Increased effectiveness of targeted skin cancer screening in the Veterans Affairs population of Northern California

Skin Malignancy in the Military: A Number Needed to Biopsy Analysis

INTRODUCTION

Skin malignancy has increased in prevalence over the last 15 years and effective diagnosis is required for adequate treatment. Retrospective data analysis of skin biopsy data has shown correlation between various independent variables, but no studies have been shown to directly assess skin malignancy risks for military personnel. Assessing correlation could lead to more effective, targeted screening programs that could lead to decreased mortality from skin malignancies. We present a 1-year analysis of the number needed to biopsy (NNB) to detect skin cancer and analysis of military-specific risk factors in a military dermatology training program. The present study aims to (1) compare skin biopsy yields to civilian institutions and patient populations and (2) determine significance of exposure variables including age, gender, military beneficiary status, branch of service, and military rank.

MATERIALS AND METHODS

We performed a retrospective observational study over 1 year by identifying all skin biopsies performed in the Walter Reed National Military Medical Center dermatology clinic from August 2015 to July 2016. Utilizing the pathology reports, we manually excluded biopsies performed for the purpose of ruling out inflammatory/immunologic conditions or cosmeses and focused only on encounters performed to rule out basal cell carcinoma, squamous cell carcinoma, or melanoma. We decided to exclude malignant diagnoses that were exceedingly rare or could mimic inflammatory conditions, such as cutaneous T-cell lymphoma. For uncertain diagnoses with vague context per pathology report, previous office clinic notes and pre-biopsy differential were referenced and included only if melanoma or non-melanoma skin cancer (NMSC) diagnosis was the intended indication.

RESULTS

A total of 3,098 biopsies were included in the study, diagnostic for 1,084 total skin malignancy and 54 melanoma diagnoses. Melanoma comprised 4.98% of all skin malignancy diagnosed. The NNB for all skin malignancy was 2.86 (95% CI 2.76-2.96) and NNB for melanoma and NMSC was 20.93 (95% CI 19.70-22.15) and 1.91 (95% CI 1.83-2.00), respectively. Patient age, gender, and military rank significantly impacted NNB values (P < .001).

CONCLUSIONS

The proportion of melanoma skin cancers is notably increased in our population compared to published population statistics with comparable total biopsy yields. Skin biopsy for purpose of screening for malignancy should be performed in the military population and consideration should be made for gender, age, and rank. Our findings can further expand on military risk factors for skin cancer and aid in further multivariant modeling.

Skin cancer in the military: A systematic review of melanoma and nonmelanoma skin cancer incidence, prevention, and screening among active duty and veteran personnel

BACKGROUND

Occupational sun exposure is a well-studied risk factor for skin cancer development, but more work is needed to assess melanoma and nonmelanoma skin cancer risk among US military personnel to improve education and screening efforts in this population.

OBJECTIVE

To conduct an extensive review of skin cancer risks for US military personnel to inform preventive education, diagnosis, and treatment efforts to better protect these individuals from future skin cancer development.

METHODS

A systematic review of published studies on the subject of melanoma and nonmelanoma skin cancer in military personnel was conducted.

RESULTS

A total of 9 studies describing skin cancer incidence in the US military were identified, with 4 studies specific to melanoma. The study findings reveal an increased risk for melanoma associated with service in the military or prisoner of war status. Service in tropical environments was associated with an increased incidence of both melanoma and nonmelanoma skin cancer among World War II soldiers. Two studies found that increased melanoma risk was also branch dependent, with the highest rates among the United States Air Force. Several of the reviewed studies implicated increased sun exposure during military service and lack of sufficient sun protection as the causes of higher rates of skin cancer among US military and veteran populations as compared with among the nonmilitary population in the United States.

LIMITATIONS

The reviewed articles have variable results; a prospective randomized controlled trial would be helpful to develop interventions that mitigate skin cancer risk in the US military.

CONCLUSION

This review identifies an abundance of evidence for an increased risk for skin cancer development among US active duty and veteran populations.

Skin Cancer Screening on a Fishing Island and in an Inland Agricultural Area of Japan

We performed skin cancer screening from 2000 to 2004 at two locations in Japan's Oita Prefecture: Himeshima, a small fishing island, and Naoiri, an inland agricultural area. We found 108 and 21 cases of AK in Himeshima and Naoiri, respectively. None of the AKs transformed into SCC, and 21.7% of the AKs underwent spontaneous remission during our observation period. The prevalence and incidence of AK in Himeshima were five times higher than in Naoiri: 1,399 and 826 per 100,000 population, respectively, in the fishing village, vs. 261 and 164 in the agricultural community. Seven and three cases of BCC were observed in Himeshima and Naoiri, respectively. There were two cases of SCC in Himeshima. The highest risk ratio of skin types I to III was 9.2 in Himeshima. Although people engaged in outdoor occupations are thought to be more prone to skin cancer and precancerous skin lesions, our results suggested different potentials for AK in people engaged in different outdoor occupations.

Identifying risk factors using a skin cancer screening program

BACKGROUND

The incidence of melanoma and nonmelanoma skin cancer continues to increase. To detect lesions at an earlier phase in their progression, skin cancer screening programs have been advocated by some. However, the effectiveness of skin cancer screening and the ideal population that these screenings should target have yet to be firmly established. This study details the relationship of a group of well-known risk factors with presumptive diagnoses in a large series of individuals self-referred for free skin cancer screening.

METHODS

Data obtained during 2007 to 2010 from a descriptive cross-sectional study skin cancer screening program are presented. Participant history was recorded using standardized medical history forms prior to skin examination. Screeners conducted a skin examination varying from whole-body to limited areas (per participant preference) and recorded diagnoses. Diagnoses were assigned to the nonmelanoma cancer (NMC) or suspicious pigmented lesion group for analysis.

RESULTS

A presumptive diagnosis of NMC was associated with male sex, age ≥ 50 years, personal history of skin cancer, lower skin phototype, increased sunscreen use, and increased chronic sun exposure (all P values ≤ .0001). After controlling for skin phototype, increased sunscreen use was not associated with a presumptive diagnosis of NMC (P = .96). Presumptive diagnosis of a suspicious pigmented lesion was associated with a reported history of "changing mole" (P < .0001) and negatively associated with age ≥ 50 years (P < .0001) and a personal history of skin cancer (P = .0119).

CONCLUSIONS

Several known risk factors for nonmelanoma skin cancer correlated with a presumptive diagnosis of NMC. The yield of presumptive atypical pigmented lesions was increased in participants aged < 50 years, supporting the notion that this population may benefit from screening.

Screening for skin cancer: a pilot study in tehran, iran

BACKGROUND

Early detection of skin cancers by screening could be very beneficial to decrease their morbidity or mortality. There is limited study about skin cancer screening in Iran.

AIM

This essay was planned as a pilot skin cancer screening campaign in Tehran, Iran to evaluate its profit and failure and further design large-scale screening program more definitely.

MATERIALS AND METHODS

Thirty one public health centers of Shahid Beheshti Medical University were selected in different areas of Tehran. The project was announced via media and invited all the people above 40 years old to come for the whole-body skin examination in a one-week period. Patients with any suspected lesions were referred to the dermatology clinics of the university.

RESULTS

1314 patients, 194 males (14.8%) and 120 females (85.2%), with mean age of 51.81 ± 10.28 years participated in this screening campaign. Physicians found suspected lesions in 182 (13.85%) of participants. The diagnosis of skin cancer was confirmed in 15 (1.14%) patients. These malignancies included 10 (0.76%) cases of basal cell carcinoma, 2 (0.15%) cases of squamous cell carcinoma and 3 (0.23%) cases of malignant melanoma.

CONCLUSION

Skin cancer screening seems to be valuable to detect skin malignancies in their early course. Regarding the considerable amount of facilities needed to perform skin cancer screening program, it might be more beneficial to perform the targeted screening programs for the high-risk groups or emphasis more on public education of skin cancer risk factors and their early signs.

Screening and prevention measures for melanoma: is there a survival advantage?

Controversy has emerged over the past decades regarding the value and impact of melanoma screening to detect early stage disease for improved prognosis. Those questioning the benefits of prevention efforts base their arguments on the absence of prospective, randomized studies demonstrating decreased melanoma mortality to justify the cost associated with screening and educational campaigns. For those in favor of melanoma screening, the lack of proven survival benefit is not a justification to abandon this approach, but rather a reflection of the lack of resources necessary to conduct a long-term trial. In 2009, the US Preventive Services Task Force (USPSTF)report did not recommend routine primary care screening for the general population given the absence of evidence. However, since the USPSTF report, a series of new studies are available, which support the potential benefit of screening and have the potential to significantly impact current policies regarding skin cancer screening, particularly for melanoma.

Factors associated with risky sun exposure behaviors among operating engineers

BACKGROUND

The objective of this study was to determine the factors associated with sun exposure behaviors among Operating Engineers (heavy equipment operators).

METHODS

Operating Engineers (N = 498) were asked to complete a cross-sectional survey. Linear and logistic regression analyses were used to determine health behavioral, perceptional, and demographic factors associated with sun exposure behavior (sun burns, blistering, use of sunscreen, and interest in sun protection services).

RESULTS

Almost half reported two or more sunburns/summer and the median times blistering was 2 with a range of 0-100. About one-third never used sun block, while just over one-third rarely used sun block. Almost one-quarter were interested in sun protection guidance. Multivariate analyses showed that perceptions of skin type, alcohol problems, fruit intake, BMI, sleep quality, age, sex, and race were significantly associated with at least one of the outcome variables (P < 0.05).

CONCLUSIONS

Operating Engineers are at high risk for skin cancer due to high rates of exposure to ultraviolet light and low rates of sun block use. Subgroups of Operating Engineers are particularly at risk for sun damage. Interventions are needed to decrease sun exposure among Operating Engineers.

Application of mobile teledermatology for skin cancer screening

BACKGROUND

With advancements in mobile technology, cellular phone-based store-and-forward teledermatology may be applied to skin cancer screening.

OBJECTIVE

We sought to determine diagnostic and management concordance between in-person and teledermatology evaluations for patients at skin cancer screening whose clinical images and history were transmitted through mobile phones.

METHODS

A total of 86 patients with 137 skin lesions presented to a skin cancer screening event in California. These patients' clinical history and skin images were captured by a software-enabled mobile phone. Patients were assessed separately by an in-person dermatologist and a teledermatologist, who evaluated the mobile phone-transmitted history and images. Diagnostic and management concordance was determined between the in-person and teledermatology evaluations.

RESULTS

The primary categorical diagnostic concordance was 82% between the in-person dermatologist and the teledermatologist (95% confidence interval 0.73-0.89), with a Kappa coefficient of 0.62 indicating good agreement. The aggregated diagnostic concordance between the in-person dermatologist and the teledermatologist was 62% (95% confidence interval 0.51-0.71), with Kappa coefficient of 0.60 indicating good agreement. Management concordance between the in-person dermatologist and the teledermatologist was 81% (95% confidence interval 0.72-0.88), with a Kappa coefficient of 0.57, which indicates moderate agreement between the dermatologists. Multivariate analysis showed that older age and presentation of atypical nevus were significantly associated with disagreement in diagnosis between the teledermatologist and in-person dermatologist, after adjusting for other factors.

LIMITATIONS

Dermatoscopic images were not captured via mobile phones, which might improve diagnostic accuracy.

CONCLUSION

Mobile teledermatology using cellular phones is an innovative and convenient modality of providing dermatologic consultations for skin cancer screening.

Early detection of skin cancer as public health policy: comparison of campaign and routine activity

OBJECTIVE

The objective of this study was to evaluate the early detection of skin cancer, with emphasis on comparison of campaign (short high-intensity periods) and routine (continuous low-intensity) activity.

METHODS

The study population consisted of 5903 campaign and 4284 routine attenders visiting a nurse at the Pirkanmaa Cancer Society between January 1, 1991, and December 31, 2000. Skin cancers were identified from the Finnish Cancer Registry. The performance of the program was evaluated in terms of sensitivity, specificity, positive and negative predictive values.

RESULTS

A single lesion was more frequently examined during campaigns whereas a partial or total body were examined less frequently (p<0.001). Attenders received referral for removal of a lesion more frequently in routine activity (52% vs. 20% p<0.001), regardless of extent of the examination. The cumulative incidence of skin cancer within 24 months was 3.2% for routine and 1.6% for campaign attenders (p<0.001). Sensitivity was higher (82% vs. 59%, p<0.001), while specificity was lower (49% vs. 79%, p<0.001) for routine activity.

CONCLUSIONS

Even though neither approach appears optimal, scheduled appointments with adequate time allocation per subject provided a lower threshold for detection and a higher yield of skin cancers compared to high-intensity campaigns.

Screening and early detection of skin cancer

Skin cancer is the most common type of cancer in the United States. US incidence of malignant melanoma is increasing faster than any other type of cancer. To minimize increasing morbidity and mortality rates, it is imperative that appropriate screening and early detection of skin cancer become more widespread. All physicians who see patients clinically have the potential for detecting skin cancers. The scope of skin cancer as a health-care problem is discussed. Evidence for the effectiveness and necessity of skin cancer screening and early detection is presented. Costs of screening and detection are discussed in relation to impact on treatment costs and overall costs of skin cancer burden. Current methods and recommendations for skin cancer screening and detection are reviewed, especially with regard to individuals and populations that may require more specialized or intensive screening and follow-up. Newer approaches involving instrument-assisted screening and detection of skin cancer are under intense development, and these exciting emerging technologies are reviewed.

The relative persuasiveness of gain-framed and loss-framed messages for encouraging disease prevention behaviors: a meta-analytic review

A meta-analytic review of 93 studies (N = 21,656) finds that in disease prevention messages, gain-framed appeals, which emphasize the advantages of compliance with the communicator's recommendation, are statistically significantly more persuasive than loss-framed appeals, which emphasize the disadvantages of noncompliance. This difference is quite small (corresponding to r = .03), however, and appears attributable to a relatively large (and statistically significant) effect for messages advocating dental hygiene behaviors. Despite very good statistical power, the analysis finds no statistically significant differences in persuasiveness between gain- and loss-framed messages concerning other preventive actions such as safer-sex behaviors, skin cancer prevention behaviors, or diet and nutrition behaviors.

Screening, early detection, and trends for melanoma: Current status (2000-2006) and future directions

In the past 5 years, there have been notable strides toward the earlier recognition and discovery of melanoma, including new technologies to complement and augment the clinical examination and new insights to help clinicians recognize early melanoma. However, incidence and mortality rates throughout most of the developed world have risen over the past 25 years, while education and screening, potentially the best means for reducing the disease, continue to be severely underutilized. Much progress needs to be made to reach middle-aged and older men and persons of lower socioeconomic status who suffer a disproportionate burden of death from melanoma. Worldwide melanoma control must also be a priority, and comprehensive educational and screening programs should be directed to Northern Ireland and a number of Eastern European nations, whose 5-year survival rates range between 53% and 60%, mirroring those of the United States and Australia more than 40 years ago.

LEARNING OBJECTIVE

After completing this learning activity, participants should be aware of the most recent melanoma epidemiologic data, both in the United States and internationally; worldwide early detection and screening programs; clinical strategies to recognize and improve the detection of early melanoma; the latest technologies for early detection of melanoma; and public and professional education programs designed to enhance early detection.

Who attends skin cancer screening in Western Australia? Results from the Lions Cancer Institute skin cancer screening program

OBJECTIVE

To examine the characteristics of persons attending a skin cancer screening clinic in Western Australia and compare the effectiveness of screening in different socio-demographic subgroups.

METHODS

Questionnaires were completed by 5,950 self-selected participants who voluntarily attended the Western Australian Lions Cancer Institute's targeted skin cancer screening clinics during the period 1996-2003. A risk assessment technique was used to identify individuals at high risk of developing melanoma. Provisional diagnoses of suspicious lesions were given at the screening by a medical specialist. Suspicious lesions were later matched with histopathologically confirmed malignant melanomas reported to the Western Australia Cancer Registry.

RESULTS

Fifty-seven per cent of attendees were female. The mean age of attendees was 53 years. The yield of suspicious malignant melanomas detected was 24.7 per 1,000 participants screened; the yield of confirmed malignant melanomas detected was 3.0 per 1,000 participants screened. Persons over 50 years of age were three times more likely to have a histopathologically confirmed malignant melanoma detected at the screening than those younger than 50 years (p = 0.049).

CONCLUSIONS

The yield of confirmed melanomas detected by the Lions Cancer Institute is among the highest reported by a skin cancer screening program. This may have been attributable to the risk assessment technique used by the program.

IMPLICATIONS

A free community skin cancer screening program that targets high-risk individuals can detect melanomas.

Risk factors for presumptive melanoma in skin cancer screening: American Academy of Dermatology National Melanoma/Skin Cancer Screening Program experience 2001-2005

BACKGROUND

Since its inception in 1985, the American Academy of Dermatology (AAD) National Melanoma/Skin Cancer Screening Program has strived to enhance early detection of cutaneous malignant melanoma (MM) by providing nationwide skin cancer education campaigns in combination with free skin cancer screenings.

OBJECTIVE

To analyze the AAD screening data from 2001 to 2005 in order to identify factors associated with MM detection, and thereby derive a model of increased likelihood for MM detection through visual skin examinations at screenings.

MATERIALS AND METHODS

Patients completed a standardized AAD pre-screening form with historical and phenotypic information. Clinicians then recorded suspected clinical findings noted at visual skin examination. Statistical analyses were conducted using SPSS 14 (SPSS Inc., Chicago, Ill).

RESULTS

Five factors, which can be remembered with the acronym HARMM, independently increased the likelihood of suspected MM being found in the 362,804 persons screened: History of previous melanoma (odds ratio [OR] = 3.3; 95% confidence interval [CI], 2.9-3.8); Age over 50 (OR = 1.2; 95% CI, 1.1-1.3); Regular dermatologist absent (OR = 1.4; 95% CI, 1.3-1.5); Mole changing (OR = 2.0; 95% CI, 1.9-2.2); and Male gender (OR = 1.4; 95% CI, 1.3-1.5). Individuals at highest risk (4 or 5 factors) comprised only 5.8% of the total population, yet accounted for 13.6% of presumptive MM findings, and were 4.4 times (95% CI, 3.8-5.1) more likely to be diagnosed with suspected MM than individuals at lowest risk (0 or 1 factor). Receipt of a total skin examination at screening independently increased the likelihood for identifying suspected MM (OR = 1.4; 95% CI, 1.3-1.6). However, significantly fewer screenees in the highest risk group versus those in the lowest risk group underwent total skin examinations (53.7% vs 62.5%).

LIMITATIONS

Risk factors studied limited to variables collected in screenee enrollment form.

CONCLUSIONS

A higher-risk subgroup of the skin cancer screening population can be identified through assessment of MM risk factors using the HARMM criteria. Refocusing efforts to provide a total skin examination to those individuals with multiple risk factors has the potential to both reduce costs and increase yields for suspected MM in future mass screening initiatives.

Validity of melanoma diagnosis in a community-based screening program

Although screening for melanoma is intuitively attractive, evidence of the effectiveness of screening programs for skin cancer is lacking. Since 1990, the Lions Cancer Institute has conducted clinics in Western Australia in which volunteer plastic surgeons and dermatologists undertake full-body skin screens. Advertisements for attendees target people with risk factors for skin cancer. Each person screened between 1994 and 2002 (n = 7,436) completed a questionnaire including basic demographic information, on which the physician added provisional diagnoses. Attendees' details were linked with the Western Australian Cancer Registry to determine the number of diagnosed melanomas up to 1 and 2 years after screening. The positive predictive value of a screening diagnosis of "any lesion" at a particular body site was 1.5% and that of a screening diagnosis of "melanoma" was 10.0%. The 1-year specificity of the screening test ranged from 95.1% to 99.5%, and 1-year sensitivity ranged from 63.6% to 81.8%. Two-year sensitivity was lower. If body site was not taken into account, the sensitivities were higher and the specificities lower. Findings suggest that the validity of skin screening diagnoses in the general population is reasonable. Body site of the lesion should be taken into account when calculating validity of these diagnoses.

Clinical outcomes from skin screening clinics within a community-based melanoma screening program

BACKGROUND

Within a randomized trial of population screening for melanoma, primary care physicians conducted whole-body skin examinations and referred all patients with suspect lesions to their own doctor for further treatment.

OBJECTIVE

Our aim was to describe characteristics of skin screening participants, clinical screening diagnoses, management following referral, and specificity and yield of screening examinations.

METHODS

Information collected from consent forms, referral forms, and histopathological reports of lesions that had been excised or undergone biopsy was analyzed by means of descriptive statistics.

RESULTS

A total of 16,383 whole-body skin examinations resulted in 2302 referrals (14.1% overall; 15.5% men, 18.2% > or = 50 years of age) for 4129 suspect lesions (including 222 suspected melanoma, 1101 suspected basal cell carcinomas [BCCs], 265 suspected squamous cell carcinomas [SCCs]). Histopathologic results were available for 94.8% of 1417 lesions excised and confirmed 33 melanomas (23 in men; 24 in participants > or = 50 years of age), 259 BCCs, and 97 SCCs. The probability of detecting skin cancer of any type within the program was 2.4%. The estimated specificity of whole-body skin examinations for melanoma was 86.1% (95% confidence interval = 85.6-86.6). The positive predictive value (number of confirmed/number of lesions excised or biopsied x 100) for melanoma was 2.5%, 19.3% for BCC, and 7.2% for SCC (overall positive predictive value for skin cancer, 28.9%).

LIMITATIONS

Follow-up of participants with a negative screening examination has not been conducted for the present investigation.

CONCLUSIONS

The rate of skin cancer detected per 100 patients screened was higher than previously reported and men and attendees older than 50 years more frequently received a referral and diagnosis of melanoma. The specificity for detection of melanoma through whole-body skin examination by a primary care physician was comparable to that of other screening tests, including mammography.

Skin cancer screening campaign in the German speaking Community of Belgium

The incidence of primary malignant melanoma (MM) and skin carcinomas, including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is progressively raising. As long as their diagnosis and therapeutic managements are initiated early, their prognosis remains favorable. This underlines the importance of early recognition of skin cancers. Furthermore, it has been demonstrated that skin cancer screening programs are efficacious in increasing the population awareness of the early signs of skin cancer and of the dangers of UV - exposure. A skin cancer screening campaign was organised by dermatologists of the German-speaking Community of Belgium in cooperation with the Department of Family, Health, and Social Affairs of the Regional Ministry of the German-speaking Community of Belgium. In order to increase the screening selectivity, two risk populations were targeted; patients presenting 30 or more moles, and patients over 50 years of age presenting recent skin changes of the head and neck area. A media campaign using radio, television and daily press was started to increase the population awareness of the dangers of UV exposure and of the early signs of skin cancer. During 2 screening days, three-hour sessions were organised in 2 health centers located in Eupen and St Vith. A total of 148 patients were examined. A total of 124/148 patients met the selection criteria predefined during the media announcement. The simultaneous presence of 4 dermatologists during the screening sessions allowed a second opinion for warning lesions. Four BBCs as well as 23 patients pesenting dysplastic nevi were clinically diagnosed. During the 2 months following the screening campaign 5 MMs were identified by the same dermatologists in their routine practice. In conclusion, this skin cancer screening campaign led to the diagnosis of 4 carcinomas. The campaign furthermore increased the patient awareness, permitting the diagnosis of 5 MMs during the 2 following months. This figure represents about 30% of all MMs diagnosed yearly in this region of Belgium.