The lower incidence of melanoma in women may be related to increased preventative behaviors

Does sex matter? Analysis of sex-related differences in the diagnostic performance of a market-approved convolutional neural network for skin cancer detection

BACKGROUND

Advances in biomedical artificial intelligence may introduce or perpetuate sex and gender discriminations. Convolutional neural networks (CNN) have proven a dermatologist-level performance in image classification tasks but have not been assessed for sex and gender biases that may affect training data and diagnostic performance. In this study, we investigated sex-related imbalances in training data and diagnostic performance of a market-approved CNN for skin cancer classification (Moleanalyzer Pro®, Fotofinder Systems GmbH, Bad Birnbach, Germany).

METHODS

We screened open-access dermoscopic image repositories widely used for CNN training for distribution of sex. Moreover, the sex-related diagnostic performance of the market-approved CNN was tested in 1549 dermoscopic images stratified by sex (female n = 773; male n = 776).

RESULTS

Most open-access repositories showed a marked under-representation of images originating from female (40%) versus male (60%) patients. Despite these imbalances and well-known sex-related differences in skin anatomy or skin-directed behaviour, the tested CNN achieved a comparable sensitivity of 87.0% [80.9%-91.3%] versus 87.1% [81.1%-91.4%], specificity of 98.7% [97.4%-99.3%] versus 96.9% [95.2%-98.0%] and ROC-AUC of 0.984 [0.975-0.993] versus 0.979 [0.969-0.988] in dermoscopic images of female versus male origin, respectively. In the sample at hand, sex-related differences in ROC-AUCs were not statistically significant in the per-image analysis nor in an additional per-individual analysis (p ≥ 0.59).

CONCLUSION

Design and training of artificial intelligence algorithms for medical applications should generally acknowledge sex and gender dimensions. Despite sex-related imbalances in open-access training data, the diagnostic performance of the tested CNN showed no sex-related bias in the classification of skin lesions.

Sex matters: men with melanoma have a worse prognosis than women

BACKGROUND

In Europe, one of the highest melanoma incidences is found in the Netherlands. Like in several other European countries, females are more prone to develop melanoma as compared to males, although survival is worse for men.

OBJECTIVE

To identify clinicopathological gender-related differences that may lead to gender-specific preventive measures.

METHODS

Data from the Dutch Nationwide Network and Registry of Histopathology and Cytopathology (PALGA) were retrieved from patients with primary, cutaneous melanoma in the Netherlands between 2000 and 2014. Patients initially presenting as stage I, II and III without clinically detectable nodal disease were included. Follow-up data were retrieved from the Netherlands Cancer Registry. Gender-related differences were assessed, and to compare relative survival between males and females, multivariable relative excess risks (RER) were calculated.

RESULTS

A total of 54.645 patients were included (43.7% men). In 2000, 41.7% of the cohort was male, as compared to 47.3% in 2014 (P < 0.001). Likewise, in 2000, 51.5% of the deceased cohort was male compared to 60.1% in 2014 (P < 0.001). Men had significantly thicker melanomas at the time of diagnosis [median Breslow thickness 1.00 mm (interquartile range (IQR): 0.60-2.00) vs. 0.82 mm (IQR: 0.50-1.50) for females] and were significantly older at the time of diagnosis, more often had ulcerated melanomas and melanomas localized on the trunk or head and neck. Over time, survival for females improved while that of men decreased (P < 0.001). RER for dying was 1.37 (95% CI: 1.31-1.45) for men in multivariable analysis.

CONCLUSION

There are evident clinicopathological differences between male and female melanoma patients. After multivariable correction for all these differences, relative survival remains worse for men. Clinicians as well as persons at risk for melanoma should be aware of these differences, as awareness and prevention might lead to a lower incidence and mortality of melanoma. This indicates the need of prevention campaigns integrating and targeting specific risk profiles.

Awareness, behavior and attitudes concerning sun exposure among beachgoers in the northern coast of Peru

Background

Skin cancer incidence has increased over the last years, becoming a major public health problem.

Objective

To describe the awareness, behavior and attitudes concerning sun exposure among beachgoers in the northern coast of Peru.

Methods

We conducted a cross-sectional study in the Pimentel beach, Peru. The “Beach Questionnaire” was used and we surveyed all the beachgoers from 8 a.m. to 4 p.m. and from March 5 to March 19. For the statistical analysis, sun exposure habits, sunburns history, knowledge, attitudes and practices were crossed with sex using the chi2 test.

Results

We surveyed 410 beachgoers, the most frequent phototype was type III (40.5%). Only the 13.66% of the respondents correctly answered the seven knowledge questions related to sun exposure and skin cancer. Men more frequently agreed that “when they are tanned their clothes looks nicer” (p = 0.048). Likewise, regarding the questions “Sunbathing is relaxing” and “Sunbathing improves my mood”, men agreed or totally agreed with more frequency than women (63.64% vs. 46.15%, p < 0.001; and 61.36% vs 49.15%, p = 0.014, respectively). Regarding sun protection practices, women more frequently used sunshade (p = 0.001) and sunscreen (SPF ≥ 15) (p < 0.001) when compared to the male group.

Conclusion

Sun exposure is a potentially preventable risk factor for skin cancer. Thus, awareness of the risks of UVR overexposure and adequate sun-protective behaviors and attitudes are essential. Our results, however, are not as favorable as expected. Public health efforts should encourage sun-safety precautions and intervention campaigns should be carried out in recreational settings, such as the beaches.

Gender aspects of recreational sun-protective behavior: results of a representative, population-based survey among Austrian residents

PURPOSE

Lifetime risk for melanoma skin cancer is enlarged by sunlight exposure and reduced by sun protection. Austrian melanoma incidence and mortality rates are constantly rising with higher rates in males. Thus, we aimed at investigating gender-specific recreational sun exposure habits among the Austrian population.

METHODS

We conducted a telephone survey among 1500 adults (50.5% females) representing sociodemographic characteristics of the Austrian population. Using a structured questionnaire, we studied gender-specific sun exposure-related knowledge, motives to tan, and behavior.

RESULTS

Overall, using sunscreen, wearing sunglasses, and seeking shade were among the three most frequent sun safe measures. Basic skin health knowledge and tanning motives were similar among genders, although females protected themselves more. In general, sunburn occurrence (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.0-1.8), skin type IV (OR = 2.4, 95% CI = 1.3-4.5), ex-/non-smoking (OR = 1.4-1.6, 95% CI = 1.0-2.1), low motives to tan (both OR = 1.3, 95% CI = 1.0-1.7), no outdoor sport (OR = 1.3, 95% CI = 1.0-1.7), all P < 0.05, as well as the use of sunscreen with lower SPF values (OR = 1.0-3.0, 95% CI = 1.4-4.3) and male gender (OR = 1.6, 95% CI = 1.2-2.0), both P < 0.001, increased the odds of practicing low sun protection.

CONCLUSION

The results of this investigation suggest considering gender specificity when planning Public (Skin) Health-related educative campaigns and programs, for example, by highlighting the appearance-related benefits of sun light avoidance.

Tanning beds: A call to action for further educational and legislative efforts

BACKGORUND AND OBJECTIVES

Melanoma is steadily increasing over the past decade. Recent studies confirmed a link between tanning bed use and melanoma. We sought to determine the prevalence and frequency of tanning bed among young patients with melanoma.

METHODS

We retrospectively analyzed tanning bed use among young melanoma patients compared to controls selected from the hospital medical records. A telephone survey investigated family history of melanoma or skin cancer, hair color, eye color, skin type, tanning bed use, and patient awareness of dangers of tanning bed use.

RESULTS

A total of 601 melanoma cases were identified; 265 (44%) completed the telephone survey as did 195 (31%) controls. Of these 460 subjects, 260 were female. Females were 3.0 times more likely to have used a tanning bed. Melanoma patients had natural light color hair, blue-green eyes, and 2.0 times more likely to use a tanning bed than controls. Among the tanning bed users, 90% were aware of danger of tanning bed.

CONCLUSIONS

Our study found that tanning beds were more likely to be used by young women, the majority of whom are aware of the associated risks. Eliminating the use of tanning beds should be considered to decrease the incidence of melanoma.

Trends of keratinocyte carcinoma mortality rates in the United States as reported on death certificates, 1999 through 2010

BACKGROUND

From 1969 to 1998, keratinocyte carcinoma (KC) mortality rates declined as reported on death certificates, despite increasing incidence of KC.

OBJECTIVE

To estimate KC mortality trends from 1999 to 2010 in the United States.

METHODS

Descriptive and linear regression analysis using population-based death certificate data from the US National Center for Health Statistics.

RESULTS

On average, 1,491 deaths from nongenital KC and 1,058 deaths from genital KC were reported annually. Keratinocyte carcinoma mortality rates were stable or increasing over the study period. Highest nongenital mortality rates were seen in those older than 85 years (p < .001), men (p < .001), whites (p < .001), the South for white males (p = .001) and white females (p = .018), and nonmetropolitan areas for white males (p <.001), white females (p < .001), and black females (p = .005). Correlation between state UV Index and KC mortality existed for men (p = .004) but not for women (p = .379). Genital KC deaths increased with age (p < .001), in women (p < .001), and in less urbanized areas for white males (p < .001).

CONCLUSION

Keratinocyte carcinoma poses a serious health burden, which may be underestimated by death certificate reporting. Mortality rates are no longer declining. Increasing awareness of genital and nongenital KC, especially the elderly, and population-based studies with controlled reporting of KC mortality are needed.

The association of indoor tanning and melanoma in adults: systematic review and meta-analysis

BACKGROUND

Tanning beds are associated with increased risk of melanoma.

OBJECTIVE

We sought to update the evidence of the association of melanoma and indoor tanning focusing on frequency of use and exposure to newer tanning beds.

METHODS

We searched Scopus, MEDLINE, and Cumulative Index to Nursing and Allied Health Literature on August 14, 2013. We included all observational studies that included patients with melanoma who had indoor tanned. Odds ratios (OR) with 95% confidence intervals (CI) were extracted and combined using generic inverse variance methods assuming a random effects model.

RESULTS

In all, 31 studies were included with data available on 14,956 melanoma cases and 233,106 controls. Compared with never using, the OR for melanoma associated with ever using indoor tanning beds was 1.16 (95% CI 1.05-1.28). Similar findings were identified in recent studies with enrollment occurring in the year 2000 onward (OR 1.22, 95% CI 1.03-1.45) and in subjects attending more than 10 tanning sessions (OR 1.34, 95% CI 1.05-1.71).

LIMITATIONS

The quality of evidence contributing to review results ranges from poor to mediocre.

CONCLUSION

Using tanning beds is associated with a subsequent melanoma diagnosis. Exposure from more than 10 tanning sessions is most strongly associated and there was no statistically significant difference in this association before and after 2000, suggesting that newer tanning technology is not safer than older models.

Sex differences in rising trends of cutaneous malignant melanoma in Norway, 1954-2008

With more than a seven-fold increase during the last 50 years, the incidence rate of cutaneous malignant melanoma in Norway is amongst the highest worldwide. The present study aims to present the incidence trends of cutaneous malignant melanoma in Norway, 1954-2008, according to period, sex, age, stage of disease, anatomical location and geographical regions, and discuss the results in relation to sun exposure habits over time. All new cases of invasive cutaneous malignant melanoma diagnosed in the Norwegian population between 1 January 1954 and 31 December 2008 were retrieved from the Cancer Registry of Norway (n=31 783). In addition to descriptive analyses, joinpoint and age-period-cohort regression models were used to explore the incidence trends. Throughout the 1980s, a steep increase in the rate of melanoma was observed in both sexes, continuing to increase from the late 1990s. Age-specific incidence rates showed the steepest increase in age groups older than 50 years, and were most pronounced in men. A clear sex-specific anatomical distribution exists, although the trunk has become the most common location for both sexes. During the entire period of follow-up, a two-fold risk was observed in inhabitants of the southern compared with the northern part of Norway. It is reasonable to suggest that the rising incidence rates of melanoma in Norway, in both sexes, reflect a strengthened intermittent sun exposure pattern over time. The particularly strong incidence increase in older men corresponds with their less favourable sun-protective behaviour.

Phototoxicity of herbal plants and herbal products

Plants are used by humans in daily life in many different ways, including as food, herbal medicines, and cosmetics. Unfortunately, many natural plants and their chemical constituents are photocytotoxic and photogenotoxic, and these phototoxic phytochemicals are widely present in many different plant families. To date, information concerning the phototoxicity and photogenotoxicity of many plants and their chemical constituents is limited. In this review, we discuss phototoxic plants and their major phototoxic constituents; routes of human exposure; phototoxicity of these plants and their constituents; general mechanisms of phototoxicity of plants and phototoxic components; and several representative phototoxic plants and their photoactive chemical constituents.

Sun protection and exposure behaviors among Hispanic adults in the United States: differences according to acculturation and among Hispanic subgroups

Background

Skin cancer prevention interventions that target the growing number of U.S. Hispanics are lacking. The current study examined the prevalence and correlates of sun protection and exposure behaviors (i.e., sunscreen use, shade seeking, use of sun protective clothing, and sunburns) among U.S. Hispanics with sun sensitive skin, with a focus on potential differences according to acculturation and Hispanic origin.

Methods

The sample consisted of 1676 Hispanic adults who reported having sun sensitive skin (i.e., they would experience a sunburn if they went out in the sun for one hour without protection after several months of not being in the sun). Participants completed survey questions as part of the nationally representative 2010 National Health Interview Survey. Analyses were conducted in August 2012.

Results

Greater acculturation was linked with both risky (i.e., not wearing sun protective clothing) and protective (i.e., using sunscreen) sun-related practices and with an increased risk of sunburns. Sun protection and exposure behaviors also varied according to individuals’ Hispanic origin, with for example individuals of Mexican heritage having a higher rate of using sun protective clothing and experiencing sunburns than several other subgroups.

Conclusions

Several Hispanic subpopulations (e.g., those who are more acculturated or from certain origins) represent important groups to target in skin cancer prevention interventions. Future research is needed to test culturally relevant, tailored interventions to promote sun protection behaviors among U.S. Hispanics. Such initiatives should focus on public health education and increasing healthcare provider awareness of the importance of skin cancer prevention among Hispanics.