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

Screening for melanoma

Although melanoma is a deadly cancer that is rising in incidence, the USA does not have uniform guidelines for melanoma screening. Screening for melanoma requires no specialized equipment and has little associated morbidity. However, screening has the greatest impact when performed among patients with the highest risk for melanoma incidence and mortality. Screening lower-risk patients may result in prohibitively high costs, unnecessary biopsies of benign lesions, and decreased access to a dermatologic specialist for patients who are actually at a higher risk. We advocate targeting melanoma screening efforts toward those patients at high risk of developing and dying from melanoma, as well as toward those at-risk patients who are least likely to detect their own melanoma.

Uptake of skin self-examination and clinical examination behavior by outdoor workers

This study investigated the association between outdoor work and response to a behavioral skin cancer early detection intervention among men 50 years or older. Overall, 495 men currently working in outdoor, mixed, or indoor occupations were randomized to a video-based intervention or control group. At 7 months post intervention, indoor workers reported the lowest proportion of whole-body skin self-examination (wbSSE; 20%). However, at 13 months mixed workers engaged more commonly in wbSSE (36%) compared with indoor (31%) and outdoor (32%) workers. In adjusted analysis, the uptake of early detection behaviors during the trial did not differ between men working in different settings. Outdoor workers compared with men in indoor or mixed work settings were similar in their response to an intervention encouraging uptake of secondary skin cancer prevention behaviors during this intervention trial.

Comparison of Florida skin cancer screening rates with those in different US regions

OBJECTIVES

Florida has the second highest incidence of melanoma in the United States, and more than 600 Floridians die from melanoma annually. Given the lack of population-based data on skin cancer screening among the different US geographic regions, we compared skin cancer screening rates among Floridians to those in the rest of the South, the Northeast, the Midwest, and the West.

METHODS

We used data from the 2000 and 2005 National Health Interview Survey. Data were grouped according to whether participants reported ever receiving a skin cancer examination in their lifetime. Data were pooled, and analyses accounted for sample weights and design effects. Multivariable logistic regression analyses were performed with self-reported skin screening as the outcome of interest.

RESULTS

Results showed that compared to the rest of the US, Floridians who were women 70 years old and older, reported being of "other" race, of non-Hispanic ethnicity, having a high school education, having health insurance, and employed in the service industry or unemployed, had significantly higher lifetime skin cancer screening rates than their subgroup counterparts residing in the other regions. Multivariable logistic regression showed that Floridians remained significantly more likely to have ever been screened for skin cancer compared to the other US regions after controlling for a variety of sociodemographic variables.

CONCLUSIONS

Increasing melanoma detection remains a national cancer goal for the US, and future identification of underlying causal factors for higher screening rates in Florida could inform intervention strategies in the other US regions.

Knowledge, perceptions, and practices of chiropractic interns in the early detection of atypical moles

OBJECTIVE

Skin cancer is a major public health concern in the United States. Chiropractic physicians and interns need to recognize and refer patients with atypical moles and skin cancer. The purpose of this study was to test chiropractic interns about their current knowledge, practices, and perceptions of atypical moles and skin cancer.

METHODS

This study was a cross-sectional study using chiropractic interns at 2 chiropractic colleges who received a 26-item survey that used a 5-point Likert scale involving close-ended questions regarding demographics, importance, knowledge, and clinical images regarding atypical moles and skin cancer. Frequencies and odds ratios (ORs) were generated using multiple regression models.

RESULTS

A total of 217 surveys were collected in the study. The importance of skin cancer recognition as a predictor of practice patterns was examined. Interns who stated it was "important/very important" to recognize skin cancer were slightly more likely to state they "frequently/always" scanned patient's skin on the initial visit, were more likely to state they "frequently/always" scanned on a treatment visit (OR = 3.30; 95% confidence interval [CI], 1.6-6.9), and stated they had noticed a mole that needed follow-up (OR = 3.04; 95% CI, 1.52-6.10). However, interns were no more likely to state they documented moles in the soap notes (OR = 1.38; 95% CI, 0.77-2.47) or to know the warning signs of melanoma (OR = 0.76; 95% CI, 0.40-1.46).

CONCLUSION

As skin cancer continues to increase in prevalence, chiropractic interns can serve in the primary screening process of patients with atypical moles; and chiropractic education should emphasize the opportunity to detect and assess atypical moles as a routine part of primary prevention in clinical education.

Ineffectiveness of sun awareness posters in dermatology clinics

BACKGROUND

Although sun awareness posters have been used in doctors' offices and clinics for decades to promote sun protective behaviour, there is no evidence of their usefulness.

OBJECTIVES

To investigate whether sun awareness posters lead to inquiry of skin cancer and sun protection measures.

METHOD

Patients considered at risk for skin cancer seen at a dermatology clinic were randomly asked to complete a questionnaire designed to assess the effectiveness of three different sun awareness posters placed in patient rooms. The posters were selected on the basis of their catchy slogan and eye-appealing images, and included those featuring parental interest, sex appeal and informative advice.

RESULTS

Only half of the patients noticed the posters (50.6%). The poster with sex appeal garnered the most attention (67.8%), followed by the informative poster (49.2%) and the parental interest poster (35.8%) (P < 0.001). Although patients who noticed the sun awareness poster inquired about cutaneous cancers and sun protection practices twice as often as those who did not notice the poster, only one-tenth of such inquiries were attributed to the poster ( approximately 5% of the target population). As reported in the questionnaire, the posters themselves were less effective than the advice of physicians in influencing patient attitudes towards sun protection measures.

CONCLUSION

Organizations that produce and disseminate posters should consider beyond focus groups when they design their posters and should consider field testing their products to ensure that they are reaching the targeted audience and are having the expected beneficial effect, otherwise their posters are simply decorative.

Skin self-examination of persons from families with familial atypical multiple mole melanoma (FAMMM)

OBJECTIVE

Early detection of melanomas might increase survival chance. Patients can usually see primary lesions while inspecting their skin. Skin self-examination (SSE) is therefore the recommended pre-screening method. To maximize the likelihood that SSE will be performed, it is important to distinguish those factors that increase the chance of performance. The aim is to examine motivational differences between (a) melanoma-prone persons who perform SSE once every 2-3 months, and (b) melanoma-prone persons with a lower SSE frequency.

METHODS

A survey to assess socio-demographic factors, attitude, social influence, self-efficacy and intention to perform SSE.

RESULTS

Members (n=71) of 18 familial atypical multiple mole melanoma (FAMMM) families participated; 70% performed SSE at least once every 2-3 months. Adequate performers were more likely to have a partner, had a more positive attitude toward SSE, perceived SSE as less difficult to perform and had a stronger intention to perform SSE compared to poor performers. Logistic regression indicated attitude as the only reliable predictor of SSE performance.

CONCLUSION

We found that about one third of our genetically predisposed population did not report an adequate frequency of performing SSE.

PRACTICE IMPLICATIONS

Deficiencies in SSE practices in a genetically predisposed population are indicated.

Time-trend of melanoma screening practice by primary care physicians: a meta-regression analysis

OBJECTIVE

To assess whether the proportion of primary care physicians implementing full body skin examination (FBSE) to screen for melanoma changed over time.

METHODS

Meta-regression analyses of available data.

DATA SOURCES

MEDLINE, ISI, Cochrane Central Register of Controlled Trials.

RESULTS

Fifteen studies surveying 10,336 physicians were included in the analyses. Overall, 15%-82% of them reported to perform FBSE to screen for melanoma. The proportion of physicians using FBSE screening tended to decrease by 1.72% per year (P =0.086). Corresponding annual changes in European, North American, and Australian settings were -0.68% (P =0.494), -2.02% (P =0.044), and +2.59% (P =0.010), respectively. Changes were not influenced by national guide-lines.

CONCLUSIONS

Considering the increasing incidence of melanoma and other skin malignancies, as well as their relative potential consequences, the FBSE implementation time-trend we retrieved should be considered a worrisome phenomenon.

Increased cancer risk for individuals with a family history of prostate cancer, colorectal cancer, and melanoma and their associated screening recommendations and practices

Prostate cancer, colorectal cancer, and melanoma are three malignancies that appear to have strong genetic components that can confer additional risk to family members. Screening tools, albeit controversial, are widely available to potentially aide in early diagnosis. Family members are now more attuned to the risks and benefits of cancer screening, thus, it is imperative that physicians understand the screening tools and how to interpret the information they provide. We reviewed the current literature regarding the cancer risks for individuals with a family history of prostate cancer, colon cancer, and melanoma, the current screening recommendations for family members, and actual screening practices of individuals with a family history of these malignancies. This review should serve as a guide for physicians and cancer control planners when advising their patients and the public regarding screening decisions.

Epidemiology of nonmelanoma skin cancer (NMSC) in Europe: accurate and comparable data are needed for effective public health monitoring and interventions

Nonmelanoma skin cancer (NMSC) is the most common malignancy occurring in white populations. It is currently becoming an important challenge in terms of public health management as the increasing incidence rates will probably have a tremendous impact on healthcare costs. Possible factors driving this rise in NMSC numbers are increases in both acute and prolonged UV exposure together with increasing numbers of older people in the population. A better understanding of NMSC epidemiology in Europe is essential if an evidence-based European-wide public health policy is to be developed. It is obvious this can only be achieved by recording and analysing comparative epidemiological data. Finally, by improving the skin examination training for physicians, developing guidelines and exchanging best practices, a high level of healthcare could be provided for NMSC.

Breslow depth of cutaneous melanoma: impact of factors related to surveillance of the skin, including prior skin biopsies and family history of melanoma

BACKGROUND

Because the early detection of cutaneous melanoma can dramatically improve survival, identification and surveillance of persons at risk have received much attention.

OBJECTIVE

Our purpose was to examine the influences of personal or family history, patterns of detection, and prior skin biopsies (considered to be a measurement of surveillance by medical personnel) on the Breslow depth of cutaneous melanomas.

METHODS

A retrospective cohort analysis of 218 patients with a history of at least one invasive cutaneous melanoma who visited the Yale Pigmented Lesion Clinic between January 1995 and January 1996 was performed. Data on patterns of detection, melanocytic nevi, and skin biopsies before and after the initial diagnosis of melanoma were collected, and patients with a family history of melanoma were compared with sporadic patients.

RESULTS

Initial melanomas discovered by dermatologists were more likely to be 0.75 mm or less in depth than those found by other physicians (P = .03). Although patients detected 45% of the initial primary melanomas (98/218), dermatologists discovered 80% of the second primary tumors (33/41; P = .001). A personal history of melanoma was predictive of a thinner Breslow depth (P = .01), but a family history of melanoma was not. Having a biopsy of any type or combination of types of skin lesion(s) performed in the 5 years, 2 years, or 1 year before the first diagnosis of melanoma did not predict a melanoma of thinner Breslow depth among either familial or sporadic patients. The mean number of skin biopsies performed per patient was 8 times higher in the 5-year period after (5.6) versus the 5-year period before (0.7) the initial diagnosis of melanoma, with a peak in the first year after the diagnosis (2.3 vs 0.25 in the prior year). In 27 patients, one or more skin biopsies were performed in the year before the initial diagnosis of melanoma; 41% of these biopsies (23/56) were of lesions in normally exposed sites (eg, the face, neck, and forearms) compared with 22% of the melanomas (6/27).

LIMITATIONS

Since an invasive melanoma (with the possible exception of a nodular melanoma) would likely have been present for at least a year, plausible explanations for why evidence of previous dermatologic care did not appear to result in earlier detection include performance of a limited rather than a total body skin examination as well as subtle clinical features of early melanomas. However, this study cannot give weight to these explanations because at the time new Pigmented Lesion Clinic patients were not routinely asked about previous total body skin examinations.

CONCLUSIONS

The disappointing trends seen in this study, with neither the well-established risk factor of a family history of melanoma nor previously having a skin biopsy predicting thinner melanomas, highlight the need to establish criteria defining the subset of patients for whom appropriate management requires periodic total body skin examination.

SunSmart? Skin cancer knowledge and preventive behaviour in a British population representative sample

The incidence of skin cancer has risen rapidly in the UK over the last 20 years, prompting public health organizations to try and raise awareness of the dangers of sun exposure and the need to practice sun-safe behaviour. This study aimed to assess baseline levels of sun-safe knowledge and behaviour in a British population-representative sample, prior to the launch of Cancer Research UK's 'SunSmart' campaign. A face-to-face survey was conducted through the Office for National Statistics as part of their Omnibus survey. In total, 1848 men and women aged 18 and over were interviewed. Knowledge of what to do to reduce skin cancer risk was modest. Two-thirds mentioned avoiding the sun by seeking shade, 50% mentioned covering up and only 43% said to use high factor sunscreen. Practice of sun-safe behaviours was also poor, with only one-third saying they sought shade, covered up or used high factor sunscreen to protect themselves from the sun. Men and those from lower socioeconomic groups were least informed and least likely to report using sun-protective behaviours. Increases in both knowledge and use of appropriate sun-protective behaviours are needed if skin cancer incidence rates are to decrease.

Role of clothes in sun protection

Ultraviolet (UV) radiation is the carcinogenic factor in sunlight. Damage to skin cells from repeated UV exposure can lead to the development of skin cancer. Apart from avoidance of the sun, the most frequently used form of UV protection has been the application of sunscreens. The use of textiles as a means of sun protection has been underrated in previous educational campaigns, even though suitable clothing offers usually simple and effective broadband protection against the sun. Apart from skin cancer formation, exacerbation of photosensitive disorders and premature skin aging could be prevented by suitable UV-protective clothing. Nevertheless, several studies have recently shown that, contrary to popular opinion, some textiles provide only limited UV protection. It has been found that one-third of commercial summer clothing items provide a UV protection factor (UPF) less than 15. Given the increasing interest in sun protection, recreationally and occupationally, test methods and a rating scheme for clothing were needed that would ensure sufficient UV protection. Various textile parameters have an influence on the UPF of a finished garment. Important parameters are the fabric porosity, type, color, weight and thickness. The application of UV absorbers into the yarns significantly improves the UPF of a garment. Under the conditions of wear and use several factors can alter the UV-protective properties of a textile, e.g., stretch, wetness and laundering. The use of UV-blocking cloths can provide excellent protection against the hazards of sunlight; this is especially true for garments manufactured as UV-protective clothing. However, further educational efforts are necessary to change people's sun behavior and raise awareness for the use of adequate sun-protective clothing.

Sunburn prevalence among adults in the United States, 1999

BACKGROUND

Exposure to high levels of sunlight, such as a sunburn, is a strong determinant of melanoma risk.

METHODS

To describe statewide and U.S. estimates of sunburn prevalence in the United States and determine demographic and behavioral predictors of sunburn, we analyzed data from the 1999 Behavioral Risk Factor Surveillance System, a population-based telephone survey conducted in all 50 states, the District of Columbia, and Puerto Rico.

RESULTS

Of 156,354 adults aged > or =18 years, 31.7% (95% confidence interval, 31.3%-32.1%) reported a sunburn in the past year; of adults aged 18 to 29 years, 57.5% reported such a sunburn. Reporting was highest among white, non-Hispanic males (44.1%), followed by white non-Hispanic females (35.3%), and lowest among black non-Hispanic males and females (5.1% and 5.3%, respectively). Statewide period prevalence of sunburn among whites was highest (>45%) in Wisconsin, Utah, Wyoming, Washington, DC, and Indiana, and lowest (<30%) in Puerto Rico, Arizona, Tennessee, Oklahoma, and New York.

CONCLUSIONS

Nationwide and statewide skin cancer prevention efforts should target young adults. Periodic monitoring of sunburn is important in evaluating the effectiveness of those efforts.

Skin cancer screening by dermatologists: prevalence and barriers

BACKGROUND

The incidence of skin cancers is increasing at an alarming rate, and there is currently no consensus by major health policy organizations regarding skin cancer screening. It has previously been shown that primary care physicians do not screen a majority of patients for skin cancer.

OBJECTIVE

This study was undertaken to determine the prevalence of skin cancer screening among dermatologists and to detect barriers to screening. As a secondary objective, we set out to determine the prevalence of dermatoscopy use.

METHODS

With the use of membership data from the 1999-2000 directory of the American Academy of Dermatology, a random sample of 464 American dermatologists was surveyed to assess their skin cancer screening practices and perceived obstacles to this practice. We then determined whether differences in knowledge of skin cancer screening recommendations, emphasis of skin cancer screening in training, or physician age affected the prevalence of screening.

RESULTS

A total of 190 dermatologists responded (41%). Fifty-seven respondents (30%) reported performing full-body skin cancer screening on all of their adult patients and 93 more (49%) reported screening only patients perceived to be at increased risk. Eighty respondents (42%) reported lack of time as an impediment to screening. Only 18 (9%) did not screen patients because of potential patient embarrassment, whereas 17 (9%) did not perform screening because of lack of financial reimbursement. Sixty-two dermatologists (33%) reported being aware of official skin cancer screening recommendations, but they were not more likely to screen all patients (P =.64) or partake in screening of all patients or only those at increased risk (P =.84). One hundred nineteen respondents (63%) reported that skin cancer screening was emphasized during their medical training and they were more likely to screen all patients (P =.04) or either all or high-risk patients (P =.02). Younger age groups of dermatologists were significantly more likely to screen all patients for skin cancer (P =.03). Twenty-two percent of respondents reported using dermatoscopy for suspicious lesions.

CONCLUSION

Dermatologists report a high rate of screening for skin cancer despite not having knowledge of skin cancer screening recommendations. Inadequate time to perform full-body skin examinations and lack of emphasis during training were identified as possible barriers to this practice.

Skin cancer screening and prevention in the primary care setting: national ambulatory medical care survey 1997

OBJECTIVE

To describe skin cancer prevention and screening activities in the primary care setting and to compare these findings to other cancer screening and prevention activities.

DESIGN

Descriptive study.

SETTING/PATIENTS

National Ambulatory Medical Care Survey 1997 data on office-based physician visits to family practitioners and internists.

MEASUREMENTS AND MAIN RESULTS

Data were obtained on 784 primary care visits to 109 family practitioners and 61 internists. We observed that the frequency of skin cancer prevention and screening activities in the primary care setting was much lower than other cancer screening and prevention activities. Skin examination was reported at only 15.8% of all visits (17.4% for family practitioners vs 13.6% for internists, P >.1). For other cancer screening, the frequencies were as follows: breast examination, 30.3%; Papanicolaou test, 25.3%; pelvic examination, 27.6%; and rectal examination, 17.9%. Skin cancer prevention in the form of education and counseling was reported at 2.3% of these visits (2.9% for family practitioners vs 1.5% for internists, P >.1), while education on breast self-examination, diet and nutrition, tobacco use, and exercise was 13.0%, 25.3%, 5.7%, and 17.9%, respectively.

CONCLUSIONS

The results of this study indicate that the proportion of primary care visits in which skin cancer screening and prevention occurs is low. Strategies to increase skin cancer prevention and screening by family practitioners and internists need to be considered.

Follow-up and evaluation of skin cancer screening in British Columbia

BACKGROUND

Skin cancer screening is thought to be a useful public health tool for the early detection of skin cancers. However, few studies have reported on follow-up and outcome of subjects who have a positive screen.

OBJECTIVE

The aims of this study were to evaluate attendance at skin cancer screening clinics in British Columbia for the period 1994 and 1995 and to assess follow-up outcome among participants who were identified to have a potentially serious skin lesion that warranted further medical review.

METHODS

A self-administered questionnaire was sent to participants screening positive for skin cancer and to their attending physicians.

RESULTS

Five hundred twenty people were screened. Of these, 105 were referred for evaluation of a potential malignancy or precursor lesion. One melanoma, 3 basal cell carcinomas, 4 atypical nevi, and 1 actinic keratosis were histologically confirmed in 76 referred participants for whom follow-up information was available. The positive predictive values ranged from 17% to 89% depending on the screening diagnosis. Several false-positive results and one false-negative result were observed. Reasons for not seeking recommended follow-up were addressed.

CONCLUSIONS

Our yield and positive predictive values for different screening diagnoses were virtually identical to those previously reported in larger US studies. Improved communication between screening physicians and screening participants may improve follow-up rates in those people who would benefit from further medical care.

Sun and the skin: evaluation of a sun awareness program for elementary school students

BACKGROUND

Research suggests that childhood exposure to ultraviolet radiation is a significant risk factor for the development of melanoma and nonmelanoma skin cancers. Sun awareness education programs for children can positively influence children's sun protective practices to decrease the risk of skin cancer.

OBJECTIVE

The purpose of this study was to evaluate a sun awareness education program, entitled "Sun and the Skin" that had recently been developed and implemented in London, Ontario.

METHOD

The study uses a pre- and posttest design to evaluate both knowledge and behaviour of Grade 4 students participating in the program at baseline, immediately after, and 1 month after the program.

RESULTS

The students demonstrated a significant increase in their sun-protective practices after participation in the "Sun and the Skin" program. There was a significant improvement in the students' level of knowledge after the program. Improvement in both behaviour and knowledge were maintained weeks after completion of the program. Minor differences in knowledge due to demographic characteristics were detected after the program.

CONCLUSIONS

A sun awareness education program for Grade 4 students can improve both their knowledge and behaviour over time. This format should be used in conjunction with changes in school policy in order to make a significant longterm impact.

The role of screening in the management of skin cancer

The incidence of skin cancer has been rising at an alarming rate for the past several years. This poses a significant public health problem in the United States. Detection and treatment of melanoma early in its course is critical for improved outcome. Of the approaches to cancer control that can reduce mortality from melanoma and nonmelanoma skin cancer, screening holds the greatest promise for a rapid and major impact. Prevention and early detection are crucial in reducing morbidity and mortality from skin cancer. For a number of reasons, however, the full effect of screening for both melanoma and nonmelanoma skin cancers has not been achieved. Controversy exists regarding who should perform screening, who should be screened, and whether screening should be performed at all. It is clear that melanoma and nonmelanoma skin cancer control programs combining primary prevention, education, and screening are in developmental stages. This review will discuss the advantages and disadvantages of screening for skin cancer.

Public health interventions for melanoma. Prevention, early detection, and education

Worldwide melanoma control programs that include some combination of primary prevention, education, and screening activities have only recently begun to undergo an evaluation process. More studies with rigorous design and evaluation are needed. Until then, the proper public health policy guidelines for melanoma control, especially screening, are open to debate. Future studies must determine how screening, early detection, case finding, and education can best be used to reduce mortality and achieve optimal melanoma control.

Basal and squamous cell carcinomas. What every primary care physician should know

Skin cancer screening should be a part of every routine physical examination, and suspicious lesions should be biopsied. Basal and squamous cell carcinomas are highly curable with early diagnosis and treatment. Patient education about protection from the sun is an important part of treatment. Patients with a history of basal or squamous cell carcinoma are at increased risk for new skin cancers as well as recurrences, and lifelong, regular, total cutaneous examinations are essential to detect potentially curable skin carcinomas and melanomas. The frequency of follow-up depends on the number and types of previous skin cancers, as well as other risk factors, but as a rule, examinations should be performed at least yearly. Such a surveillance strategy should decrease morbidity and mortality among patients with these dangerous neoplasms.