The Epidemiology, Prevention, and Detection of Melanoma
Adam I. Riker, MD, Nicolas Zea, MD, Tan Trinh, MD
Ochsner Cancer Institute, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA
We are seeing a record number of newly diagnosed skin cancers
worldwide, with the incidence of melanoma increasing at a
faster rate than almost all other cancers. As clinicians, we will
have, by far, the greatest impact on reducing this incidence
through better methods of early detection of melanoma and
proven prevention methods and techniques. The medical
community must enhance its efforts to increase its training of
new health care personnel who are capable of diagnosing and
treating this record number of patients with skin cancer. We
must also try to increase the access to our limited number of
dermatologists and provide novel ways of patient education such
as through skin self-examinations, total body photography, and
improved education for our children. By providing easier access
to skin examinations, we will increase our chances of detecting
melanoma in its earliest and most curable form. The dangers of
indoor tanning beds and salons must be transparent to those
that use them, focusing on expanding the oversight of such
facilities by our local and federal governmental agencies while
establishing legislation in several states to further limit their use
to our youth, who are especially at high risk for developing
melanoma in the future. This review will focus on the
epidemiology, prevention, and detection of melanoma.
EPIDEMIOLOGY OF MELANOMA
According to the Surveillance Epidemiology and
End Results data, melanoma is the sixth most
common fatal malignancy in the United States,
responsible for 4% of all cancer deaths and 6 of
every 7 skin cancer-related deaths.1A thorough
understanding about incidence trends, mortality rates,
risk factors, and genetics of this deadly cancer is of
critical importance in order to create a national and
even worldwide social awareness of the relationship
between overexposure to ultraviolet radiation (UVR) in
all of its forms and cutaneous melanoma. It is
predicted that 1 in 5 Americans will develop skin
cancer in his/her lifetime, resulting in 1 million new
cases per year.2It should be noted that although
melanoma represents the most lethal form of cancer,
basal cell and squamous cell carcinoma are ,100
times more common than melanoma, and only
squamous cell carcinoma is rarely associated with
resulting metastasis and death.
Notably, the American Academy of Dermatology
(AAD) reports that melanoma is the second most
common cancer in women 20 to 29 year old, with
68,000 newly diagnosed cases in the United States in
2010.3,4The annual direct cost of treating nonmela-
noma skin cancer in the United States in 2007 was
estimated to total $650 million, and when melanoma
is included, this number increased to a staggering
$2.9 billion.5According to a recent publication of the
International Agency for Research on Cancer (IARC),
Queensland, Australia, had the highest incidence of
invasive cutaneous melanoma worldwide during the
period from 1998 to 2002.4,6Additionally, the IARC
placed North America as fourth in melanoma inci-
dence worldwide, with 19.4 per 100,000 males and
14.4 per 100,000 females. However, the most recent
data from Surveillance Epidemiology and End Re-
sults, encompassing the years of 2002 to 2006, shows
a marked increase in incidence in non-Hispanic
whites of 28.9 per 100,000 in males and 18.7 per
100,000 in females.7In 2010, current estimates
indicate that 1 of every 39 people in the United States
will be diagnosed with melanoma during his/her
lifetime.8This risk is substantially greater than noted
in 1985 and 1965, when the lifetime risks were
estimated to be 1 in 150 and 1 in 600, respectively.9,10
Incidence rates vary throughout Europe as well,
with the highest rates seen in Switzerland, Norway,
Sweden, and Denmark compared with those coun-
tries in southern Europe.7,11MacKie et al11hypothe-
size that this latitudinal gradient may be related to
sun-exposure behaviors, and in particular to the
tendency for Northern Europeans to vacation in sunny
climates, resulting in intense, intermittent sun expo-
sure. A Swedish study reported 46,337 melanomas
diagnosed during the period of 1960 through 2004,
Address correspondence to:
Adam I. Riker, MD
Ochsner Cancer Institute
1514 Jefferson Highway, BH334
New Orleans, LA 70121
Tel: (504) 842-7977
Fax: (504) 842-7985
Key Words: Early detection and prevention, melanoma, skin
cancer screening, tanning salons
The Ochsner Journal 10:56–65, 2010
f Academic Division of Ochsner Clinic Foundation
56The Ochsner Journal
clearly revealing an increase in the incidence of
melanomas of the trunk and lower limb.12The number
of head and neck melanomas has also increased, but
less rapidly than other locations, most commonly
associated with older individuals, .70 years old.
Primary melanomas of the trunk and lower limb have
been associated with intermittent, high-intensity sun
exposure, as opposed to head and neck melanomas,
which appear to be associated more with chronic,
long-term sun exposure.
Ultraviolet Radiation and the Development
It is now widely accepted that the major environ-
mental risk factor for the development of primary
cutaneous melanoma is UVR, which can be subdi-
vided into ultraviolet A (UVA), ultraviolet B (UVB), and
ultraviolet C (UVC). Immediate tanning is caused by
UVA and fades within hours or days. Delayed tanning
occurs 2 to 3 days after initial exposure to UVA or
UVB and lasts several weeks to months.13Tanning
after exposure to UVR depends on the skin type and
the UV Index. UV Index as calculated by the US
National Weather Service is reported as a scale from 0
to 11 and takes into account the wavelengths of UVB
(290-320 nm), UVA (320-400 nm), strength of UVR
relative to ground level, adjusted skin sensitivity to
UVR, ozone concentration, and cloud amounts.14
Burn frequency after exposure to UVR as related to
UV index differs among the various skin types.13.15
The contribution of UVC in the development of skin
cancer is considered negligible as most is prevented
from reaching the surface of the earth by the
atmospheric ozone layer.16
Elmwood and Gallagher17identified that short,
intermittent burning episodes of sun exposure is a
major risk factor for the future development of
melanoma, resulting in a higher incidence in those
individuals with pale, nonacclimated white skin. The
specific wavelengths that are known to cause
squamous cell cancer in albino hairless mice are
bimodal in nature (peaked at 293 and 354 nm), with
the development of cutaneous melanoma seen after
exposure to wavelengths of 290 to 320 nm, or the
wavelength of UVB.18
A direct relationship between UVB and melanoma
has been demonstrated, with a 10% increase in
average annual UVB irradiation correlating with a 19%
increased risk of melanoma.19The DNA mutations
identified after UVB exposure can lead to the
generation of pyrimidine dimers that cause cytosine
to thymine and dimerization with associated DNA
mutations.20Recent evidence also shows UVA caus-
ing similar DNA changes.21The tumor suppressor
gene p53, which has the capacity to repair DNA
damage via inducing apoptosis, is itself subjected in
the skin to dipyrimidine mutagenesis. Thus, the
carcinogenic effects of UVR to DNA are twofold in
that it induces genomic mutations and impairs the
normal function of p53.22,23
Melanoma is mostly seen in the non-Hispanic
white population, making the phenotypes of pale
white, red-haired, or blond-haired as established risk
factors for developing cutaneous melanoma. The
unique distinction between such phenotypes and the
dark-skinned population is partly because of the type
of melanin produced, which is greatly influenced by
the gene, MC1R. Eumelanin is responsible for the
dark pigmentation, while phaeomelanin is responsi-
ble for red hair and freckles. Loss of function of the
wild-type MC1R gene with associated gene muta-
eumelanin production and are associated with most
of the red-haired phenotypes observed in the human
Invasive cutaneous melanoma in one or more first-
degree relatives is an additional risk factor for
melanoma. As stated by MacKie et al,11the work of
groups, Genomel and Gem, has shown that approx-
imately one third of patients in melanoma families
worldwide have an identifiable germline mutation in
CDKN2A, a gene important in controlling entry into
the cell cycle. CDKN2A codes for 2 different proteins,
p16 and p14ARF. Tucker24identified CDK4, a second
melanoma susceptibility gene found in 5 families to
date worldwide. In addition, within melanoma-prone
families, MC1R variation increases the risk of mela-
noma in families without CDKN2A and modifies the
risk of melanoma associated with CDKN2A muta-
tions24-26by conferring a sevenfold increase in the risk
of developing melanoma.
Some familial cases of melanoma are also
associated with the familial atypical multiple mole
and melanoma syndrome. This syndrome was origi-
nally described in families showing concordance for
melanoma and a cutaneous phenotype characterized
by the multiple large moles of variable size and color
with pigmentary leakage.20As stated by Tsao et al,27
a family history of cutaneous melanoma in at least 2
first-degree relatives and younger age at diagnosis
are important components of this syndrome. This is
partly because of the increased rate of p16 mutations
(protein encoded by CDKN2A) associated with this
syndrome.28Thus, the identification of populations at
high risk, such as those with a potential familial
predisposition or gene mutation, is important in our
efforts to identify high-risk groups that may benefit
from intense surveillance and skin cancer screening
Volume 10, Number 2, Summer 201057
EARLY PREVENTION OF MELANOMA
Education of Our Youth
The most modifiable risk factor for skin cancer is
UVR exposure. We must educate others as to the
importance of using sunscreens, in combination
with attempting to increase the number of people
who use safe sun practices, such as avoiding the
sun during peak hours, using protective clothing and
head gear, and avoiding the use artificial sources of
UV light.29There is great concern in regard to the
total amount of sun exposure during early child-
hood, resulting in the implementation of several
amount of sun exposure during these critical years.
The Committee on Environmental Health of the
American Academy of Pediatrics published its
recommendations in 1999, urging pediatricians to
promote the reduction of sun exposure in children
by encouraging the use of sunscreen during outdoor
activities, utilization of protective clothing, wide-
brimmed hats, use of shaded areas, and being
mindful of the daily UV index.30
Several recently established programs have re-
sulted in an overall improvement in children’s sun
protection. Aulbert et al31established a feasible
certification program for sun protection in a German
child daycare center, with the goal to establish better
policies for childhood sun protection and a long-term
goal of decreasing the incidence of skin cancer.
Several noted successes of this intervention included
a significant gain in knowledge of staff members, an
increased use of children wearing a hat from 13% to
72%, increased use of the reapplication of sunscreen,
and an increased use of shaded areas on the
playground. However, it did not succeed in keeping
the children inside during the most intense UVR
exposure or in educating the staff members to
become a convincing example of sun protection by
wearing protective clothing.
In the United States, Buller et al32randomly
selected 1,000 public elementary schools within 27
metropolitan areas from 58 US cities in 1998 to
assess current sun protection policies and the
receptiveness to new policies. They found that only
3.4% of schools had an official sun protection policy,
with the most common reason being the principal’s
lack of awareness and organizational barriers in place,
such as lack of surplus funding to instill such changes
in sun protection. In a separate study of secondary
schools, Buller et al33performed a telephone survey
of 484 secondary schools in 27 cities, addressing
whether current Centers for Disease Control and
Prevention-issued recommendations for school pro-
grams to reduce skin cancer were being implement-
ed, in use, or followed.
Although a similarly low 10% of the schools
reported having a sun protection policy, nearly all
(96%) reported sun protection education occurring
regularly, with limited and infrequent use of written
educational materials on sun protection. Such public
education efforts are questions as to their ultimate
effectiveness in terms of the goal being to reduce the
number of cases of melanoma in the future and
possibly detecting melanoma at an earlier stage.
Brackeen et al34examined the cause of the increased
incidence of melanoma in Central Texas, suggesting
that the increase in incidence is not the result of
increased detection, rather it is a failure of the current
public education efforts for sun protection.
Chemoprevention of Photocarcinogenesis
It is well-established that UVR exposure in
humans results in tumor initiation and promotion,
proceeding to complete transformation and carcino-
genesis with excessive exposure.35Although consid-
ered an essential aspect of UVR protection, standard
formulations of sunscreens have been shown to have
limited or inadequate protection against reducing skin
cancer.35Thus, considerable interest has developed
in examining the potential use of naturally occurring
botanicals for the prevention of UVR-induced photo-
damage and skin cancer. Several such naturally
occurring compounds have been identified such as
apigenin, a flavenoid found in herbs, fruits, vegeta-
bles, tea, and wine, that has been shown to prevent
UV-induced tumorigenesis in mice.36Other com-
pounds shown to have substantial photoprotective
effects include curcumin, proanthocyanidins (grape
seeds), resveratrol (grape skins, peanuts, red wine,
mulberries), silymarin (milk thistle), and green tea.35In
particular, the photoprotective effects of green tea
polyphenols are well documented in the literature,
protecting against UV-induced immunosuppression,
premature aging, sunburn response, and carcinogen-
Indoor Tanning Salon as an Industry
It is imperative that public awareness increases as
to the real dangers of UVR in all of its forms. This is
especially true for the abuse of indoor tanning beds
with its known association with the development of all
forms of skin cancer, especially melanoma. The laws
governing UVR exposure related to the use of indoor
tanning beds or sunlamps are woefully inadequate.
Given the rise in youth patronage of indoor tanning
salons, we cannot ignore the potential immediate and
long-term health risks to these young adults, espe-
cially when considering the formidable costs associ-
ated with the treatment of both melanoma and
nonmelanoma skin cancers. Most compelling is the
The Epidemiology, Prevention and Detection of Melanoma
58 The Ochsner Journal
recent classification by the World Health Organization
(WHO) clarifying that all forms of UVR (UV A, B, C),
broad-spectrum UVR, solar radiation, and exposure
to sunlamps or tanning beds are designated as class
1 carcinogens, defined as known to cause cancer in
humans. It is listed alongside cigarettes, asbestos,
mustard gas, and plutonium-239 (in atomic bombs) as
leading cancer-causing agents.
Despite such warnings, the indoor tanning salon
industry is big business worldwide, with estimated
annual revenue in 1992 of $1 billion, which grew to
more than $5.5 billion in 2009 in the United
States.38,39Although the absolute number of skin
cancers related to tanning bed use is not known, a
recent study strongly shows that exposure to tanning
beds increases the risk for developing melanoma,
especially in women aged 45 years or younger.40Of
the 1 million Americans who use tanning salons
regularly, 70% are females in the age range of 16 to
49 years old.41,42The groups of individuals that are at
most danger are teenage girls and younger women
who regularly use tanning salons, with a very high
incidence found in women between the ages of 20
and 35. Among the US consumer base are 2.3 million
teenagers, with the overall tanning trends increasing
from 1% of American adults using tanning beds in
1988 to 27% in 2007.38,43At the same time, a
decreased awareness as to the dangers of tanning
has resulted in an increased risk in the developing of
melanoma from 1994 through 2007.44
The number and density of indoor tanning facilities
per 100,000 people in the 116 most populous cities in
the United States have far exceeded other compa-
nies, such as the interval growth of Starbucks and
McDonalds. In March 2006, the number and density
of indoor tanning salons were 41.8 (SD 30.8) and 11.8
(SD 6), respectively. The mean numbers of indoor
tanning salons exceeded Starbucks and McDonalds
in the same cities, 29.6 (SD 22.5) and 19 (SD 25.2),
respectively. Cities with higher percentages of whites
and lower UV index scores had significantly higher
facility densities than those with lower percentages of
whites and higher UV index scores.45
The increasing trend of indoor tanning is encour-
aged by the indoor tanning industry as seen in a full-
page advertisement in The New York Times on March
26, 2008: ‘‘no compelling scientific evidence that
tanning causes melanoma’’…adding, ‘‘UV light—both
indoors and out—stimulates the natural production of
vitamin D…vitamin D protects against heart disease
and many types of cancer…It’s time to rethink sun
bathing.’’46This type of unsubstantiated advertising is
seen throughout the United States, with groups such
as the Smart Tan Network, a lobbying group for the
tanning industry, falsely implying that sunscreen is not
needed every day and that it may completely block
the body’s ability to produce vitamin D.47
The UV Foundation, a division of the Indoor Tanning
Salon, has falsely concluded that regular use of tanning
bed leads to higher vitamin D serum concentrations,
despite several groups disputing such unfounded
conclusions.48Studies have shown that exposure
through indoor tanning beds far exceeds the dosage
required for vitamin D synthesis. The recommended
UVB exposure dose is 25% of 1 minimal erythema
(ie, 25% of 1 MED requires 3 minutes) and for type 3
skin is 17.7 minutes (25% MED requires 4.5 minutes)
using a standard tanning bed. A normal tanning session
consists of 20 minutes of UVB exposure, or an extra 4.5
to 7 times the amount of UVB required for the
production of vitamin D.49
A recent study shows that 0.5 to 2 hours per week
of hands and face exposure was adequate for vitamin
D biosynthesis.50A randomized double-blind con-
trolled trial in Australia that compared a group wearing
SPF 17 versus a placebo group showed that either
group did not develop any deficiencies in the levels of
vitamin D.51The recommendations of using a tanning
bed as a means to induce vitamin D production was
specifically advocated by Holick,52solely for those
individuals with intestinal malabsorption via exposing
hands, face, arms, and legs to an amount of time to
reach 25% of what would develop a mild sunburn,
that is, 1 MED for 2 to 3 times per week appears to be
more than adequate.
The increase in indoor tanning is alarming when
viewed relative to strong evidence that links indoor UV
radiation exposure via tanning bed usage to skin
cancer. A recent study analyzing patients diagnosed
with basal cell carcinoma, squamous cell carcinoma,
and 540 controls showed that those who have used a
tanning device previously were at a 50% higher risk
for developing basal cell carcinoma (odds ratio [OR]
1.5; 95% confidence interval [CI]: 1.1-2.1) and more
than double the risk for squamous cell carcinoma (OR,
2.5; 95% CI: 1.7-3.8).53Ting et al40found that use of a
tanning bed by 1,518 dermatologic patients showed a
64% increase in the risk of developing melanoma (OR,
1.64; 95% CI: 1.01-2.67), with a stronger risk in
women ,39 years old (OR, 3.22; 95% CI: 1.01-11.46).
A 2007 study by the IARC revealed that the first
exposure to indoor tanning prior to the age of 35 was
associated with a 75% increased risk of developing
melanoma (RR, 1.75; 95% CI: 1.35-2.26).54A Swedish
study showed that people who regularly use tanning
beds have a relative risk for developing melanoma of
1.8, with a much higher risk for those ,36 years old of
8.1, adjusting for hair color, raised nevi, skin type, and
number of sunburns.55A Norwegian and Swedish
Volume 10, Number 2, Summer 201059
study of 106,379 women demonstrated that regular
(at least once per month) solarium use at any age had
a 55% increased risk of developing melanoma, with
the greatest association in the 20- to 29-year-old age
Youth Access to Tanning Salons
A telephone survey has previously shown that
10% of youth age 11 to 18 and 8% of their primary
caregivers used tanning sunlamps in 1997, and 30%
of youths whose caregivers used tanning beds also
used them.57A cross-sectional study from 50 states
included 10,079 boys and girls age 12 to 18 and
showed only a basic understanding of UVR overex-
posure, the proper use of sunscreen, high rates of
sunburning, and tanning bed use. Notably, girls were
likely more than boys to report using tanning beds,
with girls age 15 to 18 more so than girls age 12 to 14.
The increase in tanning bed usage increased with
age: 7% of girls 14 years old increased to 16% by age
15 and 35% by age 17.58Independent predictors
associated with indoor tanning sunlamp use include
age 17 to 18, female, parents who use sunlamps in
the previous year, nonusers of sunscreening products
at the beach, and pool and low sun sensitivity.57
Current Laws Governing the Indoor Tanning
In 1986, the Food and Drug Administration (FDA)
recommended a schedule for tanning sessions,
stating a maximum 0.75 MED 3 3 in the first week,
increased gradually to a total maintenance of 4 MED
weekly or biweekly. The manufacturers were asked to
formulate their own schedules based on these
overriding recommendations.59Additionally, the FDA
limited the amount of exposure to UVC, not the ratio
of UVA to UVB. Moreover, compliance to the limits of
dosage of UVR by tanning salons is not reviewed at
the federal or state level. Not surprisingly, a survey in
North Carolina showed that 95% of clients exceed the
recommended daily dose.60Few inquiries have been
made into the enforcement practices of indoor
tanning salons. A recent review shows 28 states have
some form of law in place as of 2006, with licensure
required in 22 of 28 cities, less than half gave citations
to facilities that violated the state laws as written, with
32% of the city officials not inspecting these facilities,
and another 32% inspected them less regularly than
Pertaining to youth access, an analysis of 3,647
indoor tanning facilities demonstrated that states with
youth access laws are more likely than states without
to require parental consent, with parents required to
be present during tanning sessions.62Infractions to
the recommendations by the FDA are not isolated to
the United States, with 83% of tanning salons in
England exceeding the European standards for UVB
radiation levels.63Similar increased UV intensity was
found in Norway.64In the December 2008 Report to
Congress, the FDA noted that UV exposures found in
sunlamp products are excessive and that comparable
cosmetic results can be obtained with exposures that
are one-fourth to one-third current levels used.3
The state of North Carolina has taken the lead in
attempting to restrict the use of tanning bed usage to
adults only. They have passed legislation that includes
an active inspection program of tanning salons to
ensure that tanning beds are up to standards and
enforcement of rules against minors from tanning. In
2004, North Carolina banned the use of indoor tanning
salons/beds of adolescents under the age of 13.
Other states have followed, such as Michigan; in
December 2008, the Michigan legislature took an
important step to help combat the rise in skin cancer
rates by passing House Bill 4146, which regulates
tanning salons by specifically requiring onsite parental
consent for anyone under 18 years old. They
additionally required larger warning signs in tanning
salons, listing the potential health care consequences
of tanning bed usage and also required a signed
consent form for all customers.
Approximately 25 other states have some form of
restricted access for minors who want to use tanning
salons. The banning of tanning in minors is currently
recommended by the WHO and the AAD. It should not
go unsaid that physicians of all types should not be
afraid to enter the political ring in order to bring about
changes in the current laissez-faire attitude toward
the tanning salon industry. Many physicians have
done so; however, until an organized effort emerges in
an attempt to bring about legislation that would
outlaw the use of tanning beds, we must continue to
educate our patients and the population of the
substantial dangers of tanning beds.
EARLY DETECTION OF MELANOMA
Skin Cancer Screening
In February 2009, the US Preventive Services Task
Force published an update stating that there is
insufficient evidence available to recommend for or
against skin cancer screening.65Furthermore, there
has never been a randomized, controlled trial exam-
ining the efficacy of skin cancer screening. Thus, no
data exist to demonstrate the effectiveness of early
detection of skin cancer or the benefits on morbidity
and mortality, including a reasonable calculation of
the benefits of screening in the general population.
However, many clinicians rightfully point out that the
bar is held too high for such a screening test because
this is one of the few cancers that merely requires a
The Epidemiology, Prevention and Detection of Melanoma
60 The Ochsner Journal
visual examination to make the diagnosis, with no risk
to the actual screening process itself. The minimal
risks associated with a biopsy also are small com-
pared with other screening tests, such as colonosco-
py or mammography. Despite these strongly held
perceptions, the US Preventive Services Task Force
found no new evidence that proves that whole-body
skin examinations, whether by the physician or self-
examination by the patient, reduce morbidity and
mortality from skin cancer.
Dermatologists in particular are quick to point out
that it appears almost intuitive to think that screening
for melanoma can be both effective and beneficial in
their practices, citing a wealth of data in support of
early detection of melanoma. Berwick66examined
whether skin self-examination (SSE) was associated
with a decrease in lethal melanomas by interviewing
650 people with newly diagnosed melanoma and 549
without disease on whether they had previously
performed SSE. She found that the 15% who reported
practicing SSE had a reduced risk for melanoma
incidence (OR, 0.66; 95% CI: 0.44-0.99). Additionally,
SSE was reported to reduce the risk for advanced
disease among patients with melanoma (OR, 0.58;
95% CI: 0.31-1.11).
A recent US survey shows that only 22% of the
adult population has ever had a full head-to-toe skin
examination.67Young adults are especially lacking in
basic knowledge of skin cancer awareness. Arnold
and DeJong68sampled Boston-area young adults and
found that more than half did not know what to look
for on their skin or ever thought about performing an
SSE. The National Skin Cancer Screening Programs
of the AAD (1986-2001) showed that 80% of American
adults did not have a regular dermatologist, 78% had
never had a previous AAD skin cancer screening
examination, and 60% had never had their skin
checked by any doctor, with 51% not even willing to
see a doctor unless the screening was offered at no
Thus, it will ultimately rely on the persons’ ability to
perform a sufficient SSE at home, in the hope that if
they do find a suspicious skin lesion, that they will
then be seen by their local dermatologist. Muhn et al69
artificially enlarged skin spots by 2 mm and 4 mm and
found that the sensitivity for self-detecting was 58%
and 75%, respectively, with an overall specificity of
62%. Epstein et al70demonstrated that earlier and
thinner melanomas were detected by physicians,
nearly 0.7 mm difference in thickness, when com-
pared with those detected by patients, spouses, or
family friends. Schwartz et al71found similar results,
with physician-detected melanoma (0.40 mm) show-
ing the thinnest lesions compared with either patient-
detected (1.17 mm) or spouse-detected (1.00 mm)
lesions. A recent study from 2005 to 2008 showed
56.3% of melanomas and 60% of melanoma in situ
were initially detected by dermatologists and were not
part of the presenting complaint.72
Interestingly, Losina et al1found that one-time
melanoma screenings of the general population were
shown to be cost effective when compared with other
cancer screening programs in the United States, with
one-time, once every 2 years, and annual skin cancer
screenings saving 2.5, 8.8, and 10.2 quality-adjusted
life years, respectively, per 1,000 people screened.
Despite current recommendations, many dermatolo-
gists continue to perform full-body skin cancer
screening on their patients, acknowledging that it is
a relatively no-risk, simple, cost-effective, and prac-
tical method for the early detection of nonmelanoma
and melanoma skin cancers.
Role of Total Body Photography
Total body photography (TBP) is used to sequen-
tially document the stability of skin lesions, detect
subtle changes in existing lesions, and to recognize
new lesions.73Additionally, TBP was shown to help
identify melanoma in its earlier stages and promote
continued surveillance of skin lesions via the patient
performing SSE. It is still utilized in many practices
today, and the most common reasons for its use are
for those patients with multiple (.5) atypical nevi,
reducing patient anxiety, and earlier detection of
melanomas, and that it leads to fewer biopsies. Feit
et al74reported on patients who were undergoing TBP
as part of their regular follow-up skin examinations,
showing that 74% of the melanomas detected were a
direct result of a noted subtle change on serial TBP.
Others have shown its role in increasing the rates and
compliance of SSE when the patients are actually
given the photographs to take home with them as part
of the SSE.75-78
Dermoscopy is a simple and inexpensive tech-
nique that permits the visualization of morphologic
characteristics that are not readily detectable with the
naked eye. It is a real-time, in vivo method for the
early detection of melanoma and other pigmented
skin lesions. It has been shown to improve diagnostic
sensitivity for melanoma by 10% to 27%.79Such
improvements in diagnosis are the result of incorpo-
rating the use of various scoring algorithms, based on
pattern analysis and pigmentary differences among
others. For example, the Board of the Consensus
Netmeeting on Dermoscopy in 2003 developed a 2-
step process for the classification of melanocytic from
nonmelanocytic skin lesions as well as a series of
algorithms to differentiate between benign, suspi-
cious, or malignant skin lesions.80These include
Volume 10, Number 2, Summer 2010 61
pattern analysis, ABCD rules of dermoscopy, Menzies
scoring method, and the 7-point checklist.
The 7-point checklist includes 3 major criteria
(atypical pigment network, blue-white veil, and atyp-
ical vascular pattern) and 4 minor criteria (irregular
streaks, irregular pigmentation, irregular dots and
globules, and regression structures). Blum et al81
developed a simplified and highly accurate dermo-
scopic point list for cutaneous melanocytic lesions to
diagnose a consecutive series of 269 melanocytic
lesions. Using their modified ABC-point list, which
was derived from the ABCD rule of Stolz, Menzies
score, and the modified ABCD rule of Kittler, they
achieved an overall sensitivity of 90.5%, specificity of
87%, and a diagnostic accuracy of 88.1% for the
diagnosis of melanoma. Overall, dermoscopy has
developed as a very useful tool for dermatologists as
a method of increasing the diagnostic accuracy of up
to 30% over clinical visual inspection.
Clinical Significance of Dysplastic Nevi
BK moles, Clark’s nevi, and atypical nevi are terms
that refer to lesions with specific clinical and patho-
logic characteristics associated with an increased risk
for the development of melanoma. These typically
become clinically apparent at puberty or adolescence
and continue to appear throughout life. Some clini-
cians have described patients having many nevi as
having ‘‘dysplastic nevus syndrome,’’ although the
classic definition refers to a patient with a triad of
.100 nevi, at least 1 nevi that is $8 mm in diameter,
and at least 1 nevus with clinically atypical features.
The clinical significance of dysplastic nevi is in their
association with the development of melanoma, with
an age-adjusted incidence of melanoma ,15 times
higher in those patients with dysplastic nevi versus
the general population (154 vs 10 per 100,000 person-
years).82This risk also increases as the total number
of dysplastic nevi increases and in the presence of a
personal or family history of melanoma. For instance,
there is a 100-fold increase in the incidence of
melanoma in patients who previously were diagnosed
with melanoma, a 200-fold increase in those with at
least 2 family members with melanoma, and a .1,200-
fold increase in those with both a personal history and
a family history of melanoma.82
There is continued controversy as to the appro-
priate clinical management of dysplastic nevi. Ac-
cording to the available evidence, it is not necessary
to confirm the diagnosis histologically.82,83Addition-
ally, despite the recognized association between
dysplastic nevi and the risk for developing melanoma,
the majority of dysplastic nevi will never progress to
melanoma.84For example, based on the assumption
that in a population of 10 million people, up to 20% of
all melanomas develop in contiguity with a dysplastic
nevus, it is estimated that only 1 in 10,000 dysplastic
nevi per year will progress to melanoma.85These
estimates underscore the argument against prophy-
lactic excision of dysplastic nevi as it is not cost
effective and can provide the patient with a false
sense of security, because an increased risk of
developing melanoma remains the same after these
nevi have been removed. In regard to the surveillance
and overall management of dysplastic nevi, there are
2 published sets of guidelines, one from the US
National Institutes of Health and the second from the
Melanoma Working Group in the Netherlands.
In conclusion, it is clear that UVR is the primary
culprit for the development of melanoma. The WHO
has again highlighted this important information for
the general public, thoroughly showing that UVR is
now considered a class I carcinogen, known to cause
cancer in humans. We must continue our educational
efforts to make the public aware of these dangers.
The early prevention of melanoma through education
of our youth will be essential if we are to have an
impact on lowering the incidence rates for melanoma.
Along these lines, parents must take personal
responsibility and oversight in order to prevent their
teenagers from using indoor tanning salons. As
physicians and health care providers, we must
actively become involved in the political process to
bring about change in current practices related to
indoor tanning. The early detection of melanoma must
continue with full-body skin examinations by derma-
tologists who can use other tools to enhance early
detection, such as full-body photography and dermos-
copy. Lastly, it is imperative that we continue the
community outreach efforts to increase the public’s
understanding of the eminent dangers of UVR overex-
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