Systematic underreporting of cutaneous malignant melanoma in Massachusetts. Possible implications for national incidence figures

Use and Costs of Sentinel Lymph Node Biopsy in Non-Ulcerated T1b Melanoma: Analysis of a Population-Based Registry

BACKGROUND

The utility of sentinel lymph node biopsy (SLNB) for non-ulcerated T1b melanoma is debated and associated costs are poorly characterized. Prior work using institutional registries may overestimate the incidence of nodal positivity in this population.

OBJECTIVE

The aim of this study was to estimate the use of SLNB, positivity prevalence, and procedural costs in patients with non-ulcerated T1b melanoma using a population-based registry.

METHODS

We identified patients with clinically node-negative, non-ulcerated melanoma 0.8-1.0 mm thick (T1b according to the 8th edition standard of the American Joint Committee on Cancer) in the Surveillance, Epidemiology, and End Results database from 2010 to 2016. The prevalence of SLNB procedures and positive sentinel nodes were calculated. Factors associated with SLNB and sentinel node positivity were assessed using logistic regression. Medicare reimbursement costs and patient out-of-pocket expenses for SLNB and wide local excision (WLE) versus WLE alone were estimated.

RESULTS

Among 7245 included patients, 3835(53%) underwent SLNB, 156 (4.1%, 95% confidence interval 3.5-4.7) of whom had a positive SLNB. Younger age, >1 mitosis per mm², female sex, and truncal tumor location were associated with higher odds of positivity. The estimated SLNB cost to identify one patient with stage III disease was $71,700 (range $54,648-$83,172). Out-of-pocket expenses for a Medicare patient were estimated to be $652 for a WLE and SLNB and $79 for a WLE alone.

CONCLUSIONS

In this population-based study, only 4% of selected non-ulcerated T1b patients had a positive SLNB, which is lower than prior reports. At the population level, SLNB is associated with high costs per prognostic information gained.

Trends in Melanoma Mortality in the Population Groups of South Africa

The incidence of cutaneous melanoma (CM) is increasing in countries around the world. However, little is known about melanoma trends in African countries by population group. We studied CM mortality in South Africa from 1997 to 2014 to partly address this knowledge gap. Unit record mortality data for all South Africans who died from CM (n = 8,537) were obtained from Statistics South Africa. Join-point regression models were used to assess whether there was a statistically significant change in the direction and/or magnitude of the annual trends in CM mortality. A significant increasing trend of 11% per year was observed in age-adjusted mortality rates in men between 2000 and 2005 (p < 0.01), rising from 2 to 3 per 100,000. There was also a statistically significant increase of 180% per year among White South Africans from 1997 to 1999 (p < 0.05) and of 3% from 1999 to 2014 (p < 0.01). These results may be used to inform CM awareness campaigns and will motivate efforts to improve the collection and analysis of relevant statistics regarding the present burden of CM in South Africa.

Comprehensive capture of cutaneous melanoma by the Ontario Cancer Registry: validation study using community pathology reports

Melanoma is often managed outside hospital settings, creating the potential for underreporting to cancer registries. To our knowledge, completeness of melanoma capture in cancer registries has not been assessed using external data sources since the 1980s. We evaluated the melanoma capture rate from 1993 to 2009 in a provincial cancer registry. We identified all melanoma diagnoses in pathology reports from a major community laboratory in Ontario, Canada. Pathologically confirmed diagnoses were linked to Ontario Cancer Registry (OCR) records using health insurance numbers. We calculated capture rates as the proportion of patients with melanoma confirmed by a pathology report, with a corresponding melanoma diagnosis in OCR. OCR captured 3,798 of 4,275 (88.8, 95 % confidence interval: 87.9, 89.8 %) invasive melanoma diagnoses over the 17-year period. Annual capture rates of 94 % or higher were found for over half the study period. Among all 29,133 melanoma diagnoses in OCR, 27.6 % were registered based on a pathology report alone, compared with 3.4 % for non-cutaneous malignancies. This suggests that comprehensive capture of melanoma cases by a provincial cancer registry is achievable using source data from community laboratories. There is a need for ongoing validation to ensure data remain accurate and complete to reliably inform clinical care, research, and policy.

Melanoma Incidence in Children and Adolescents: Decreasing Trends in the United States

OBJECTIVE

To assess trends in the incidence of melanoma in children and adolescents in the US from 2000-2010.

STUDY DESIGN

Using the Surveillance, Epidemiology, and End Results cancer registry data, we calculated age-adjusted incidence rates of melanoma in children and adolescents (age <20 years) from 2000-2010, as well as annual percent changes. We analyzed incidence trends using joinpoint regression models. We further stratified incidence rates and trends by age group, sex, race, and melanoma-specific characteristic (histology, anatomic site, Breslow depth, ulceration status, lymph node involvement, and presence of metastasis).

RESULTS

We included 1185 pediatric patients (age <20 years) diagnosed with melanoma from 2000-2010. In patients age <20 years overall, we found a significant decreasing incidence (11.58% per year) from 2004-2010. Overall, significant decreasing incidence trends were also noted in males, melanoma located on the trunk, melanoma located on the upper extremities, superficial spreading melanoma, and melanoma with good prognostic indicators. When further subdividing the pediatric population by age group, these significant decreasing incidence trends were most notable in adolescents (age 15-19 years), decreasing 11.08% per year from 2003-2010. Furthermore, in 15- to 19-year-olds, decreasing trends were found to be significant in melanoma located on the trunk, superficial spreading melanoma, and melanoma with good prognostic indicators.

CONCLUSIONS

Decreasing trends in melanoma incidence in the pediatric population from 2000-2010 stand in contrast to previous reports of increasing long-term incidence trends. Possible contributors to these decreasing trends include effective public health initiatives, decreased time spent outdoors, and increased sunscreen use.

Increasing incidence of melanoma among young adults: an epidemiological study in Olmsted County, Minnesota

OBJECTIVE

To identify the change in the incidence of cutaneous melanoma over time among young adults.

PATIENTS AND METHODS

Using Rochester Epidemiology Project data, we identified patients aged 18 to 39 years who had a first lifetime diagnosis of melanoma from January 1, 1970, through December 31, 2009, in Olmsted County, Minnesota. Demographic and clinical information, including survival, was abstracted, and estimates of the incidence of melanoma and overall and disease-specific survival were generated.

RESULTS

From 1970 to 2009, the incidence of melanoma increased by 8-fold among young women and 4-fold among young men. Overall and disease-specific survival seemed to improve over time; hazard ratios comparing year of diagnosis with mortality were 0.92 and 0.91, respectively.

CONCLUSION

The incidence of cutaneous melanoma among young adults is rapidly increasing, especially among women. Continued close monitoring of this high-risk population is necessary.

Incidence of cancer in the general population and in patients with or without atopic dermatitis in the U.K

BACKGROUND

Atopic dermatitis (AD) affects approximately 20% of children and 1-3% of adults in developed countries.

OBJECTIVE

To study the incidence of cancer in patients with AD in the U.K. general population.

METHODS

We conducted a follow-up study in the U.K. using The Health Improvement Network (THIN) database. We calculated the incidence rate (IR) of the first occurrence of overall cancer, lymphoma, melanoma and nonmelanoma skin cancer (NMSC) in the general population, in patients with AD and in individuals without AD. In addition we calculated the IR ratio (IRR) of overall cancer and subtypes of cancer in patients with AD vs. those without.

RESULTS

The study population included 4,518,131 patients [2,336,230 (51·7%) female]. There were 129,972 subjects [68,688 (52·8%) female] with a diagnosis of cancer (excluding NMSC). The IR (per 10,000 person-years) of cancer (excluding NMSC) was 42·41 [95% confidence interval (CI) 42·18-42·64]; of lymphoma 1·70 (95% CI 1·65-1·74); of skin melanoma 1·71 (95% CI 1·67-1·76) and of NMSC 11·76 (95% CI 11·64-11·88). The age- and sex-adjusted IRR for cancer (excluding NMSC) was 1·49 (95% CI 1·39-1·61); for lymphoma 2·21 (95% CI 1·65-2·98); for melanoma 1·74 (95% CI 1·25-2·41); and for NMSC 1·46 (95% CI 1·27-1·69).

CONCLUSIONS

Our results indicate an increased incidence of cancer overall as well as of specific cancer subtypes, including lymphoma, in patients with AD. Further studies are needed to disentangle the effects of treatment for AD from AD itself.

Kinetic model of progression of cutaneous melanoma population

A kinetic model for progression of a population of cutaneous melanomas through categories defined by the range of Breslow thickness, with melanomas in situ (MIS) in category 0, and melanomas with Breslow thickness > or =2 mm in category 3, is described. The model assumes that all melanomas start out in category 0; this category is further subdivided into indolent and progressing melanomas. Steady-state solutions for the distributions of excised melanomas were found. Depending on the proportion of indolent MIS, these solutions predict very different distributions of excised melanomas and melanoma mortality, when either frequency of examinations by physicians or sensitivity to melanoma is changed. Although it is not currently possible to differentiate between indolent and progressing MIS either clinically or histologically, solutions of this kinetic model can be used to determine the proportion of such indolent lesions in a population-based study. The steady-state solutions of the kinetic model can be used to analyze melanoma progression in any stable patient population, in which the total number of melanomas detected per year is either stable or varies slowly. As an example, melanoma progression is analyzed using the American Cancer Society estimates of melanoma incidence and mortality. For a fixed incidence rate, melanoma mortality and melanoma treatment cost in the USA could be significantly reduced by increasing the biopsy sensitivity of physicians to in-situ and thin-invasive melanomas.

The geographic distribution of melanoma incidence in Massachusetts, adjusted for covariates

Background

The aims of this study were to determine whether observed geographic variations in melanoma cancer incidence in both gender groups are simply random or are statistically significant, whether statistically significant excesses are temporary or persistent, and whether they can be explained by risk factors such as socioeconomic status (SES) or the percent of the population residing in an urban rather than a rural area. Between 1990 and 1999, 4774 female and 5688 male melanomas were diagnosed in Massachusetts residents. Cases were aggregated to census tracts and analyzed for deviations from random occurrence with respect to both spatial location and time.

Results

Thirteen geographic areas that deviated significantly from randomness were uncovered in the age-adjusted analyses of males: five with higher incidence rates than expected and eight lower than expected. In the age-adjusted analyses of females, six areas with higher incidence rates and eight areas with lower than expected incidence rates were found. After adjustment for SES and percent urban, several of these areas were no longer significantly different.

Conclusion

These analyses identify geographic areas with invasive melanoma incidence higher or lower than expected, the times of their excess, and whether or not their status is affected when the model is adjusted for risk factors. These surveillance findings can be a sound starting point for the shoe-leather epidemiologist.

Population-based analysis of lymphatic mapping and sentinel lymphadenectomy utilization for intermediate thickness melanoma

BACKGROUND AND OBJECTIVES

Lymphatic mapping and sentinel lymphadenectomy (LM/SL) is the nodal staging procedure of choice for patients with intermediate thickness melanoma. We hypothesize that a significant portion of these patients are not undergoing LM/SL. We explore factors that influence use of LM/SL.

METHODS

Analysis was performed of all incident cases of invasive cutaneous melanoma in North Carolina between January 1, 1999 and December 31, 2001.

RESULTS

Three thousand four hundred and thirty-six cases of melanoma were reported for 1999-2001. Two hundred and seventy-three cases (8%) were excluded due to metastases. Nine hundred and sixteen cases (29%) were excluded because the T classification was not reported. Of the remaining cases, 1,242 (55%) were intermediate thickness (T2-3); 48% (596/1,242) underwent LM/SL. Subjects >or=60 years old were less likely to receive LM/SL than subjects <60 years (39% vs. 55.4%, P < 0.001). Subjects with head/neck primary tumors were less likely to receive LM/SL than other subjects (33% vs. 51%, P < 0.001). Subjects with T3 tumors were more likely to receive LM/SL than those with T2 tumors (54% vs. 42%, P < 0.001).

CONCLUSIONS

Half of all patients with intermediate thickness melanoma in North Carolina do not receive LM/SL. Use of LM/SL varies by patient age and primary tumor site. Further investigation is warranted to explore these differences.

Reporting cutaneous melanoma to cancer registries in the United States

BACKGROUND

Central cancer registries provide data to monitor incidence rates of cutaneous melanoma.

OBJECTIVE

The aim of this study was to assess the completeness of melanoma reporting in the United States.

METHODS

Data provided by central cancer registries were used to calculate age-adjusted, average annual incidence rates and were compared by time period (1992-1994, 1995-1997), stage, and program (Surveillance Epidemiology and End Results [SEER] and National Program of Cancer Registries [NPCR]). Completeness was measured with incidence/mortality ratio.

RESULTS

Incidence rates among whites for 1995-1997 from SEER registries ranged from 11.8 to 33.9 per 100,000 population; 18 of 40 NPCR registries were within this range. For 1992-1994, 8 of 30 NPCR registries were within the range of SEER incidence rates. NPCR registry incidence rates were generally higher for 1995-1997 than 1992-1994. The percentage of cases of localized melanoma did not increase substantially in most SEER registries over the study period, but some NPCR registries had substantial increases. Among NPCR registries that had incidence rates comparable with those of SEER in 1995-1997, the incidence/mortality ratios were generally lower among NPCR registries than SEER registries.

CONCLUSION

Although melanoma incidence rates are generally increasing, part of the increases in incidence rates reported by NPCR registries over the study time period are likely due to increased case ascertainment and reporting.

The systematic relationship between melanomas diagnosed in situ and when invasive

The Surveillance, Epidemiology and End Results (SEER) Program of the US National Cancer Institute has provided population-based, histologically confirmed incidence data for melanomas restricted to the epidermis (in situ) and invasive melanomas for representative areas of the US for the years 1975 to 1997. The incidence of in situ melanomas has increased more rapidly than that for invasive melanoma, but both appear to conform to the birth-cohort pattern. As both changed from year to year, the incidence of melanoma in situ and invasive melanoma at the time of diagnosis were linked by simple proportional relationships. The ratio of in situ to invasive tumours was similar in males and females, suggesting that the generally better female prognosis develops once the tumour has spread into the dermis. Across the age groups, the patients with in situ tumours were older than those with invasive tumours. This suggests slower growth, while histological confirmation of the diagnoses and the precise linkage between the incidence rates for in situ and invasive melanomas implies a close biological connection between tumours that progress and those that do not. Study of the in situ tumours could reveal what was holding them back.

Malignant melanoma in South Wales: changing trends in presentation (1986-98)

In 1990 we reported the trends in presentation of malignant melanoma (MM) from 1986 to 1988 in a defined population in South Wales. Ten years after this initial study we reassessed the incidence of invasive MM in this defined population over a similar 3 year period. Using the local skin cancer registry we identified 186 cases of MM representing a 74% increase. Age standardization to the world population gives an overall incidence of 11.8 per 100 000 population per annum. This is the highest published standard incidence of MM to date from the UK and certainly one of the highest in Europe. We also have observed a continuing trend for diagnosis of thinner lesions with a better prognosis. Information about mortality for the whole of Wales over the corresponding period is also presented.

Recent trends in cutaneous melanoma incidence among whites in the United States

BACKGROUND

It is not yet clear whether increasing melanoma incidence is real or whether recent incidence trends mainly reflect improved diagnosis. To address this question, we examined the most recent melanoma incidence patterns among the white population stratified by sex, age, tumor stage, and tumor thickness by use of data from the Surveillance, Epidemiology, and End Results Program.

METHODS

We examined log-transformed age-specific rates for melanoma by 5-year age groups and time periods by year of diagnosis and birth cohort. Melanoma trends were further examined among broader age groups (<40 years, 40-59 years, and > or =60 years) by tumor stage and tumor thickness. Rates were age-adjusted to the 1970 U.S. standard population, and trends were tested by use of a two-sided Student's t test.

RESULTS

Melanoma incidence increased in females born since the 1960s. From 1974-1975 through 1988-1989, upward trends for the incidence of localized tumors and downward trends for the incidence of distant-stage tumors occurred in the age group under 40 years. In the more recent time period, 1990-1991 through 1996-1997, age specific rates among females compared with males generally remained stable or declined more for distant-stage tumors and increased less for local-stage tumors. Thin tumors (<1 mm) increased statistically significantly in all age groups (P<.05 for all), except in men under age 40 years. In contrast, rates for thick tumors (> or =4 mm) increased statistically significantly (P =.0003) only in males aged 60 years and older.

CONCLUSION

Melanoma incidence may well continue to rise in the United States, at least until the majority of the current population in the middle-age groups becomes the oldest population. The recent trends may reflect increased sunlight exposure.

Cancer surveillance series: changing patterns of cutaneous malignant melanoma mortality rates among whites in the United States

BACKGROUND

Mortality from melanoma among whites is still increasing in the United States. In this study, we describe the changing patterns of melanoma mortality rates among whites by demographic factors and geography and further assess the relationship between the geographic patterns and the UV radiation (UV-B) level.

METHODS

Age-adjusted incidence and mortality rates were computed by use of the 1970 U.S. population standard. Annual percent changes of mortality were estimated by fitting regression lines to the logarithm of rates. The relationships between melanoma mortality rates and UV-B level over time were assessed by weighted regressions. All statistical tests were two-sided.

RESULTS

From 1950-1954 through 1990-1994, melanoma mortality rates increased by 191% and 84% among males and females, respectively. Mortality rates peaked in the 1930 through 1950 birth cohorts for females and in the 1935 through 1950 birth cohorts for males. In the 1950 through 1969 study period, melanoma mortality rates showed a strong North-South gradient, but the gradient weakened in recent periods. The absolute change in mortality for a 10% increase in UV-B among females decreased from 0.08 additional deaths per 100 000 person-years in 1950-1959 to 0.01 additional deaths in 1990-1995. In contrast, the absolute change in mortality among males showed little change over time; additional deaths increased from 0.11 to 0.12 per 100 000 person-years.

CONCLUSIONS

Melanoma mortality in the United States reflects the complex interplay of UV radiation levels in each geographic region, the sun-protection behaviors of each generation of males and females in childhood and adulthood, the geographic mobility of the population, and the risk awareness and early detection.

Update on the incidence and mortality from melanoma in the United States

BACKGROUND

Increases in the incidence of malignant melanoma have been among the largest of all cancers in the United States.

OBJECTIVE

We report updated trends in melanoma rates among the US white population.

METHODS

Incidence and mortality rates were calculated for 1973 to 1994. Trends were examined with stratification by state, age, and sex, and by anatomic site, stage, and melanoma thickness at diagnosis.

RESULTS

Melanoma incidence and mortality rates increased dramatically from 1973 to 1994, rising 120.5% and 38.9%, respectively. In recent years, however, rates for most age-sex groups appeared to stabilize or even decline. Male patients continued to have higher incidence and mortality rates than female patients, but for both male and female patients the largest increases by site were for the trunk. A large proportion of melanomas were detected in the local stage and with a thickness less than 0.75 mm.

CONCLUSION

Prevention of sun exposure is recommended to reverse the high incidence rates of melanoma.

Issues in the epidemiology of melanoma

Malignant melanoma imposes a considerable public health burden. Both incidence and mortality have increased many fold over the past several decades, although current trends suggest possible change in the prior patterns. Etiologic factors have been established, of which the most important is intense sun exposure. Primary prevention and early detection are both potentially critical in reducing the burden of melanoma. Much remains to be clarified in our management of this disorder on a population basis, and methodologic difficulties are plentiful. The potential for substantial reductions in melanoma mortality requires that we address the difficulties so that maximally effective public health initiatives may be undertaken.

Assessing incidence rates and secular trends in nonmelanocytic skin cancer: which method is best?

BACKGROUND

Evaluating the incidence of nonmelanocytic skin cancers in white populations and assessing the direction and strength of secular trends in these cancers have become important issues to dermatologists, oncologists, health policy analysts, and health care funders.

OBJECTIVE

The objective of this paper is to evaluate the three principal methods used to assess incidence rates and secular trends.

CONCLUSIONS

Each of the three methods has strengths and weaknesses. An understanding of these will enable proper assessment of the value and significance of findings presented in the literature.

The multidisciplinary melanoma clinic: a cost outcomes analysis of specialty care

The traditional process of melanoma care delivery can differ substantially among providers regarding screening laboratories, staging work-ups, surgical margins, and outpatient versus inpatient surgical management. It has been suggested that multidisciplinary care may provide a more cost-effective management approach. We sought to evaluate whether coordinated multidisciplinary melanoma care that follows evidence-based, consensus-approved clinical practice guidelines at a large academic medical center can provide a more efficient alternative to traditional community-based strategies with clinical outcomes that are at least equivalent. The University of Michigan Multidisciplinary Melanoma Clinic (MDMC) possesses a database of demographic, clinical, and treatment information for all patients seen since its inception. A consecutive sample of 104 patients with local disease who were treated in the Michigan community were compared with 104 blindly selected subjects treated at the MDMC during an identical time period, matched for Breslow depth and melanoma body site. Patients treated in the MDMC would save a third party payer roughly $1600 per patient when compared with a similar group treated in the Michigan community. Surgical morbidity, length of hospitalization, and long-term survival of MDMC patients were similar to those reported in the literature. The cost discrepancy is explained by the fundamental differences in the usage pattern of health care resources exhibited by the MDMC compared with the community setting.

The independent pathology laboratory as a reporting source for cutaneous melanoma incidence in Iowa, 1977-1994

BACKGROUND

Health care changes during the past decade have resulted in a greater proportion of cutaneous melanoma (CM) cases diagnosed in nonhospital settings, increasing the potential for cases to be missed by population-based cancer registries.

OBJECTIVE

Our purpose was to assess changes in case-finding sources in Iowa from 1977 to 1994 and to determine the extent of underreporting for the State Health Registry of Iowa, a population-based cancer registry.

METHODS

This study examines changing trends in the incidence of CM and compares case-finding sources (hospitals/clinics, hospital pathology laboratories, and independent pathology laboratories). A survey of dermatologists serving Iowans provides estimates of underreporting.

RESULTS

During the period 1977 to 1994, invasive CM increased 82%, whereas in situ CM increased 900%. The proportion of CM cases diagnosed in independent pathology laboratories increased to 25% of all cases. A range of 10.4% to 17.1% underreporting was estimated based on the survey of dermatologists.

CONCLUSION

To improve the accuracy of surveillance, population-based cancer registries need to make a greater effort accessing pathology reports from nonhospital settings.

Malignant melanoma: incidence issues and their effect on diagnosis and treatment in the 1990s

The incidence of melanoma is increasing at a rate faster than that for any other cancer in the United States and worldwide. Several factors show that this increase in incidence is real and not due to artifact. The rapid increase is not attributable to better overall counting of the cases of cancer (because the incidence of other cancers is decreasing). Furthermore, it is not due to changes in histologic criteria. Finally, the mortality rate from melanoma continues to increase at a time when survival rates are also increasing. This apparent paradox can be true only if the actual incidence is increasing at an even faster rate than the death rate. This dramatic increase in the incidence of melanoma highlights the need for improved methods of prevention, diagnosis, and treatment as melanoma becomes increasingly important as a public health issue.

Full proceedings from the National Conference to Develop a National Skin Cancer Agenda. American Academy of Dermatology and Centers for Disease Control and Prevention, Washington, D.C., April 8-10, 1995

National efforts to reduce skin cancer incidence and mortality require scientifically coordinated efforts. This report summarizes the first American Academy of Dermatology/Centers for Disease Control and Prevention national conference to develop a skin cancer agenda. Leading experts in dermatology, public health, medicine, health education, nursing, behavioral sciences, environmental health and epidemiology identified and prioritized skin cancer control issues in five key areas. Discussion centered around strategies for reducing UV exposure and increasing public and professional awareness of skin cancer. Panelists in five sessions developed consensus on several public and professional recommendations and a series of research strategies.

The incidence of malignant melanoma in the United States: issues as we approach the 21st century

The risk of malignant melanoma developing in an American in the United States has now reached 1 in 87 (up more than 1800% since the 1930s). This rising incidence of malignant melanoma is, in fact, real because (1) it is not due to increased surveillance; (2) it is not due to better cancer-counting methods in general; (3) it is not due to changes in histologic diagnostic criteria; (4) it is being noted worldwide; and (5) most importantly, despite rising survival percentages, the mortality rate from malignant melanoma also continues to rise. On the basis of these trends, incidence rates for malignant melanoma will continue to rise for at least the next 10 to 20 years, although the demographics of those affected may change. Effective programs to improve public and professional education must be developed to enhance early clinical detection and behavioral changes. An establishment of a National Melanoma Registry is needed to more effectively assess the magnitude and impact of future incidence and the success of prevention program efforts into the next century.

False-negative findings in skin cancer and melanoma screening

BACKGROUND

Few data are available on the accuracy of visual skin examination by dermatologists as a skin cancer and melanoma screening tool.

OBJECTIVE

The purpose of this study was to assess the number of false-negative findings in a skin cancer-melanoma screening program.

METHODS

We obtained follow-up information regarding 1551 persons with a negative screening result in a skin cancer-melanoma screening program in 1990. Follow-up was established by record linkage with two different population-based registries.

RESULTS

Fifteen persons had new skin cancers. Three of their lesions had been present at the original screening and had probably been missed; 12 were genuinely new. No melanomas were among the missed cases. The calculated sensitivity of the screening was 93.3%, its specificity was 97.8%, its positive predictive value was 54.0%, and its negative predictive value was 99.8%.

CONCLUSION

Visual examination by dermatologists as a screening tool for skin cancer and melanoma is appropriate.

An estimate of the incidence of malignant melanoma in the United States. Based on a survey of members of the American Academy of Dermatology

BACKGROUND

The incidence of malignant melanoma (MM) in the United States (US) must be known to accurately evaluate the costs that MM imposes on the health care system and society in general. Furthermore, knowledge of the incidence is needed to determine the benefit of MM prevention programs.

OBJECTIVE

To obtain an estimate of the incidence of MM in the US.

METHODS

The data for this study were collected by means of a questionnaire that was sent to all members of the American Academy of Dermatology practicing in the US (N = 7412).

RESULTS

Based on the mean number of MMs seen annually per dermatologist in each state and the number of dermatologists per state, the number of new in situ and invasive MMs in the US in 1992 was calculated to be 80,000. This translates to an incidence of 32 MMs per 100,000 persons.

CONCLUSIONS

Our estimate of 80,000 new MMs diagnosed in 1992 in the US suggests that MM places much greater burdens on the US health care system and society than that based on current published estimates.

The early detection of and screening for melanoma. International status

Cutaneous melanoma is an increasingly common public health problem in industrialized nations. In theory, education and early detection should decrease melanoma morbidity and mortality, because the lesion is external and visible, risk factors are known, and thin tumors are associated with a high 5-year survival rate. The efficacy of early detection and screening programs, however, remains untested by randomized trials. Some early data are available from melanoma prevention and control efforts that have begun in many nations over the past decade. Textbook definitions of cancer screening are particularly challenging when applied to skin cancer control. Although some propose that there are rigid differences among screening, education, and early detection of skin cancer, the visible nature of this cancer makes early detection through education and screening inextricably intertwined. This article discusses the intermediate measures of education and screening within the context of the American Academy of Dermatology programs. Over the next few decades, screening and education for melanoma and other skin cancer will receive increasing worldwide attention. Multiple strategies will be required to combat increasing incidence and mortality rates. Screening and educational programs have been implemented worldwide, but data on their effects are only just being collected. Future collaborative work in melanoma/skin cancer prevention, education, and early detection holds promise as a way to decrease mortality and save lives.

Skin cancer. Melanoma and other specific nonmelanoma skin cancers

BACKGROUND

Malignant melanoma accounts for most of the growing mortality from skin cancer. However, survival rates are increasing for individual cases, probably because of earlier diagnoses.

METHODS

Skin cancers collected by the SEER population-based data base between 1973 and 1987 are described in terms of their histologic classification and their distribution by sex, race, anatomical location, geographic locality, and time period of occurrence.

RESULTS

There were 30,519 invasive skin cancers in the 15-year reporting period. Because the common basal cell and squamous cell cancers are not reportable to SEER, most of the cancers (28,206) were melanomas. In addition, 4386 in situ melanomas were reported. The rate of melanoma was 13-fold higher in whites than in blacks and 29% higher in white males than in white females. There was a 52% increase in the age-adjusted incidence rate for invasive melanoma and a 600% increase in the incidence rate of in situ melanoma over the 15-year period for whites and a 12% decrease in the incidence rate of invasive melanoma in blacks. The incidence of melanoma in the ear and trunk predominated in males, whereas melanoma of the lower limb predominated in females. Incidence rates and rate of increase of incidence of melanoma varied by anatomical subsite, sex, and geographic location within the United States.

CONCLUSIONS

The variations among incidence rates of melanoma by sex, subsite, race, geographic location, and time period support prevailing theories of a solar cause for most but not all cases of this disease. Although melanoma rates are rising overall, the disproportionate rise in the rate of diagnosis of in situ compared with invasive melanoma suggests that melanomas are being diagnosed earlier.

Melanoma and sunburn

A computer-aided search identified 16 case-control studies which specifically assessed sunburn as a risk factor for cutaneous malignant melanoma. Using unadjusted estimates, a history of sunburn was associated with significantly increased risk of melanoma in all but one study. Four studies were defined as core studies after assessment of study quality; however, only two of these had sufficiently similar definitions of sunburn to allow pooling of results. Using pooled data, the risk of melanoma in those ever sunburned was 2.0 (95 percent confidence interval [CI] = 1.6-2.6), while the highest category of sunburn exposure had a risk of 3.7 (CI = 2.5-5.4). The suggestion that sunburns in childhood carry greater risk of melanoma cannot be supported by pooled analysis. This review demonstrated considerable variation in design and method among the studies, and identified sources of bias which prevented a pooled analysis using all available data. The need for strong epidemiologic evidence relating sunburn to melanoma, particularly in childhood, is of prime importance, since avoidance of sunburn is one of the few potential means of primary prevention of melanoma.

Melanoma: linked temporal and latitude changes in the United States

The rise in the incidence and mortality from melanoma of the skin is slowing down in younger age groups in the United States. In many White populations, including that of the US, melanoma incidence and mortality rates increase according to proximity of residence to the Equator. Variations with age in this gradient do not seem to have been examined. We examined how the influence of latitude on melanoma rates varied with age. Estimates of age-specific trends by time and by latitude for natural logarithm (Ln) melanoma incidence-rates from the Surveillance, Epidemiology and End Results (SEER) programs, and Ln melanoma mortality rates from the US Vital Statistics were derived from fitted regression equations. Unexpectedly, a decline from old age to youth in the influence of latitude was found for both incidence and mortality from melanoma of the skin in males, and for mortality in females. Further, these changes in the relationship to latitude with age correlated with the changes in time trends with age. The link with exposure suggests that the time trends in melanoma are driven by variations in damage to melanocytes in early life that increases sensitivity to sunlight. This has implications for the general understanding of melanoma etiology and for health education.

Cutaneous melanoma at Lawrence Livermore National Laboratory: comparison with rates in two San Francisco bay area counties

During the period 1974 through 1985, employees at Lawrence Livermore National Laboratory (LLNL), Livermore, CA (United States) were diagnosed with cutaneous malignant melanoma at approximately three times the rate of the surrounding community. We investigated two explanations for this excess: the first explanation examined was that the recorded incidence of the neighboring community underestimates actual incidence. We estimated the amount of excess attributable to underreporting by using data from a survey conducted among San Francisco Bay Area clinicians and pathologists to determine previously unrecorded occurrences. We found that underreporting has negligible impact on melanoma incidence. The second explanation examined was that heightened medical awareness of the disease among LLNL employees and their physicians has led to greater detection. We found that LLNL melanomas are thinner than those from the surrounding community and that no excess was observed if we limited our attention to thicker, more invasive melanomas.

The detection and management of dysplastic nevi and early melanoma

Worldwide, the incidence and mortality rates for melanoma are increasing at an alarming rate. Recently, the recognition of dysplastic nevi as markers and potential precursors for melanoma has identified one group of individuals with an increased risk to develop this disease. Close surveillance of these individuals should improve the ability of clinicians to detect melanoma at an early stage when surgical excision of the primary tumor is curative in the majority of patients.

Histologic evaluation of pigmented lesions in Connecticut and its influence on the reporting of melanoma

BACKGROUND

Underreporting of melanoma to state tumor registries has been identified as a problem in gathering accurate statistics on melanoma incidence.

OBJECTIVE

Our purpose was to examine two factors that could influence the reporting of melanoma to the Connecticut Tumor Registry: histologic diagnosis of melanoma in the private offices of dermatologists and histologic diagnosis of melanoma in out-of-state laboratories.

METHODS

From December 1990 to April 1991, questionnaires were sent to all known practicing dermatologists in the state of Connecticut (N = 149). Of the 127 dermatologists who were eligible, 124 (97.6%) completed the survey.

RESULTS

The estimated number of melanomas diagnosed in private offices during 1990 was 9 to 18; this was based on the number of dermatologists who officially read their own slides (n = 19), the estimated number of melanomas diagnosed by these 19 dermatologists (n = 91), and the percentage of melanomas and uncertain pigmented lesion cases sent for consultation (80% to 90%). According to the estimates of Connecticut dermatologists, out-of-state laboratories diagnosed 84 of 523 melanomas (16%) in Connecticut residents.

CONCLUSION

The diagnosis of melanoma in private offices did not appear to be a significant factor in underreporting whereas the diagnosis of melanoma in out-of-state laboratories did appear to be more significant. However, the possibility exists that some of these latter melanomas would eventually be reported at the time of reexcision.