Prevalence of skin examination behaviours among Australians over time

3D Total-Body Photography in Patients at High Risk for Melanoma: A Randomized Clinical Trial

Importance

Three-dimensional (3D) total-body photography (TBP) can support clinicians in monitoring and identifying changes to skin lesions in patients at high risk of melanoma.

Objective

To assess clinical outcomes between patients at high risk of melanoma receiving usual clinical care compared with those receiving usual care plus 3D TBP and sequential digital dermoscopy imaging (SDDI) every 6 months via teledermatology.

Design, Setting, and Participants

This randomized clinical trial was conducted at a research hospital in Brisbane, Australia, from April 2018 to October 2021, with adult patients (≥18 years) at high risk of developing a primary or subsequent melanoma. Data analysis was conducted from March 2022 to June 2024.

Intervention

Usual care plus 3D-TBP in person and SDDI via teledermatology at baseline, 6, 12, 18, and 24 months. The control group continued usual care and completed online surveys every 6 months.

Main Outcome Measures

Number and rates of excisions and/or biopsies of lesions suggestive of melanoma, and results of histopathologic testing.

Results

The analysis included 314 participants (mean [SD] age, 51.6 [12.8] years; 194 females [62%]) who completed all of the study procedures (158 in the intervention and 156 in the control). In all, 1527 excisions (905 intervention and 622 in the control) were performed among 226 participants (122 intervention and 104 controls), with 67 (4%) histopathologically confirmed as melanoma and 402 (26%) as keratinocyte cancer (KC). The mean (SD) number of lesions of any type excised per person was significantly higher in the intervention (5.73 [6.77]; 95% CI, 4.66-6.79) compared to the control group (3.99 [5.72]; 95% CI, 3.08-4.89; P = .02). Fewer melanomas were detected among the intervention group compared with the control (24 [35%] vs 43 [64%], respectively), and therefore, a lower incidence rate: 2.03 (95% CI, 1.30-3.02) vs 3.62 (95% CI, 2.62-4.88), respectively. After 1 year of follow-up, the intervention had a lower, but not statistically significant, rate of melanoma per person: 0.08 (95% CI, 0.03-0.13) compared with 0.16 (95% CI, 0.08-0.25) in the control; an average of 0.86 (95% CI, 0.55-1.16) vs 0.42 (95% CI, 0.24-0.59) KCs per person; and 2.01 (95% CI, 1.50-2.51) vs 1.39 (95% CI, 0.98-1.82) excisions or biopsies per person, respectively.

Conclusions and Relevance

The results of this randomized clinical trial indicate that the addition of 3D-TPB and SDDI to usual care in a teledermatology setting without AI (artificial intelligence) increased the number and rate of skin excisions and biopsies performed. Further studies are required to compare teledermatology to usual care rather than adding it, and to study whether the use of AI can improve the teledermatology outcomes. Larger studies in multiple settings with a greater number of teledermatologists are needed. This study shows that conducting clinical trials in this setting is feasible.

Trial Registration

anzctr.org.au Identifier: ACTRN12618000267257.

Melanoma as a detection-dependent cancer: proxy measures of screening and surveillance associated with 3-year incidence of detection procedures for skin cancer in a national prospective study

BACKGROUND

Increased levels of skin detection activities are suspected of driving recent rapid increases in melanoma incidence. While ecological studies report rising rates of skin biopsies in many industrialized populations, few studies have accessed individual-level clinical data to test the hypothesis that people exposed to skin screening and surveillance go on to experience higher levels of biopsies and excisions, and a higher incidence of melanoma.

OBJECTIVES

To measure the incidence rates of detection events and melanoma diagnoses in a national cohort during follow-up, stratified according to screening or surveillance activities in the index year.

METHODS

We conducted a prospective cohort study of 10 674 200 adults using linked data from Australia's universal health insurance scheme (2011-2016). Participants who underwent biopsies or who were diagnosed with skin cancer in 2011-12 were excluded. We then defined participants as surveilled, screened or unscreened for skin cancer based on medical claims occurring in 2013. We compared rates of biopsies, excisions for suspected melanoma and excisions for histologically confirmed melanoma during follow-up (2014-2016).

RESULTS

After adjusting for sociodemographic factors, screened people were significantly more likely than unscreened people to undergo skin biopsies [rate ratio (RR) 2.59, 95% confidence interval (CI) 2.56-2.63], excisions for suspected melanoma (RR 2.57, 95% CI 2.53-2.60) and excisions for confirmed melanoma (hazard ratio 3.32, 95% CI 3.24-3.40) during follow-up. Similarly elevated rates of subsequent diagnostic events were observed for the surveilled group. Importantly, rates of detection and rates of melanoma remained elevated in each of the subsequent years of follow-up among those who were screened or surveilled in the index year.

CONCLUSIONS

People undergoing skin screening or surveillance subsequently experience higher rates of diagnostic scrutiny and higher rates of melanoma.

Estimating the magnitude and healthcare costs of melanoma in situ and thin invasive melanoma overdiagnosis in Australia

BACKGROUND

Research suggests that a high proportion of melanoma in situ (MIS) may be overdiagnosed, potentially contributing to overtreatment, patient harm and inflated costs for individuals and healthcare systems. However, Australia-wide estimates of the magnitude of melanoma overdiagnosis are potentially outdated and there has been no estimation of the cost to the healthcare system.

OBJECTIVES

To estimate the magnitude and cost of overdiagnosed MIS and thin invasive melanomas in Australia.

METHODS

Using two different methods to calculate lifetime risk, we used routinely collected national-level data to estimate overdiagnosed MIS and thin invasive melanomas (stage IA) in Australia in 2017 and 2021, separately for men and women. We multiplied the number of overdiagnosed melanomas by the estimated annual cost of a MIS or thin invasive melanoma, to quantify the financial burden of melanoma overdiagnosis to the Australian healthcare system in the year following diagnosis.

RESULTS

We estimated that 67-70% of MIS were overdiagnosed in 2017, rising to 71-76% in 2021, contributing to between 19 829 [95% confidence interval (CI) 19 553-20 105] and 20 811 (95% CI 20 528-21 094) cases of overdiagnosed MIS. In 2021, the estimated costs in Australia ranged between $17.7 million Australian dollars (AUD; 95% CI 17.4-17.9 million) and AUD$18.6 million (95% CI 18.3-18.8 million). We estimated that 22-29% of thin invasive melanomas were overdiagnosed in 2017, rising to 28-34% in 2021, contributing to between 2831 (95% CI 2726-2935) and 3168 (95% CI 3058-3279) overdiagnosed thin invasive melanomas. In 2021, the estimated costs from thin invasive melanoma overdiagnoses ranged between AUD$2.5 million (95% CI 2.4-2.6 million) and AUD$2.8 million (95% CI 2.7-2.9 million).

CONCLUSIONS

Melanoma overdiagnosis is a growing clinical and public health problem in Australia, producing significant economic costs in the year following overdiagnosis. Limiting melanoma overdiagnosis may prevent unnecessary healthcare resource use and improve financial sustainability within the Australian healthcare system.

Targeted Screening for Cancer: Learnings and Applicability to Melanoma: A Scoping Review

This scoping review aims to systematically gather evidence from personalized cancer-screening studies across various cancers, summarize key components and outcomes, and provide implications for a future personalized melanoma-screening strategy. Peer-reviewed articles and clinical trial databases were searched for, with restrictions on language and publication date. Sixteen distinct studies were identified and included in this review. The studies' results were synthesized according to key components, including risk assessment, risk thresholds, screening pathways, and primary outcomes of interest. Studies most frequently reported about breast cancers (n = 7), followed by colorectal (n = 5), prostate (n = 2), lung (n = 1), and ovarian cancers (n = 1). The identified screening programs were evaluated predominately in Europe (n = 6) and North America (n = 4). The studies employed multiple different risk assessment tools, screening schedules, and outcome measurements, with few consistent approaches identified across the studies. The benefit-harm assessment of each proposed personalized screening program indicated that the majority were feasible and effective. The establishment of a personalized screening program is complex, but results of the reviewed studies indicate that it is feasible, can improve participation rates, and screening outcomes. While the review primarily examines screening programs for cancers other than melanoma, the insights can be used to inform the development of a personalized melanoma screening strategy.

International patterns and trends in the incidence of melanoma and cutaneous squamous cell carcinoma, 1989-2020

BACKGROUND

Cutaneous squamous cell carcinoma (cSCC) and melanoma have different associations with sun exposure.

OBJECTIVES

To compare trends in the incidence rates of cSCC and melanoma, to provide insight into changing patterns of exposure to ultraviolet radiation (UVR).

METHODS

We compared trends in the incidence of cSCC and melanoma in seven susceptible populations residing at mid-to-high latitudes: Finland, Norway, Sweden, Denmark, Scotland, the Netherlands and Tasmania (Australia). We fitted Joinpoint models to describe trends in age-standardized incidence rates for melanoma and cSCC and calculated the average annual percentage rate of change for the period 1989-2020 (1989-2018 for Tasmania). We calculated the incident rate ratio (IRR) as the ratio of the age-standardized rates (European Standard Population) for cSCC to melanoma and conducted age-period-cohort modelling to compare age, period and cohort effects.

RESULTS

The ratio of cSCC-to-melanoma incidence increased with proximity to the equator and over time. In the most recent time period, the incidence of cSCC was higher than the incidence of melanoma for men and women in all seven populations. While the ratio of cSCC-to-melanoma incidence was higher for men vs. women, in most countries the cSCC-to-melanoma IRR increased over time to a greater extent in women than in men. Melanoma incidence was higher among younger people and cSCC incidence was higher among older people; the age at which the incidence of cSCC overtook the incidence of melanoma was progressively younger with proximity to the equator.

CONCLUSIONS

Despite concerted international efforts to preserve the ozone layer over the past four decades resulting in significant reductions in surface ultraviolet B at mid-latitudes, the incidence of skin cancer, particularly cSCC, continues to rise in those regions. Our findings are consistent with a stronger association with age-associated cumulative sun exposure for cSCC vs. melanoma and suggest that women are currently receiving greater UV radiation exposure than in the past.

Acceptability and appropriateness of a risk-tailored organised melanoma screening program: Qualitative interviews with key informants

INTRODUCTION

In Australia, opportunistic screening (occurring as skin checks) for the early detection of melanoma is common, and overdiagnosis is a recognised concern. Risk-tailored cancer screening is an approach to cancer control that aims to provide personalised screening tailored to individual risk. This study aimed to explore the views of key informants in Australia on the acceptability and appropriateness of risk-tailored organised screening for melanoma, and to identify barriers, facilitators and strategies to inform potential future implementation. Acceptability and appropriateness are crucial, as successful implementation will require a change of practice for clinicians and consumers.

METHODS

This was a qualitative study using semi-structured interviews. Key informants were purposively selected to ensure expertise in melanoma early detection and screening, prioritising senior or executive perspectives. Consumers were expert representatives. Data were analysed deductively using the Tailored Implementation for Chronic Diseases (TICD) checklist.

RESULTS

Thirty-six participants were interviewed (10 policy makers; 9 consumers; 10 health professionals; 7 researchers). Key informants perceived risk-tailored screening for melanoma to be acceptable and appropriate in principle. Barriers to implementation included lack of trial data, reluctance for low-risk groups to not screen, variable skill level in general practice, differing views on who to conduct screening tests, confusing public health messaging, and competing health costs. Key facilitators included the perceived opportunity to improve health equity and the potential cost-effectiveness of a risk-tailored screening approach. A range of implementation strategies were identified including strengthening the evidence for cost-effectiveness, engaging stakeholders, developing pathways for people at low risk, evaluating different risk assessment criteria and screening delivery models and targeted public messaging.

CONCLUSION

Key informants were supportive in principle of risk-tailored melanoma screening, highlighting important next steps. Considerations around risk assessment, policy and modelling the costs of current verses future approaches will help inform possible future implementation of risk-tailored population screening for melanoma.

Skin cancer-related conditions managed in general practice in Australia, 2000-2016: a nationally representative, cross-sectional survey

OBJECTIVE

Skin cancer is Australia's most common and costly cancer. We examined the frequency of Australian general practice consultations for skin cancer-related conditions, by patient and general practitioner (GP) characteristics and by time period.

DESIGN

Nationally representative, cross-sectional survey of general practice clinical activity.

SETTING, PARTICIPANTS

Patients aged 15 years or older having a skin cancer-related condition managed by GPs in the Bettering the Evaluation And Care of Health study between April 2000 and March 2016.

PRIMARY OUTCOME MEASURES

Proportions and rates per 1000 encounters.

RESULTS

In this period, 15 678 GPs recorded 1 370 826 patient encounters, of which skin cancer-related conditions were managed 65 411 times (rate of 47.72 per 1000 encounters, 95% CI 46.41 to 49.02). Across the whole period, 'skin conditions' managed were solar keratosis (29.87%), keratinocyte cancer (24.85%), other skin lesion (12.93%), nevi (10.98%), skin check (10.37%), benign skin neoplasm (8.76%) and melanoma (2.42%). Over time, management rates increased for keratinocyte cancers, skin checks, skin lesions, benign skin neoplasms and melanoma; but remained stable for solar keratoses and nevi. Skin cancer-related encounter rates were higher for patients aged 65-89 years, male, living in Queensland or in regional or remote areas, with lower area-based socioeconomic status, of English-speaking background, Veteran card holders and non-healthcare card holders; and for GPs who were aged 35-44 years or male.

CONCLUSION

These findings show the spectrum and burden of skin cancer-related conditions managed in general practice in Australia, which can guide GP education, policy and interventions to optimise skin cancer prevention and management.

The effect of screening on melanoma incidence and biopsy rates

BACKGROUND

Cutaneous melanomas are common cancers in white-skinned populations, and early detection is promoted as a means of reducing morbidity and mortality. There is concern that increased skin screening is leading to overdiagnosis of indolent melanomas with low risk of lethality. The extent of melanoma overdiagnosis associated with screening is unknown.

OBJECTIVES

To estimate possible overdiagnosis by comparing subsequent melanoma incidence and biopsy rates among people subjected to skin screening those who were not.

METHODS

We recruited 43 762 residents of Queensland, Australia, aged 40-69 years, with no prior history of melanoma, selected at random from a population register in 2010. At baseline, participants completed a comprehensive melanoma risk factor survey and were asked if their skin had been examined by a doctor in the 3 years prior to baseline. We calculated incidence and relative risk of histologically confirmed melanoma (invasive and in situ) in years 2-7 of follow-up, obtained through linkage to the cancer registry. In secondary analyses, we measured biopsy rates in years 2-6 of follow-up. We used propensity score analysis to calculate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

In total, 28 155 participants underwent skin screening prior to baseline. We observed 967 first-incident melanomas (381 invasive) during 197 191 person-years of follow-up. Those screened had higher rates of melanoma (aHR 1·29, 95% CI 1·02-1·63) and subsequent skin biopses (aHR 1·85, 95% CI 1·69-2·04) than unscreened participants. The higher risk associated with skin screening was evident for in situ melanoma (aHR 1·45, 95% CI 1·09-1·92) but not invasive melanoma (aHR 1·05, 95% CI 0·72-1·54). In secondary analyses, where screening was defined as having a skin biopsy in the first year after baseline, we observed significantly increased risks of melanoma (aHR 1·53, 95% CI 1·23-1·89) and subsequent biopsies (aHR 2·64, 95% CI 2·46-2·84) relative to those who did not have a biopsy.

CONCLUSIONS

People who undergo skin screening subsequently experience higher rates of biopsies and melanoma (especially in situ melanoma), even after adjusting for all known risk factors, consistent with overdiagnosis. What is already known about this topic? Cutaneous melanomas are common cancers in white-skinned populations for which early detection is promoted as a means of reducing morbidity and mortality. There is concern that increased surveillance is leading to the overdiagnosis of indolent melanomas that are not destined to be lethal. The extent of melanoma overdiagnosis associated with surveillance is not known. What does this study add? People subjected to skin examinations by a doctor or who undergo skin biopsies subsequently have higher numbers of biopsies and higher rates of melanoma than people not subjected to either, even after adjusting for all known risk factors. These findings suggest that heightened surveillance leads to a proportion of melanomas being diagnosed that otherwise may not have come to clinical attention.

Incidence of in Situ vs Invasive Melanoma: Testing the "Obligate Precursor" Hypothesis

Background

Melanoma incidence has been rising in populations with predominantly European ancestry (White), speculated to be partly driven by heightened detection of indolent tumors. If in situ melanomas are destined to evolve to invasive cancers, detecting and removing them should deplete the pool of invasive lesions, and people with in situ melanoma should, on average, be younger than those with invasive melanoma.

Methods

We analyzed long-term incidence trends (1982-2018) for in situ and invasive melanomas in 3 predominantly White populations with high, medium, and low melanoma rates: Queensland (Australia), United States White, and Scotland. We calculated the incidence rate ratio (IRR) of in situ to invasive melanomas and estimated the contributions of age, period, and cohort effects. We compared age at diagnosis of in situ vs invasive melanomas overall and stratified by sex and anatomic site.

Results

In all 3 populations, the in situ to invasive incidence rate ratio increased statistically significantly from less than 0.3 in 1982 to 1.95 (95% confidence interval [CI] = 1.88 to 2.02) in Queensland, 0.93 (95% CI = 0.90 to 0.96) in the US White population, and 0.58 (95% CI = 0.54 to 0.63) in Scotland in 2018. The mean age at diagnosis of in situ melanomas was the same or higher than invasive melanomas for almost all time periods among men and women and on all body sites except the lower limbs.

Conclusions

The increasing ratio of in situ to invasive melanoma incidence over time, together with the high (and increasing) mean age at diagnosis of in situ melanomas, is consistent with more indolent lesions coming to clinical attention than in previous eras.

Genetically determined cutaneous nevi and risk of cancer

Numerous epidemiologic studies have reported positive associations between higher nevus counts and internal cancers. Whether this association represents a true relationship or is due to bias or confounding by factors associated with both nevus counts and cancer remains unclear. We used germline genetic variants for nevus count to test whether this phenotypic trait is a risk-marker for cancer. We calculated polygenic risk scores (PRS) for nevus counts using individual-level data in the UK Biobank (n = 394 306) and QSkin cohort (n = 17 427). The association between the nevus PRS and each cancer site was assessed using logistic regression adjusted for the effects of age, sex and the first five principal components. In both cohorts, those in the highest nevus PRS quartile had higher risks of melanoma than those in the lowest quartile (UK Biobank odds ratio [OR] 1.42, 95% confidence interval [CI]: 1.29-1.55; QSkin OR 1.58, 95% CI: 1.29-1.94). We also observed increases in risk of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) associated with higher nevus PRS quartiles (BCC UK Biobank OR 1.38, 95% CI: 1.33-1.44; QSkin OR 1.20, 95% CI: 1.05-1.38 and SCC UK Biobank OR 1.41, 95% CI: 1.28-1.55; QSkin OR 1.44, 95% CI: 1.19-1.77). We found no consistent evidence that nevus count PRS were associated with risks of developing internal cancers. We infer that associations between nevus counts and internal cancers reported in earlier observational studies arose because of unmeasured confounding or other biases.

Association Between Melanoma Detected During Routine Skin Checks and Mortality

Importance

Early melanoma diagnosis is associated with better health outcomes, but there is insufficient evidence that screening, such as having routine skin checks, reduces mortality.

Objective

To assess melanoma-specific and all-cause mortality associated with melanomas detected through routine skin checks, incidentally or patient detected. A secondary aim was to examine patient, sociodemographic, and clinicopathologic factors associated with different modes of melanoma detection.

Design, Setting, and Participants

This prospective, population-based, cohort study included patients in New South Wales, Australia, who were diagnosed with melanoma over 1 year from October 23, 2006, to October 22, 2007, in the Melanoma Patterns of Care Study and followed up until 2018 (mean [SD] length of follow-up, 11.9 [0.3] years) by using linked mortality and cancer registry data. All patients who had invasive melanomas recorded at the cancer registry were eligible for the study, but the number of in situ melanomas was capped. The treating doctors recorded details of melanoma detection and patient and clinical characteristics in a baseline questionnaire. Histopathologic variables were obtained from pathology reports. Of 3932 recorded melanomas, data were available and analyzed for 2452 (62%; 1 per patient) with primary in situ (n = 291) or invasive (n = 2161) cutaneous melanoma. Data were analyzed from March 2020 to January 2021.

Main Outcomes and Measures

Melanoma-specific mortality and all-cause mortality.

Results

A total of 2452 patients were included in the analyses. The median age at diagnosis was 65 years (range, 16-98 years), and 1502 patients (61%) were men. A total of 858 patients (35%) had their melanoma detected during a routine skin check, 1148 (47%) self-detected their melanoma, 293 (12%) had their melanoma discovered incidentally when checking another skin lesion, and 153 (6%) reported "other" presentation. Routine skin-check detection of invasive melanomas was associated with 59% lower melanoma-specific mortality (subhazard ratio, 0.41; 95% CI, 0.28-0.60; P < .001) and 36% lower all-cause mortality (hazard ratio, 0.64; 95% CI, 0.54-0.76; P < .001), adjusted for age and sex, compared with patient-detected melanomas. After adjusting for prognostic factors including ulceration and mitotic rate, the associations were 0.68 (95% CI, 0.44-1.03; P = .13), and 0.75 (95% CI, 0.63-0.90; P = .006), respectively. Factors associated with higher odds of routine skin-check melanoma detection included being male (female vs male, odds ratio [OR], 0.73; 95% CI, 0.60-0.89; P = .003), having previous melanoma (vs none, OR, 2.36; 95% CI, 1.77-3.15; P < .001), having many moles (vs not, OR, 1.39; 95% CI, 1.10-1.77; P = .02), being 50 years or older (eg, 50-59 years vs <40 years, OR, 2.89; 95% CI, 1.92-4.34; P < .001), and living in nonremote areas (eg, remote or very remote vs major cities, OR, 0.23; 95% CI, 0.05-1.04; P = .003).

Conclusions and Relevance

In this cohort study, melanomas diagnosed through routine skin checks were associated with significantly lower all-cause mortality, but not melanoma-specific mortality, after adjustment for patient, sociodemographic, and clinicopathologic factors.

Impact of personal genomic risk information on melanoma prevention behaviors and psychological outcomes: a randomized controlled trial

Purpose

We evaluated the impact of personal melanoma genomic risk information on sun-related behaviors and psychological outcomes.

Methods

In this parallel group, open, randomized controlled trial, 1,025 Australians of European ancestry without melanoma and aged 18–69 years were recruited via the Medicare database (3% consent). Participants were randomized to the intervention (n = 513; saliva sample for genetic testing, personalized melanoma risk booklet based on a 40-variant polygenic risk score, telephone-based genetic counseling, educational booklet) or control (n = 512; educational booklet). Wrist-worn ultraviolet (UV) radiation dosimeters (10-day wear) and questionnaires were administered at baseline, 1 month postintervention, and 12 months postbaseline.

Results

At 12 months, 948 (92%) participants completed dosimetry and 973 (95%) the questionnaire. For the primary outcome, there was no effect of the genomic risk intervention on objectively measured UV exposure at 12 months, irrespective of traditional risk factors. For secondary outcomes at 12 months, the intervention reduced sunburns (risk ratio: 0.72, 95% confidence interval: 0.54–0.96), and increased skin examinations among women. Melanoma-related worry was reduced. There was no overall impact on general psychological distress.

Conclusion

Personalized genomic risk information did not influence sun exposure patterns but did improve some skin cancer prevention and early detection behaviors, suggesting it may be useful for precision prevention. There was no evidence of psychological harm.