baseline and after follow-up.
We inspected baseline and follow-up images of 499 melanocytic skin lesions from 461 patients. The histopathologic diagnosis was melanoma in 91 cases and melanocytic nevus in 408. Most melanomas (58.2%; n = 53) were in situ, and the median thickness of invasive melanomas was 0.38 mm. Dermoscopy features of melanomas and nevi did not differ significantly at baseline. After follow-up of 1.5 to 4.5 months, 61.8% of the melanomas showed no specific dermoscopy features for melanoma. This value declined to 45.0% after follow-up of 4.5 to 8.0 months and to 35.1% after more than 8.0 months. We could not differentiate melanomas and changing nevi by means of observed changes or dermoscopy features when follow-up was shorter than 4.5 months. With longer follow-up, melanomas tended to enlarge asymmetrically with architectural and color changes, and nevi tended to enlarge symmetrically without architectural and color changes.
Sequential dermoscopy imaging detects incipient melanomas when they are still featureless. Interpretation of changes observed during follow-up depends on the length of follow-up.
To evaluate the cost-effectiveness of various melanoma screening strategies proposed in the United States.
We developed a computer simulation Markov model to evaluate alternative melanoma screening strategies.
Hypothetical cohort of the general population and siblings of patients with melanoma. Intervention We considered the following 4 strategies: background screening only, and screening 1 time, every 2 years, and annually, all beginning at age 50 years. Prevalence, incidence, and mortality data were taken from the Surveillance, Epidemiology, and End Results Program. Sibling risk, recurrence rates, and treatment costs were taken from the literature.
Outcomes included life expectancy, quality-adjusted life expectancy, and lifetime costs. Cost-effectiveness ratios were in dollars per quality-adjusted life year (US dollars/QALY) gained.
In the general population, screening 1 time, every 2 years, and annually saved 1.6, 4.4, and 5.2 QALYs per 1000 persons screened, with incremental cost-effectiveness ratios of US dollars 10,100/QALY, US dollars 80,700/QALY, and US dollars 586,800/QALY, respectively. In siblings of patients with melanoma (relative risk, 2.24 compared with the general population), 1-time, every-2-years, and annual screenings saved 3.6, 9.8, and 11.4 QALYs per 1000 persons screened, with incremental cost-effectiveness ratios of US dollars 4000/QALY, US dollars 35,500/QALY, and US dollars 257,800/QALY, respectively. In higher risk siblings of patients with melanoma (relative risk, 5.56), screening was more cost-effective. Results were most sensitive to screening cost, melanoma progression rate, and specificity of visual screening.
One-time melanoma screening of the general population older than 50 years is very cost-effective compared with other cancer screening programs in the United States. Screening every 2 years in siblings of patients with melanoma is also cost-effective.
Many factors have been identified as important determinants that increase the risk of malignant melanoma (MM) developing. Patients with classic atypical mole syndrome (CAMS) have multiple such factors and are known to be at high risk for MMs developing.Objective
We sought to evaluate the risk for newly diagnosed MMs developing in patients with CAMS and in a heterogeneous group of patients at high risk (ie, those with high-risk non-CAMS [HRNCAMS]) who had 1 or more risk factors: personal history of nonmelanoma skin cancers; family history of melanoma; biopsy specimen–confirmed dysplastic nevi; and meeting 1 or 2 of the 3 CAMS criteria. We also aimed to report our experience treating these patients at high risk with annual total cutaneous examination, total cutaneous photography, and dermoscopy.Methods
Consecutive medical records from a private dermatology practice were reviewed. A total of 258 patients were selected who fulfilled the criteria of having: (1) total cutaneous photography as an aid for follow-up; (2) total cutaneous examination at least once per year; (3) at least 6 months of clinical follow-up; and (4) no personal history of melanomas. A total of 160 patients with CAMS and 98 with HRNCAMS were included in this study. The 10-year risk for MM developing in these 2 cohorts was computed using the Kaplan-Meier method.ResultsIn the CAMS cohort, 28 new MMs developed in 19 patients resulting in a cumulative 10-year risk of 14% (95% confidence interval: 7-20). In the HRNCAMS cohort, 10 new MMs developed in 9 patients, and the cumulative 10-year risk was 10% (95% confidence interval: 2-17). The difference between the 2 groups was not statistically significant (P = .91). The MMs diagnosed in both cohorts were either in situ or less than 1 mm in Breslow thickness. There were no MM metastases or MM-related deaths in either cohort during a mean follow-up period of 120 months for the CAMS and 98 months for the HRNCAMS group.Conclusion
Both the patients with CAMS and HRNCAMS were at very high risk for MMs developing. The combination of total cutaneous photography, total cutaneous examination, and dermoscopy were used in treating our patients. No MM 1 mm or greater in thickness developed during follow-up in either group.
BACKGROUND
Sun and ultraviolet radiation exposure are major risk factors for skin cancer, and sun-protective behaviors and skin cancer examinations are means of primary prevention of skin cancer. The objective of this study was to evaluate the extent to which demographics and other high-risk behaviors may predict the reported level of participation in sun-protection behaviors and skin cancer primary prevention in the United States adult population.METHODS
Data on reported sun-protection behaviors and skin cancer examinations were obtained from surveys completed by adults in the 1998 National Health Interview Survey. Univariate and multivariate data analyses were performed using specialized statistics software.RESULTSFor the United States adult population surveyed (n = 32,440), only 21% of those surveyed indicated that they had ever had a skin cancer examination, and, of those, only 45% indicated that the skin cancer examination was within the past year. For sun-protective behaviors, only 23%, 27%, and 30% of those surveyed reported that they were very likely to wear protective clothing, stay in the shade, and use sunscreen, respectively.CONCLUSIONS
The likelihood of participation in sun-protective behaviors and skin cancer prevention was related to a number of demographic characteristics and high-risk behaviors, including currently smoking cigarettes and wearing seatbelts. Cancer 2001;92:1315–24. © 2001 American Cancer Society.
OBJECTIVE: To describe skin cancer prevention and screening activities in the primary care setting and to compare these findings to other cancer screening and prevention activities.
DESIGN: Descriptive study.
SETTING/PATIENTS: National Ambulatory Medical Care Survey 1997 data on office-based physician visits to family practitioners and internists.
MEASUREMENTS AND MAIN RESULTS: Data were obtained on 784 primary care visits to 109 family practitioners and 61 internists. We observed that the frequency of skin cancer prevention and screening activities in the primary care setting was much lower than other cancer screening and prevention activities. Skin examination was reported at only 15.8% of all visits (17.4% for family practitioners vs 13.6% for internists, P>.1). For other cancer screening, the frequencies were as follows: breast examination, 30.3%; Papanicolaou test, 25.3%; pelvic examination, 27.6%; and rectal examination, 17.9%. Skin cancer prevention in the form of education and counseling was reported at 2.3% of these visits (2.9% for family practitioners vs 1.5% for internists, P>.1), while education on breast self-examination, diet and nutrition, tobacco use, and exercise was 13.0%, 25.3%, 5.7%, and 17.9%, respectively.
CONCLUSIONS: The results of this study indicate that the proportion of primary care visits in which skin cancer screening and prevention occurs is low. Strategies to increase skin cancer prevention and screening by family practitioners and internists need to be considered.
Objective:To determine whether persons with melanoma were integrated into the health care system prior to diagnosis.
Design:Population-based survey by mailed questionnaire.
Patients/participants:216 persons with malignant melanoma diagnosed in Massachusetts in 1986.
Main results:Of the 216 cases, 87% stated that they had regular physicians, 63% had seen those physicians in the year prior to diagnosis,
but only 20% had regular dermatologists. Overall, only 24% had examined their own skin prior to diagnosis and 20% reported
physician skin examinations.
Conclusions:Persons diagnosed with melanoma reported extensive contact with regular physicians in the year prior to diagnosis. However,
most of these persons neither received skin examinations nor examined their own skin during that time. While additional study
is necessary to confirm these findings, the authors suggest that physicians caring for patients at risk for melanoma integrate
melanoma screening into routine care.
Background:
Skin cancer is the most common cancer in the United States. Increasing evidence suggests that screening for malignant melanoma is effective, but its cost-effectiveness has not been determined.
Objective:
We attempted to determine the effectiveness and costs of a visual screen to diagnose malignant melanoma in high-risk persons.
Methods:
We developed a decision analysis comparing no skin cancer screen with a single screen by a dermatologist. Clinical outcomes included malignant melanoma, nonmelanoma skin cancer, or no skin cancer. Life expectancy and costs of care were projected on the basis of clinical findings.
Results:
Skin cancer screening increased average discounted life expectancy from 15.0963 years to 15.0975 years. Based on the prevalence of malignant melanoma, however, this translates into an increased discounted life expectancy of 0.9231 years for each person with diagnosed melanoma. Using a cost of $30 per screen, total skin cancer-related costs for a cohort of 1 million people increased from $826 million with no screen to $861 million with screening, with an increase of 1200 years of life. This results in an incremental cost-effectiveness ratio of $29,170 per year of life saved (YLS) with screening. Sensitivity analysis showed that the cost-effectiveness ratio for screening remained below $50,000/YLS if the prevalence of melanoma in the screened population was at least 0. 0009, the probability that a melanoma detected in screening was localized was at least 94.8%, or the cost of each screen was below $57.
Conclusion:
Skin cancer screening in high-risk patients is likely to be associated with a small increase in discounted life expectancy and is reasonably cost-effective compared with other cancer screening strategies.
The value of total body skin examination (TBSE) for skin cancer screening is controversial.
We sought to determine whether TBSE could be helpful in patients with focused skin symptoms who would not otherwise have undergone TBSE.
In a prospective, multicenter, cross-sectional study consecutive adult patients were recruited during a period of 18 months. Physicians first inspected problem areas and uncovered areas and then performed TBSE. Equivocal lesions detected in both steps were excised or biopsied. Primary outcomes were the absolute and relative risks of missing skin cancer and the number of patients needed to examine to detect melanoma or another malignancy. A secondary outcome was the proportion of false-positive results obtained by TBSE.
We examined 14,381 patients and detected 40 (0.3%) patients with melanoma and 299 (2.1%) with at least one nonmelanoma skin cancer by TBSE. In 195 (1.3%) patients equivocal lesions found by TBSE turned out to be benign. We calculated that 47 patients need to be examined by TBSE to find one skin malignancy and 400 patients to detect one melanoma. The risk of missing one malignancy if not performing TBSE was 2.17% (95% confidence interval 1.25-3.74). Factors significantly increasing the chance to find a skin cancer were age, male gender, previous nonmelanoma skin cancer, fair skin type, skin tumor as the reason for consultation, and presence of an equivocal lesion on problem/uncovered areas.
The impact of TBSE on skin cancer mortality was not evaluated.
TBSE improves skin cancer detection in patients with focused skin symptoms and shows a low rate of false-positive results.
Melanoma is one of the fastest growing cancers worldwide. We need to have tools to identify patients with high risk of melanoma. We carried out a case-control study and tested three methods to develop an individual score of melanoma risk, usable in routine practice. All cases included newly diagnosed invasive cutaneous melanoma of stage I or II (6th American Joint Committee on Cancer) seen in 2007 at the Skin Cancer Unit of Nantes Hospital, France. Controls included 1500 consecutive patients consulting their general practitioners. A self-administrated questionnaire was used for assessment of melanoma risk factors. Three methods of scoring were used and compared: one with common relative risks reported in the literature, one with odds ratios estimated by logistic regression, and a combinatorial analysis. The method based on combinatorial analysis permitted one to obtain a simple rule to define individuals at risk: the association of the rule 'presence of at least three risk factors or presence of more than 20 naevi on the arms' for the patients aged under 60 years and 'presence of at least three risk factors or presence of freckles' for the patients aged 60 years and above (sensitivity: 63.2% and specificity: 68.8%). The tool we propose is easy to use every day in routine health care to select patients with high risk of melanoma. It can be assessed without any computer or calculator and is based on the self-assessment of the melanoma risk factors by the patient and thus is not medical time consuming.
Estimates of the worldwide incidence and mortality from 27 cancers in 2008 have been prepared for 182 countries as part of the GLOBOCAN series published by the International Agency for Research on Cancer. In this article, we present the results for 20 world regions, summarizing the global patterns for the eight most common cancers. Overall, an estimated 12.7 million new cancer cases and 7.6 million cancer deaths occur in 2008, with 56% of new cancer cases and 63% of the cancer deaths occurring in the less developed regions of the world. The most commonly diagnosed cancers worldwide are lung (1.61 million, 12.7% of the total), breast (1.38 million, 10.9%) and colorectal cancers (1.23 million, 9.7%). The most common causes of cancer death are lung cancer (1.38 million, 18.2% of the total), stomach cancer (738,000 deaths, 9.7%) and liver cancer (696,000 deaths, 9.2%). Cancer is neither rare anywhere in the world, nor mainly confined to high-resource countries. Striking differences in the patterns of cancer from region to region are observed.
To determine barriers and facilitating factors to skin cancer screening practices among US primary care physicians and dermatologists.
Survey.
Physicians randomly selected from the American Medical Association's Medical Marketing Services database from April 1 through November 30, 2005.
A total of 2999 US dermatologists, family practitioners, and internists.
Results based on 1669 surveys returned regarding practice characteristics, skin cancer screening behaviors, and barriers and facilitating factors to performing full-body skin examinations for patients.
The overall response rate was 59.2%. More dermatologists (552 [81.3%]) reported performing full-body skin examinations on patients than did family practitioners (333 [59.6%]) (P < .05) or internists (243 [56.4%]) (P < .05). Among all physicians, time constraints, competing comorbidities, and patient embarrassment were reported as the top 3 barriers to performing full-body skin examinations, and these barriers were different among medical specialties. Among all physicians, having patients at high risk for skin cancer, patient demand for complete examination/mole check, and the influence of medical training were reported as facilitating factors to performing full-body skin examinations.
Becoming more knowledgeable about physician barriers to skin cancer screening could help improve primary and secondary practices in both the primary care and dermatology settings.
To determine the influence of age and sex on why individuals seek skin cancer screening and their understanding of its benefits.
Voluntary survey.
Academic dermatology department.
Individuals 18 years or older being seen for skin cancer screening from May to October 2009.
Patients' reasons for seeking and perceived benefits of skin cancer screening and understanding of screening recommendations.
Of 546 patients, 487 eligible individuals (89.2%) participated in the survey. Most (80.6%) sought screening without a particular lesion of concern. Women were more likely than men to present with a lesion they believed could be skin cancer (24.6% vs 11.9%; P < .001) or because they were concerned about previous sun exposure (34.3% vs 23.8%; P < .05). Individuals younger than 50 years were more likely than older patients to seek screening because of a family history of melanoma (30% vs 18.9%; P < .01). Men 50 years or older were more likely than other patients to seek skin cancer screening because of a previous skin cancer diagnosis (64.6% vs 40.8%; P < .001). Most patients believed that screening reduces the risk of death from skin cancer and prevents skin cancer. There was no consensus among patients regarding the frequency with which healthy adults should be screened for skin cancer.
There is a need for better educational campaigns with specific recommendation for who should be screened for skin cancer. Men 50 years or older, the group at highest risk for death from melanoma, are most likely to seek screening only after being diagnosed as having a skin cancer.
Survival from melanoma is strongly related to tumour thickness, thus earlier diagnosis has the potential to reduce mortality from this disease. However, in the absence of conclusive evidence that clinical skin examination reduces mortality, evidence-based assessments do not recommend population screening. We aimed to assess whether clinical whole-body skin examination is associated with a reduced incidence of thick melanoma and also whether screening is associated with an increased incidence of thin lesions (possible overdiagnosis).
A population-based case-control study of all Queensland residents aged 20-75 years with a histologically confirmed first primary invasive cutaneous melanoma diagnosed between January 2000 and December 2003. Telephone interviews were completed by 3,762 eligible cases (78.0%) and 3,824 eligible controls (50.4%)
Whole-body clinical skin examination in the three years before diagnosis was associated with a 14% lower risk of being diagnosed with a thick melanoma (>0.75mm) (OR= 0.86, 95% CI=0.75, 0.98). Risk decreased for melanomas of increasing thickness: the risk of being diagnosed with a melanoma 0.76-1.49mm was reduced by 7% (OR=0.93, 95% CI 0.79, 1.10), by 17% for melanomas 1.50-2.99mm (OR=0.83, 95% CI=0.65, 1.05) and by 40% for melanomas ≥3mm (OR=0.60, 95% CI=0.43, 0.83). Screening was associated with a 38% higher risk of being diagnosed with a thin invasive melanoma (≤0.75mm) (OR=1.38, 95% CI=1.22, 1.56).
This is the strongest evidence to date that whole-body clinical skin examination reduces the incidence of thick melanoma. Because survival from melanoma is strongly related to tumour thickness, these results suggest that screening would reduce melanoma mortality.
The objective of this study was to create a self-administrated questionnaire for people to enable them to assess their own melanoma risk factors. To test the validity of this questionnaire in a large prospective study, the answers given by the patient were systematically checked by his or her general practitioner. In this prospective study, the choice of questions was based on a review of the literature. The validity of the questionnaire was assessed by testing 1500 consecutive patients attending a consultation with their general practitioner. Considerable variations concerning the prevalence of different melanoma risk factors were noticed in the population: 44.1% had a phototype I or II, 41% had severe sunburn during infancy, 29.9% had freckling tendency, 22% had more than 50 naevi and 1.4% a personal history of melanoma. In total, 45% had more than one melanoma risk factor. The accuracy of the answers given by the patients was assured by the correction given by their general practitioners. The percentage of correct answers given by the patients was 79.9% for the phototype, 90.6% for freckling tendency, 86.6% for the number of naevi, 96.5% for severe sunburn during infancy and 98.1 and 95.8% for personal and familial history of melanoma. This study confirms that individuals with multiple risk factors for melanoma are common among patients consulting their general practitioners. Furthermore, self-screening with the self-assessment questionnaire is easily feasible and is accurate for identifying high-risk individuals. This tool might be useful for carrying out melanoma-targeted screening.
To revise the staging system for cutaneous melanoma on the basis of data from an expanded American Joint Committee on Cancer (AJCC) Melanoma Staging Database.
The melanoma staging recommendations were made on the basis of a multivariate analysis of 30,946 patients with stages I, II, and III melanoma and 7,972 patients with stage IV melanoma to revise and clarify TNM classifications and stage grouping criteria.
Findings and new definitions include the following: (1) in patients with localized melanoma, tumor thickness, mitotic rate (histologically defined as mitoses/mm(2)), and ulceration were the most dominant prognostic factors. (2) Mitotic rate replaces level of invasion as a primary criterion for defining T1b melanomas. (3) Among the 3,307 patients with regional metastases, components that defined the N category were the number of metastatic nodes, tumor burden, and ulceration of the primary melanoma. (4) For staging purposes, all patients with microscopic nodal metastases, regardless of extent of tumor burden, are classified as stage III. Micrometastases detected by immunohistochemistry are specifically included. (5) On the basis of a multivariate analysis of patients with distant metastases, the two dominant components in defining the M category continue to be the site of distant metastases (nonvisceral v lung v all other visceral metastatic sites) and an elevated serum lactate dehydrogenase level.
Using an evidence-based approach, revisions to the AJCC melanoma staging system have been made that reflect our improved understanding of this disease. These revisions will be formally incorporated into the seventh edition (2009) of the AJCC Cancer Staging Manual and implemented by early 2010.
Skin cancer is the most commonly diagnosed cancer in the United States. The majority of skin cancer is nonmelanoma cancer, either basal cell cancer or squamous cell cancer. The incidence of both melanoma and nonmelanoma skin cancer has been increasing over the past 3 decades. In 2001, the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against routine screening for skin cancer by using whole-body skin examination for early detection of skin cancer.
To update the evidence of benefits and harms of screening for skin cancer in the general population.
MEDLINE and Cochrane Library searches from 1 June 1999 to 9 August 2005 for English-language articles; recent systematic reviews; reference lists of retrieved articles; and expert suggestions.
English-language studies were selected to answer the following key question: Does screening in asymptomatic persons with whole-body examination by a primary care clinician or by self-examination reduce morbidity and mortality from skin cancer? Randomized, controlled trials and case-control studies of screening for skin cancer were selected. One author selected English-language studies to answer the following contextual questions: Can screening with whole-body examination by primary care clinicians or by self-examination accurately detect skin cancer? Does screening with whole-body examination or by self-examination detect melanomas at an earlier stage (thinner lesions)?
All studies for the key question were reviewed, abstracted, and rated for quality by using predefined USPSTF criteria.
No new evidence from controlled studies was found that addressed the benefit of screening for skin cancer with a whole-body examination by a physician. One article of fair quality, which reanalyzed data from a 1996 study identified for the 2001 report for the USPSTF, provides limited but insufficient evidence on the benefit of skin self-examination in the reduction of morbidity and mortality from melanoma.
Direct evidence linking skin cancer screening to improved health outcomes is lacking. Information is limited on the accuracy of screening by physicians or patients using real patients and lesions.
The limited evidence prevents accurate estimation of the benefits of screening for skin cancer in the general primary care population.
To determine whether persons with melanoma were integrated into the health care system prior to diagnosis.
Population-based survey by mailed questionnaire. Patients/participants: 216 persons with malignant melanoma diagnosed in Massachusetts in 1986.
Of the 216 cases, 87% stated that they had regular physicians, 63% had seen those physicians in the year prior to diagnosis, but only 20% had regular dermatologists. Overall, only 24% had examined their own skin prior to diagnosis and 20% reported physician skin examinations.
Persons diagnosed with melanoma reported extensive contact with regular physicians in the year prior to diagnosis. However, most of these persons neither received skin examinations nor examined their own skin during that time. While additional study is necessary to confirm these findings, the authors suggest that physicians caring for patients at risk for melanoma integrate melanoma screening into routine care.
Increasing incidence and mortality rates from cutaneous melanoma are a major public health concern. As part of a national effort to enhance early detection of melanoma/skin cancer, the American Academy of Dermatology (AAD) has sponsored an annual education and early detection program that couples provision of skin cancer information to the general public with almost 750,000 free skin cancer examinations (1985-1994).
To begin to evaluate the impact of this effort, we determined the final pathology diagnosis of persons attending the 1992-1994 programs who had a suspected melanoma at the time of examination.
We directly contacted all such persons by telephone or mail and received pathology reports from those who had a subsequent biopsy.
We contacted 96% of the 4458 persons with such lesions among the 282,555 screenings in the 1992-1994 programs. We obtained a final diagnosis for 72%, and the positive predictive value for melanoma was 17%. Three hundred seventy-one melanomas were found in 364 persons. More than 98% had localized disease. More than 90% of the confirmed melanomas with known histology were in situ or "thin" lesions (< or = 1.50 mm thick). The median thickness of all melanomas was 0.30 mm. The 8.3% of AAD cases with advanced melanoma (metastatic disease, regional disease, or lesions > or = 1.51 mm) is a lower proportion than that reported by the 1990 Surveillance, Epidemiology and End Result Registry. The rate of thickest lesions (> or = 4 mm) and late-stage melanomas among all participants was 2.83 per 100,000 population. Of persons with a confirmed melanoma, 39% indicated (before their examination) that without the free program, they would not have considered having a physician examine their skin.
The 1992-1994 free AAD programs disseminated broad skin cancer educational messages, enabled thousands to obtain a free expert skin cancer examination, and found mostly thin, localized stage 1 melanomas (usually associated with a high projected 5-year survival rate). Because biases impose possible limitations, future studies with long-term follow-up and formal control groups should determine the impact of early detection programs on melanoma mortality.
Although the survival benefits of early stage melanoma have been clearly documented, the potential economic impact of early versus late stage disease has not been assessed.
Our purpose was to estimate the annual direct cost of diagnosing and treating melanoma, based on the number of projected cases of melanoma entering each stage in 1997.
A model was constructed with assumptions derived from the literature and clinical experience at the Massachusetts General Hospital Melanoma Center and the Boston University Medical Center. Cost estimates were based on 1997 Boston area Medicare reimbursements.
The annual direct cost of treating newly diagnosed melanoma in 1997 was estimated to be $563 million. Stage I and II disease each comprised about 5% of the total cost; stage III and stage IV disease consumed 34% and 55% of the total cost, respectively. About 90% of the total annual direct cost of treating melanoma in 1997 was attributable to less than 20% of patients (those patients with advanced disease, that is, stage III and stage IV).
In addition to the potential survival advantages, aggressive primary prevention through sun protection and intensive screening to enhance earlier detection should reduce the economic burden of melanoma care.
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.
Sun and ultraviolet radiation exposure are major risk factors for skin cancer, and sun-protective behaviors and skin cancer examinations are means of primary prevention of skin cancer. The objective of this study was to evaluate the extent to which demographics and other high-risk behaviors may predict the reported level of participation in sun-protection behaviors and skin cancer primary prevention in the United States adult population.
Data on reported sun-protection behaviors and skin cancer examinations were obtained from surveys completed by adults in the 1998 National Health Interview Survey. Univariate and multivariate data analyses were performed using specialized statistics software.
For the United States adult population surveyed (n = 32,440), only 21% of those surveyed indicated that they had ever had a skin cancer examination, and, of those, only 45% indicated that the skin cancer examination was within the past year. For sun-protective behaviors, only 23%, 27%, and 30% of those surveyed reported that they were very likely to wear protective clothing, stay in the shade, and use sunscreen, respectively.
The likelihood of participation in sun-protective behaviors and skin cancer prevention was related to a number of demographic characteristics and high-risk behaviors, including currently smoking cigarettes and wearing seatbelts.
Health promotion strategies to prevent deaths from skin cancer, particularly melanoma, have two components: advice on early recognition and advice on prevention. The population is perhaps heeding advice on early recognition. Five year survival from melanoma in England and Wales is improving, particularly in female patients,1 probably because the cancer is diagnosed at an earlier stage owing to increased public awareness. But the incidence of melanoma is increasing in the United Kingdom and the United States; 1 2 in the United Kingdom it has doubled over the past 20 years.1 This contrasts with a falling incidence in Australia,3 but it is not clear whether this difference is attributable to the Australian prevention campaign having been active for longer or whether prevention messages are less effective in the United Kingdom. By 1996, attitudes among Australian students had already shifted positively towards avoiding exposure to the sun and away from the use of sunscreen and desire for a tan.4 In contrast, a study of 80 students in the United Kingdom published in 2000 found that most emphasised positive benefits of sun exposure, enjoyed sunbathing, protected themselves inadequately, and did not intend to change this behaviour.5
Experts believe that 90% of non-melanoma skin cancers and two …
Digital dermoscopy for the follow-up of melanocytic naevi (MN) is becoming more common in dermatological private practice.
To evaluate the clinical outcome, including the patient's compliance, in a long-term follow-up of single MN.
Criteria for the selection of MN for follow-up: clinically suspicious without dermoscopically atypical features, or typical for the patient. Clinical outcome measures: number of detected malignant melanomas (MM) and/or atypical MN; quantity, quality, and differences in morphological changes between 'low-risk' patients (no MM in history and < 50 MN) and 'high-risk' patients (MM in history and/or > 50 MN). Compliance: the number of patients who joined a recommended follow-up scheme.
No MM was found in 145 consecutive patients (mean age 28 years, 54% female) during a 4-year period (median follow-up per patient: 24 months; ranging 4-45; at least three visits). In five patients (3%), seven histologically proven atypical MN were shown on whole body examination at sites other than those documented. A total of 1968 images in 177 'low-risk' and 95 'high-risk' MN were analysed: 37% (n = 65) of 'low-risk' and 32% (n = 30) of 'high-risk' MN showed dermoscopic changes (difference not statistically significant), none were suspicious for MM. Compliance, evaluated within a separate database of 303 consecutive patients (mean age 32 years, 52% female) over a 6-month period, was only 46%, although recall letters were used.
(i) In our setting of daily routines in dermatological private practices long-term follow-up of a single MN seems not to be helpful for the detection of MM. (ii) A whole body examination must be done at each visit. (iii) The clinician's experience of the type and number of possible morphological changes in MN is crucial in order to avoid unnecessary excisions. (iv) The patient's compliance might be an important problem. (v) Cost-effectiveness has yet to be analysed.
A systematic meta-analysis of observational studies of melanoma and family history, actinic damage and phenotypic factors was conducted as part of a comprehensive meta-analysis of all major risk factors for melanoma. Following a systematic literature search, relative risks were extracted from 60 studies published before September 2002. Fixed and random effects models were used to obtain pooled estimates for family history (RR = 1.74, 1.41-2.14), skin type (I vs. IV: RR = 2.09, 1.67-2.58), high density of freckles (RR = 2.10, 1.80-2.45), skin colour (Fair vs. Dark: RR = 2.06, 1.68-2.52), eye colour (Blue vs. Dark: RR = 1.47, 1.28-1.69) and hair colour (Red vs. Dark: RR = 3.64, 2.56-5.37), pre-malignant and skin cancer lesions (RR = 4.28, 2.80-6.55) and actinic damage indicators (RR = 2.02, 1.24-3.29). Sub-group analysis and meta-regression were carried out to explore sources of between-study variation and bias. Sensitivity analyses investigated reliability of results and publication bias. Latitude and adjustment for phenotype were two study characteristics that significantly influenced the estimates.
Within a randomized trial of population screening for melanoma, primary care physicians conducted whole-body skin examinations and referred all patients with suspect lesions to their own doctor for further treatment.
Our aim was to describe characteristics of skin screening participants, clinical screening diagnoses, management following referral, and specificity and yield of screening examinations.
Information collected from consent forms, referral forms, and histopathological reports of lesions that had been excised or undergone biopsy was analyzed by means of descriptive statistics.
A total of 16,383 whole-body skin examinations resulted in 2302 referrals (14.1% overall; 15.5% men, 18.2% > or = 50 years of age) for 4129 suspect lesions (including 222 suspected melanoma, 1101 suspected basal cell carcinomas [BCCs], 265 suspected squamous cell carcinomas [SCCs]). Histopathologic results were available for 94.8% of 1417 lesions excised and confirmed 33 melanomas (23 in men; 24 in participants > or = 50 years of age), 259 BCCs, and 97 SCCs. The probability of detecting skin cancer of any type within the program was 2.4%. The estimated specificity of whole-body skin examinations for melanoma was 86.1% (95% confidence interval = 85.6-86.6). The positive predictive value (number of confirmed/number of lesions excised or biopsied x 100) for melanoma was 2.5%, 19.3% for BCC, and 7.2% for SCC (overall positive predictive value for skin cancer, 28.9%).
Follow-up of participants with a negative screening examination has not been conducted for the present investigation.
The rate of skin cancer detected per 100 patients screened was higher than previously reported and men and attendees older than 50 years more frequently received a referral and diagnosis of melanoma. The specificity for detection of melanoma through whole-body skin examination by a primary care physician was comparable to that of other screening tests, including mammography.
Identifying high-risk individuals for melanoma education and risk reduction may be a viable strategy to curb the incidence of melanoma, which has risen precipitously in the past 50 years. The first-degree relatives of melanoma patients represent a risk group who may experience a 'teachable moment' for enhanced education and risk reduction.
We report a randomized trial testing an intervention that provided personalized telephone counseling and individually tailored materials to siblings of recently-diagnosed melanoma patients. The purpose of this study was to test whether an intervention could lead to improvements in siblings' skin cancer risk reduction practices. Intervention condition participants received the following: (1) an initial motivational and goal-setting telephone intervention session delivered by the health educator; (2) three sets of computer-generated materials specifically tailored to individual responses from the baseline survey; (3) three telephone counseling sessions with the health educator, timed to follow receipt of the mailed materials; and (4) linkages to free screening programs. Families in the usual care arm received the suggestion from the physician that patients diagnosed with melanoma notify the family members about their diagnosis and encourage the family members to be screened.
494 siblings were recruited to the study and 403 siblings remained in the study through at least 6 months. At 12 months, intervention siblings were more likely to examine all moles, including those on the back (OR, 1.76; 95% CI, 1.06-2.91). Compared with baseline, the number of participants in both groups that had received a skin cancer examination more than doubled, with no differences between groups. At 12 months, two-thirds of siblings in both groups reported routine use of sunscreen, but there were no differences in change over baseline between the two groups.
This study is the one of the first, to our knowledge, to address skin cancer risk-reduction strategies in a sample of individuals who have a recent family diagnosis of melanoma. Diagnosis of melanoma in a family member provides an important opportunity to intervene with others in that family. The components of the intervention may provide a useful foundation for future efforts to target the more than half million siblings at risk for melanoma, a lethal but preventable disease.
The screening behavior and screening outcomes of men age > or =50 years was investigated within a randomized controlled trial of a community-based intervention of screening for melanoma, consisting of a community education program, an education program for medical practitioners, and the provision of dedicated skin-screening clinics.
Data from cross-sectional telephone surveys before (559 completed interviews), at the end (591 completed interview), and at 2 years after the intervention (445 completed interviews) were analyzed. In addition, the authors analyzed data from skin-screening clinics within the intervention program (3355 men age > or =50 years participated).
During the intervention period men age > or =50 years increased both their screening behavior and intention to screen. Those men age > or =50 years who reported a past history of removal of a mole as well as other risk factors for skin cancer and positive attitudes toward screening were more likely to participate in skin screening across time. Men age > or =50 years accounted for 20.5% of all skin-screening clinic attendees, 31.3% of those referred for a suspicious lesion, 48.5% of melanomas, and 45% of all keratinocyte carcinomas diagnosed within the screening program, respectively.
The intervention program successfully motivated men age > or =50 years to attend screening for skin cancer, resulting in the highest yield of skin cancer within this subgroup of the population. Messages addressing skin cancer risk factors and attitudes toward skin cancer and screening could be used to target a screening program for melanoma toward men age > or =50 years.
The objective of this study was to describe the risk factor profile of skin cancer screening participants and to determine whether there is an association between the number of skin cancer/melanoma risk factors and the likelihood of diagnosis of a malignant melanoma. Seventy skin cancer screening clinics were held by the Lions Cancer Institute in predominantly rural areas of Western Australia between 1996 and 2003. Participants were self-selected and voluntary, responding to an advertisement seeking people at 'high-risk' of melanoma. The Lions Cancer Institute skin screening clinics targeted participation by individuals with three or more of the established risk factors for skin cancer/melanoma. Questionnaires collecting information on the self-report of nine risk factors were completed by 5950 participants who were screened for melanoma between 1996 and 2003. The number and type of risk factors, and of provisionally diagnosed and histopathologically confirmed malignant melanomas were measured. Of 5950 participants, 18 histopathologically confirmed malignant melanomas were detected. A participant's total number of risk factors showed some association with the provisional melanoma diagnosis given at the time of screening. No relationship, however, was observed between the number of risk factors and a melanoma that was histopathologically confirmed after screening. The risk factor method is effective in selecting a 'high risk' population, but does not seem to have high value in predicting who will be diagnosed with melanoma as a result of screening. Further studies are needed to verify this finding owing to the rarity of melanoma and the small number of confirmed melanomas in this study.