Socioeconomic characteristics and melanoma incidence

Clustering trends of melanoma incidence and mortality: A worldwide assessment from 1995 to 2019

BACKGROUND

Melanoma is a skin cancer that has higher mortality among cutaneous malignant tumours. Tumour incidence in most world regions is rising. Here, we intend to highlight these trends in the world.

METHODS

We used the global burden of disease dataset to assess the incidence and mortality of melanoma from 1995 to 2019 in 204 countries/territories. To identify country/territory groups with similar trends of melanoma incidence and mortality, a model-based clustering with a mixture of multivariate t-distributions was used.

RESULTS

Australia and New Zealand had the largest incidence and mortality rates. Men in Egypt and women in Sri Lanka and Guam had the lowest incidence and mortality rates. The clustering analysis revealed 4 classes of incidence in both gender and 3 and 2 classes of mortality in male and female, respectively. All groups had a growing incidence rate in both gender, similar to the worldwide trend. In 10% of the countries/territories, central and Western Europe, the incidence increase rate was greater than in the countries/territories with the greatest incidence. The total mortality rate for men was steadily growing, although it was decreasing in Asian and African countries/territories. Overall, the mortality rate for women remained relatively steady over time.

CONCLUSION

Due to the increasing trend of melanoma in the world, primary and secondary prevention of this disease, especially in areas with higher incidence and mortality, is essential. Raising awareness about the disease is helpful in prevention and early detection of melanoma.

Malignant melanoma incidence among children and adolescents in Texas and SEER 13, 1995-2013

BACKGROUND

Epidemiological knowledge and predictors of melanoma among children and adolescents in multiethnic populations are limited.

PROCEDURE

Using data from the Texas Cancer Registry (TCR) and the Surveillance, Epidemiology, and End Results (SEER) 13 database, we identified incident melanoma cases diagnosed at 0-20 years old during 1995-2013 in Texas and the United States, respectively. Using negative binomial regression, associations between demographic factors and melanoma incidence rates (IR) were evaluated by calculating incidence rate ratios (IRR) and 95% confidence intervals (CI). Annual percent change in IRs was assessed with joinpoint regression.

RESULTS

Overall, the melanoma IR was 4.16 (TCR, n = 634) and 4.84 (SEER, n = 1260) per million. Females, adolescents, non-Hispanic (NH) whites, and Hispanics had higher IRs compared with other groups (P < 0.05). In adjusted analyses, Hispanics had a higher incidence of melanoma than NH non-whites (Texas IRR = 2.17; 95% CI, 1.30-3.61; SEER IRR = 2.88; 95% CI, 1.97-4.21). In Texas, NH whites with melanoma were more likely to live in low poverty areas, whereas the opposite trend was observed in Hispanics. Melanoma IRs increased throughout 1995-2004 followed by an average annual decrease of 7.6% (95% CI, -12.6%, -2.2%) in Texas and 6.0% (95% CI, -8.5%, -3.4%) in SEER during 2005-2013 (P < 0.05). However, these decreasing trends were not observed among Hispanics or those <10 years old.

CONCLUSION

Although the overall melanoma IR in children and adolescents appears to be decreasing, this trend is not evident among Hispanics and young children, implicating the need for further research investigating the etiologies and risk factors in these groups.

Disparities in the Presentation and Management of Cutaneous Melanoma That Required Admission

OBJECTIVE

In this study, we aimed to examine the association of demographic and socioeconomic factors with cutaneous melanoma that required admission.

METHODS

A cross-sectional study utilizing the Nationwide Inpatient Sample database, 2003-2009, was merged with County Health Rankings Data.

RESULTS

A total of 2,765 discharge -records were included. Men were more likely to have melanoma in the head, neck, and trunk regions (p < 0.001), while extremities melanoma was more common in women (p < 0.001). Males had a higher risk of lymph node metastasis on presentation (OR 1.54, 95% CI [1.27-1.89]). Blacks and Hispanics were more likely to present with extremities melanoma. Patients with low annual income were more likely to be treated by low-volume surgeons and in hospitals located in high-risk communities (p < 0.05 each). Patients with Medicaid coverage were twice as likely to present with distant metastasis and were more likely to be managed by low-volume surgeons (p < 0.05 each).

CONCLUSIONS

The presentation and outcomes of cutaneous melanoma have a distinct pattern of distribution based on patients' characteristics.

Menopausal hormone therapy and risk of melanoma: Do estrogens and progestins have a different role?

The association between use of menopausal hormone therapy (HT) and occurrence of skin malignant melanoma (SMM) is controversial. We investigated the issue in a nationwide cohort of 684,696 Norwegian women, aged 45-79 years, followed from 2004 to 2008. The study was based on linkage between Norwegian population registries. Multivariable Poisson regression models were used to estimate the effect of HT use, different HT types, routes of administration and doses of estrogen and progestin on the risk of SMM. During the median follow-up of 4.8 years, 178,307 (26%) women used HT, and 1,476 incident SMM cases were identified. Current use of HT was associated with increased risk of SMM (rate ratios (RR) = 1.19; 95% confidence interval (CI) 1.03-1.37). Plain estrogen therapy was associated with an increased risk of SMM (RR 1.45; 95% CI 1.21-1.73), both for oral (RR 1.45; 95% CI 1.09-1.93) and vaginal (RR 1.44; 95% CI 1.14-1.84) formulations, while combined estrogen and progestin therapy (EPT) was not (RR 0.91; 95% CI 0.70-1.19). We performed a dose-response analysis of estrogen and progestin in women using tablets, and found that use of estrogens was associated with increased risk (RR 1.24; 95% CI 1.00-1.53 per 1 mg/day) and use of progestins with decreased risk (RR 0.71; 95% CI 0.57-0.89 per 10 mg/month) of SMM. In conclusion, estrogens were associated with increased risk of SMM, while combinations of estrogens and progestins were not. Our results suggest that estrogens and progestins might affect the risk of SMM in opposite ways.

The role of spatially-derived access-to-care characteristics in melanoma prevention and control in Los Angeles county

Among 10,068 incident cases of invasive melanoma, we examined the effects of patient characteristics and access-to-care on the risk of advanced melanoma. Access-to-care was defined in terms of census tract-level sociodemographics, health insurance, cost of dermatological services and appointment wait-times, clinic density and travel distance. Public health insurance and education level were the strongest predictors of advanced melanomas but were modified by race/ethnicity and poverty: Hispanic whites and high-poverty neighborhoods were worse off than non-Hispanic whites and low-poverty neighborhoods. Targeting high-risk, underserved Hispanics and high-poverty neighborhoods (easily identified from existing data) for early melanoma detection may be a cost-efficient strategy to reduce melanoma mortality.

Alcohol consumption and risk of melanoma among women: pooled analysis of eight case-control studies

While alcohol consumption is known to increase the risk of several types of cancer, evidence regarding the association between alcohol and melanoma is inconclusive. This pooled analysis was conducted to examine total alcohol consumption (grams per day), and type of alcohol consumed (beer, wine, beer and wine combined, and liquor) in relation to melanoma among women using original data from eight completed case-control studies (1886 cases and 2113 controls), with adjustment for the potential confounding effects of sun exposure-related factors. We found a positive association with ever consuming alcohol [adjusted pooled odds ratio (pOR) 1.3, 95 % confidence interval (CI) 1.1-1.5]. Specifically the pORs were 1.4 (95 % CI 1.1-1.8) for wine, 1.1 (95 % CI 0.9-1.5) for beer and 1.2 (95 % CI 1.0-1.4) for liquor. However, the pOR for the highest fourth of consumption compared with never consumption was 1.0 (95 % CI 0.7-1.3) without evidence of a trend with increasing amount of total alcohol, or separately with amount of beer, wine or liquor consumed. Stratifying by anatomic site of lesion, number of nevi, age group, or histologic subtype did not alter these results. Although the results showed a weak positive association between ever consuming alcohol and melanoma occurrence, our findings do not provide strong support for the hypothesis that alcohol consumption plays a role in the development of melanoma in women.

Socioeconomic status and glioblastoma risk: a population-based analysis

PURPOSE

Socioeconomic status (SES) is associated with risk of various cancer types because of correlation between SES and causal factors or increased case ascertainment, or both. Studies evaluating the association between glioblastoma and occupational or SES factors have yielded inconsistent results. We evaluated the association between SES and glioblastoma risk using a large, population-based cancer registry dataset.

METHODS

Data of the Surveillance, Epidemiology, and End Results Program were used to evaluate the impact of SES on glioblastoma risk. SES was divided into quintiles on the basis of census tract of residence. Census tracts are small, geographically defined areas with relatively homogeneous population characteristics.

RESULTS

Higher SES was strongly associated with increased risk of glioblastoma (p < .001). Relative to persons living in census tracts of the lowest SES quintile, the highest SES quintile had a rate ratio of 1.45 (95 % CI 1.39-1.51) (p < .001). Similar associations were seen in population subgroups defined by age, sex, and race.

CONCLUSIONS

The strong association between higher SES and greater glioblastoma risk is unlikely to represent an ascertainment effect because glioblastoma is rapidly progressive and ultimately fatal. A number of previously proposed glioma risk factors may be correlated with SES, including atopy and allergy rates, cellular telephone use, and body morphometric measures. Further research is needed to define the mechanism of this association.

The association between a living wage and subjective social status and self-rated health: a quasi-experimental study in the Dominican Republic

Poverty, both absolute and relative, is associated with poorer health. This is of particular concern in middle- and low-income countries facing a significant and growing burden of disease. There has been limited research specifically on whether interventions that increase income may foster better health outcomes. The establishment of a "living wage" apparel factory in the Dominican Republic provided a minimum income standard for factory workers, thus creating a natural experiment through which to study the effects of increased income on health indicators. The primary component of the intervention was a 350% wage increase, but apparel workers in the intervention factory also received education and professional development and were exposed to an enhanced occupational health and safety program. Workers at the intervention factory (n = 99) were compared with workers at a matched apparel factory (n = 105). Data were collected via in-person interviews in July and August of 2011, which was 15-16 months after workers were initially hired at the intervention site. Primary analyses used employment at the intervention factory as the independent variable and examined associations with two dependent variables: subjective social status and self-rated health. Results showed that receiving a 350% higher wage was associated with substantially higher subjective social status scores, as well as higher global and comparative self-rated health scores; effects were strongest in women. Subjective social status and self-rated health are associated with future health outcomes, so these results indicate that income increases for apparel workers may have positive long-term health outcomes, particularly for women.

Randomized controlled trial of a sun protection intervention for children of melanoma survivors

BACKGROUND

We studied whether a melanoma survivor-centered intervention was more effective than materials available to the general public in increasing children's sun protection.

METHODS

In a randomized controlled trial, melanoma survivors (n = 340) who had a child ≤ 12 years received a targeted sun protection intervention (DVD and booklets) or standard education. Primary outcomes were children's sunburns, children's sun protection, and survivors' psychosocial factors at baseline and postintervention (1 and 4 months).

RESULTS

The intervention increased children's sunscreen reapplication at 1 month (P = 0.002) and use of wide-brimmed hats at 4 months (P = 0.045). There were no effects on other behaviors or sunburns. The intervention improved survivors' hats/clothing self-efficacy at both follow-up assessments (P = 0.026, 0.009). At 4 months, the intervention improved survivors' clothing intentions (P = 0.029), knowledge (P = 0.010), and outcome expectations for hats (P = 0.002) and clothing (P = 0.037). Children's sun protection increased with survivors' intervention use. The intervention was less effective in survivors who were female or who had a family history, older children, or children with higher baseline sun protection scores.

CONCLUSIONS

A melanoma survivor-centered sun protection intervention can improve some child and survivor outcomes. The intervention may be more effective in survivors who have younger children or less experience with sun protection. Intervention delivery must be enhanced to maximize use.

IMPACT

This is the first study to examine a sun protection intervention for children of melanoma survivors. Findings will guide interventions for this important population at increased melanoma risk.

Melanoma thickness: the role of patients' characteristics, risk indicators and patterns of diagnosis

BACKGROUND

Factors associated with early vs. late diagnosis of cutaneous melanoma remain poorly understood.

OBJECTIVE

To identify factors with a significant impact on melanoma thickness.

METHODS

Patients with previous melanoma (n = 347, median age at diagnosis: 56.5 years, 44.7% female, 55.3% male) were recruited for this monocentre, non-randomized, observational study between April 2012 and March 2013. All patients were assessed by means of a structured interview and systematic clinical and dermoscopic full-body examination. Melanoma thickness in association with patients' characteristics, risk indicators and patterns of diagnosis was submitted to statistical analyses.

RESULTS

Univariate analyses revealed associations between a statistically significant lower Breslow thickness and participation in specialized dermoscopic screening programs, personal history of more than one previous melanoma, diagnostic examination with a dermatoscope, diagnostic examination by board certified dermatologist, high number of common and/or atypical nevi, younger age at time of diagnosis, higher level of education, or superficial spreading or lentigo maligna melanoma subtype (all P ≤ 0.01). In a multivariate regression analysis only three of these criteria: (i) participation in specialized screening programs (P < 0.0001); (ii) melanoma subtype (P < 0.0001); and (iii) diagnostic examination with a dermatoscope (P = 0.040) and one interaction term ('younger age' x 'female sex', P < 0.0001) showed an independent influence on a significantly lower melanoma thickness.

CONCLUSIONS

The screening of patients in specialized surveillance programs resulted in melanoma detection at significantly earlier stages. The use of dermoscopy, SSM or LMM histotype and younger age in connection with female sex were also characteristics that were independently associated with significantly thinner melanomas in multivariate analyses.

Correlation of cancer incidence with diet, smoking and socio- economic position across 22 districts of Tehran in 2008

BACKGROUND

Variation in cancer incidence in geographical locations is due to different lifestyles and risk factors. Diet and socio-economic position (SEP) have been identified as important for the etiology of cancer but patterns are changing and inconsistent. The aim of this study was to investigate correlations of the incidence of common cancers with food groups, total energy, smoking, and SEP.

MATERIALS AND METHODS

In an ecological study, disaggregated cancer data through the National Cancer Registry in Iran (2008) and dietary intake, smoking habits and SEP obtained through a population based survey within the Urban Health Equity Assessment (Urban-HEART) project were correlated across 22 districts of Tehran.

RESULTS

Consumption of fruit, meat and dairy products adjusted for energy were positively correlated with bladder, colorectal, prostate and breast and total cancers in men and women, while these cancers were adversely correlated with bread and fat intake. Also prostate, breast, colorectal, bladder and ovarian cancers had a positive correlation with SEP; there was no correlation between SEP and skin cancer in both genders and stomach cancer in men.

CONCLUSIONS

The incidence of cancer was higher in some regions of Tehran which appeared to be mainly determined by SEP rather than dietary intake. Further individual data are required to investigate reasons of cancer clustering.

Desigualdades socioeconômicas na incidência e mortalidade por câncer: revisão de estudos ecológicos, 1998-2008

INTRODUÇÃO: Desigualdades socioeconômicas se manifestam na incidência e mortalidade por neoplasias malignas. Estudos ecológicos representam abordagem essencial em epidemiologia e podem contribuir na investigação dos determinantes sociais dos eventos em saúde. OBJETIVO: Investigar associações entre nível socioeconômico e incidência e mortalidade por câncer e seus tipos, através de revisão de estudos ecológicos. Definir a real importância desempenhada pelos estudos ecológicos na investigação dessa relação. MÉTODO: As principais bases de dados regionais e internacionais foram pesquisadas na seleção de artigos em português, espanhol e inglês, publicados entre 1998 e 2008. RESULTADOS: 32 estudos elegíveis foram incluídos. Verificou-se associação positiva e consistente do nível socioeconômico da área de residência com incidência de câncer de próstata e mortalidade pelo de cólon nos homens, e com incidência e mortalidade por câncer de mama e mortalidade pelo de cólon nas mulheres. Associação consistente e negativa foi encontrada para incidência e mortalidade por cânceres de esôfago e estômago, para incidência dos de cólon e pulmão e mortalidade pelos de laringe e cavidade oral, nos homens, e para incidência e a mortalidade pelos de esôfago, estômago e colo uterino e para incidência dos de cólon e pulmão, nas mulheres. CONCLUSÃO: Apesar da presença de efeito residual de área e de viés relacionado à medida agregada de nível socioeconômico, estudos ecológicos podem ser eficientemente utilizados na mensuração das desigualdades socioeconômicas em câncer. Uso de pequenas unidades geográficas e de dados de registros de câncer em países em desenvolvimento pode contribuir para melhor conhecimento de suas desigualdades em saúde.

Glitch in the gradient: additional education does not uniformly equal better health

While the relationship between education and general health has been firmly established in the literature, surprisingly little research has analyzed individual components of the global health judgments, such as chronic conditions or pain. We present a systematic account of the health gradient for multiple health outcomes by detailed educational categories among U.S. working-age adults. Using the 1997-2010 National Health Interview Surveys (N = 204,764), we analyze individual health outcomes ranging from cardiovascular disease to vision problems with a series of logistic regression models. The results at the presecondary and baccalaureate levels are consistent with the health gradient. An unexpected finding occurs among adults with some college but no degree, and those with technical/vocational associate degrees: these groups report more pain and a higher prevalence of a broad range of conditions than high school graduates who never attended college. We discuss several explanations for the observed patterns. The findings challenge the broadly accepted educational gradient in health; additionally, the lower postsecondary groups comprise a quarter of American adults. Jointly, there is a clear research and policy impetus to understand the source of this 'glitch' in the health gradient.

Update on the current state of melanoma incidence

The incidence of melanoma is rising worldwide, and in the United States has increased by approximately 2.8% annually since 1981. Melanoma is more common in whites, and is generally more prevalent in men. However, there is a 6.1% annual increase in US incidence of melanomas in white women younger than age 44, with growing concern that increases in skin cancer in younger women may reflect recent trends in indoor tanning. Melanoma incidence is also greater in higher economic groups. Globally, melanoma incidence is highest in Australia, followed by the United States and parts of Europe.

Association of cutaneous melanoma incidence with area-based socioeconomic indicators-United States, 2004-2006

BACKGROUND

Socioeconomic status (SES) has been associated with melanoma incidence and outcomes. Examination of the relationship between melanoma and SES at the national level in the United States is limited. Expanding knowledge of this association is needed to improve early detection and eliminate disparities.

OBJECTIVE

We sought to provide a detailed description of cutaneous melanoma incidence and stage of disease in relationship to area-based socioeconomic measures including poverty level, education, income, and unemployment in the United States.

METHODS

Invasive cutaneous melanoma data reported by 44 population-based central cancer registries for 2004 to 2006 were merged with county-level SES estimates from the US Census Bureau. Age-adjusted incidence rates were calculated by gender, race/ethnicity, poverty, education, income, unemployment, and metro/urban/rural status using software. Poisson multilevel mixed models were fitted, and incidence density ratios were calculated by stage for area-based SES measures, controlling for age, gender, and state random effects.

RESULTS

Counties with lower poverty, higher education, higher income, and lower unemployment had higher age-adjusted melanoma incidence rates for both early and late stage. In multivariate models, SES effects persisted for early-stage but not late-stage melanoma incidence.

LIMITATIONS

Individual-level measures of SES were unavailable, and estimates were based on county-level SES measures.

CONCLUSION

Our findings show that melanoma incidence in the United States is associated with aggregate county-level measures of high SES. Analyses using finer-level SES measures, such as individual or census tract level, are needed to provide more precise estimates of these associations.

Recent trends in cutaneous melanoma incidence and death rates in the United States, 1992-2006

BACKGROUND

Increasing cutaneous melanoma incidence rates in the United States have been attributed to heightened detection of thin (≤ 1-mm) lesions.

OBJECTIVE

We sought to describe melanoma incidence and mortality trends in the 12 cancer registries covered by the Surveillance, Epidemiology, and End Results program and to estimate the contribution of thin lesions to melanoma mortality.

METHODS

We used joinpoint analysis of Surveillance, Epidemiology, and End Results incidence and mortality data from 1992 to 2006.

RESULTS

During 1992 through 2006, melanoma incidence rates among non-Hispanic whites increased for all ages and tumor thicknesses. Death rates increased for older (>65 years) but not younger persons. Between 1998 to 1999 and 2004 to 2005, melanoma death rates associated with thin lesions increased and accounted for about 30% of the total melanoma deaths.

LIMITATIONS

Availability of long-term incidence data for 14% of the US population was a limitation.

CONCLUSIONS

The continued increases in melanoma death rates for older persons and for thin lesions suggest that the increases may partly reflect increased ultraviolet radiation exposure. The substantial contribution of thin lesions to melanoma mortality underscores the importance of standard wide excision techniques and the need for molecular characterization of the lesions for aggressive forms.

Association between cutaneous melanoma incidence rates among white US residents and county-level estimates of solar ultraviolet exposure

BACKGROUND

Recent US studies have raised questions as to whether geographic differences in cutaneous melanoma incidence rates are associated with differences in solar ultraviolet (UV) exposure.

OBJECTIVES

We sought to assess the association of solar UV exposure with melanoma incidence rates among US non-Hispanic whites.

METHODS

We assessed the association between county-level estimates of average annual solar UV exposure for 1961 to 1990 and county-level melanoma incidence rates during 2004 to 2006. We used Poisson multilevel mixed models to calculate incidence density ratios by cancer stage at diagnosis while controlling for individuals' age and sex and for county-level estimates of solar UV exposure, socioeconomic status, and physician density.

RESULTS

Age-adjusted rates of early- and late-stage melanoma were both significantly higher in high solar UV counties than in low solar UV counties. Rates of late-stage melanoma incidence were generally higher among men, but younger women had a higher rate of early-stage melanoma than their male counterparts. Adjusted rates of early-stage melanoma were significantly higher in high solar UV exposure counties among men aged 35 years or older and women aged 65 years or older.

LIMITATIONS

The relationship between individual-level UV exposure and risk for melanoma was not evaluated.

CONCLUSIONS

County-level solar UV exposure was associated with the incidence of early-stage melanoma among older US adults but not among younger US adults. Additional studies are needed to determine whether exposure to artificial sources of UV exposure or other factors might be mitigating the relationship between solar UV exposure and risk for melanoma.

Skin cancer risk perceptions: a comparison across ethnicity, age, education, gender, and income

BACKGROUND

Studies of noncutaneous and cutaneous malignancies support the hypothesis that poor risk-perception status contributes to health disparity.

OBJECTIVE

We evaluated skin cancer (SC) risk perceptions across race and other demographic markers using the Health Information National Trends Survey (HINTS) and compared them to discover differences in perception that may contribute to the disparities in SC diagnosis and treatment.

METHODS

Respondents with no history of SC were randomly selected to answer questions assessing perceived risk and knowledge of preventive strategies of SC. Logistic regression was performed to identify associations between perceptions of SC and demographic variables including self-described race, age, sex, education, income, and health insurance status.

RESULTS

Blacks, the elderly, and people with less education perceived themselves as at lower risk of developing SC. They, along with Hispanics, were also more likely to believe that one cannot lower their SC risk and that there are so many different recommendations on how to prevent SC that it makes it difficult to know which ones to follow. Lower education also correlated with greater reluctance to have a skin examination.

LIMITATIONS

HINTS is a cross-sectional instrument, thus it only provides a snapshot of SC perceptions.

CONCLUSION

Uncertainty and altered perceptions are more common in the SC risk perceptions of ethnic minorities, the elderly, and those with less education. These are the same groups that are subject to disparities in SC outcomes. Educational programs directed at these demographic groups may help to reduce the SC-related health disparities.

Socioeconomic factors and diagnosis of uveal melanoma in the mid-southern United States

PURPOSE

To establish the base incidence of uveal melanoma in the mid-southern United States and to explore the regional frequency of uveal melanoma diagnosis as a function of area-based socioeconomic measures (ABSM) aggregated at the level of small geographic units delimited by Zoning Improvement Plan (ZIP) codes.

METHODS

Based on a retrospective chart review (1996-2007) of patients seen at our institutions with the diagnosis of uveal melanoma, the number of uveal melanoma cases was calculated for each ZIP-code in Arkansas, Mississippi, western Tennessee and Louisiana. The base incidence of uveal melanoma was calculated using the population size reported in the 2000 census as the population at risk for each geographic area. Data on the average house value and average household income reported in the 2000 census were used in a Poisson regression analysis to examine their effect on the frequency of uveal melanoma diagnosis.

RESULTS

There were 327 (of 1,669) regional ZIP-codes that were the source of 457 patients with uveal melanoma. Higher ABSM, defined as greater average house value or household income, were positively associated with the number of observed melanoma cases per ZIP-code. The annualized incidence of uveal melanoma was at least 3.5 cases per million in the areas studied.

CONCLUSION

Higher ABSM were associated with the increased frequency of uveal melanoma diagnosis in the regions studied. Extrapolating from similar trends observed with non-ocular cancers, this may signify a need for increased access to ophthalmologic care to ensure timely diagnosis.

Racial differences in survival after surgical treatment for melanoma

BACKGROUND

Surgical-treatment outcomes for melanoma in African Americans are poorly characterized as a result of low incidence of melanoma among African Americans. We examined differences by race in overall and melanoma-specific survival, stratified by receipt of surgical treatment and by specific types of surgical treatment.

METHODS

Data from the 1973-2004 public-use Surveillance, Epidemiology and End Results Program (SEER) were analyzed by Cox proportional hazard models to compare the effects of surgical treatments on overall and melanoma-specific survival in blacks, whites, and other race, controlling for confounding demographic and tumor-related variables.

RESULTS

Of 151,154 patients with first primary melanoma (148,883 whites, 789 blacks and 1,532 other race), 142,653 (94.4%) received surgical treatment. Among patients who received surgical treatment, 10-year melanoma-specific survival was lower in blacks (73%) than in whites (88%) and other race (85%); black patients were at significantly higher risk of overall and melanoma-specific mortality when compared with white (hazard ratio [HR] = 1.64, 95% confidence interval [CI] 1.44-1.86, P < 0.0001 and HR = 1.50, 95% CI 1.25-1.79, P < 0.0001, respectively) and with other race (HR = 1.55, 95% CI 1.31-1.85, P < 0.0001 and HR = 1.49, 95% CI 1.16-1.91, P = 0.0017, respectively). Blacks who underwent biopsy, wide excision and surgery not otherwise specified were at higher risk of overall mortality compared with whites with the same treatment.

CONCLUSION

Overall and melanoma-specific survival was lower in blacks undergoing surgical treatment for melanoma compared to both whites and other race. Reasons for these disparities remain poorly understood.

Interaction of area-level socioeconomic status and UV radiation on melanoma occurrence in California

BACKGROUND

Melanoma incidence has been correlated strongly and positively with both socioeconomic status (SES) and lower latitude and other measures of ambient UV radiation (UVR). However, because high-SES populations may be colocated in areas of high UVR, we assessed their joint influences on melanoma occurrence to better target subpopulations for melanoma education and screening.

METHODS

We obtained from the California Cancer Registry information regarding 23,564 incident cases of invasive cutaneous melanoma among non-Hispanic white residents between January 1, 1998, and December 31, 2002. We geocoded each case based on residence at diagnosis and linked previously tested neighborhood measures of SES and average annual UVR to calculate age-adjusted incidence rates, rate ratios, and the corresponding 95% confidence intervals. Poisson regression was used to calculate multivariately adjusted rate ratios.

RESULTS

UVR was significantly and positively associated with melanoma incidence only among persons living in the top 40% of California neighborhoods ranked by SES. People in neighborhoods of the highest SES and UVR categories had 60% higher rates of melanoma than those from neighborhoods in the lowest categories (rate ratio, 1.60; 95% confidence interval, 1.02-2.51).

CONCLUSION

Our findings indicate that UVR and SES interact to influence melanoma occurrence and suggest that socioeconomic gradients in melanoma incidence are not explained entirely by UVR.

IMPACT

Cancer prevention and early detection educational efforts should be targeted to high-SES groups in areas of high UVR exposure. Contextual measures of both SES and UVR should be considered important determinants of melanoma occurrence in future studies.

The expanding melanoma burden in California hispanics: Importance of socioeconomic distribution, histologic subtype, and anatomic location

BACKGROUND

The incidence patterns and socioeconomic distribution of cutaneous melanoma among Hispanics are poorly understood.

METHODS

The authors obtained population-based incidence data for all Hispanic and non-Hispanic white (NHW) patients who were diagnosed with invasive cutaneous melanoma from 1988 to 2007 in California. By using a neighborhood-level measure of socioeconomic status (SES), the variables investigated included incidence, thickness at diagnosis, histologic subtype, anatomic site, and the relative risk (RR) for thicker (>2 mm) versus thinner (≤ 2 mm) tumors at diagnosis for groups categorized by SES.

RESULTS

Age-adjusted melanoma incidence rates per million were higher in NHWs (P < .0001), and tumor thickness at diagnosis was greater in Hispanics (P < .0001). Sixty-one percent of melanomas in NHWs occurred in the High SES group. Among Hispanics, only 35% occurred in the High SES group; and 22% occurred in the Low SES group. Lower SES was associated with thicker tumors (P < .0001); this association was stronger in Hispanics. The RR of thicker tumors versus thinner tumors (≤ 2 mm) in the Low SES group versus the High SES group was 1.48 (95% confidence interval [CI], 1.37-1.61) for NHW men and 2.18 (95% CI, 1.73-2.74) for Hispanic men. Patients with lower SES had less of the superficial spreading melanoma subtype (especially among Hispanic men) and more of the nodular melanoma subtype. Leg/hip melanomas were associated with higher SES in NHW men but with lower SES in Hispanic men.

CONCLUSIONS

The socioeconomic distribution of melanoma incidence and tumor thickness differed substantially between Hispanic and NHW Californians, particularly among men. Melanoma prevention efforts targeted to lower SES Hispanics and increased physician awareness of melanoma patterns among Hispanics are needed.

Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study

BACKGROUND

Population-based cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute (NCI) are mainly based on medical records and administrative information. Individual-level socioeconomic data are not routinely reported by cancer registries in the United States because they are not available in patient hospital records. The U.S. representative National Longitudinal Mortality Study (NLMS) data provide self-reported, detailed demographic and socioeconomic data from the Social and Economic Supplement to the Census Bureau's Current Population Survey (CPS). In 1999, the NCI initiated the SEER-NLMS study, linking the population-based SEER cancer registry data to NLMS data. The SEER-NLMS data provide a new unique research resource that is valuable for health disparity research on cancer burden. We describe the design, methods, and limitations of this data set. We also present findings on cancer-related health disparities according to individual-level socioeconomic status (SES) and demographic characteristics for all cancers combined and for cancers of the lung, breast, prostate, cervix, and melanoma.

METHODS

Records of cancer patients diagnosed in 1973-2001 when residing 1 of 11 SEER registries were linked with 26 NLMS cohorts. The total number of SEER matched cancer patients that were also members of an NLMS cohort was 26,844. Of these 26,844 matched patients, 11,464 were included in the incidence analyses and 15,357 in the late-stage diagnosis analyses. Matched patients (used in the incidence analyses) and unmatched patients were compared by age group, sex, race, ethnicity, residence area, year of diagnosis, and cancer anatomic site. Cohort-based age-adjusted cancer incidence rates were computed. The impact of socioeconomic status on cancer incidence and stage of diagnosis was evaluated.

RESULTS

Men and women with less than a high school education had elevated lung cancer rate ratios of 3.01 and 2.02, respectively, relative to their college educated counterparts. Those with family annual incomes less than $12,500 had incidence rates that were more than 1.7 times the lung cancer incidence rate of those with incomes $50,000 or higher. Lower income was also associated with a statistically significantly increased risk of distant-stage breast cancer among women and distant-stage prostate cancer among men.

CONCLUSIONS

Socioeconomic patterns in incidence varied for specific cancers, while such patterns for stage were generally consistent across cancers, with late-stage diagnoses being associated with lower SES. These findings illustrate the potential for analyzing disparities in cancer outcomes according to a variety of individual-level socioeconomic, demographic, and health care characteristics, as well as by area measures available in the linked database.

Education and risk of cancer in a large cohort of men and women in the United States

BACKGROUND

Education inequalities in cancer incidence have long been noted. It is not clear, however, whether such inequalities persist in the United States, especially for less common malignancies and after adjustment for individual risk factors.

METHODOLOGY/PRINCIPAL FINDINGS

Within the NIH-AARP Diet and Health Study, we examined the association between education and the risk of developing cancers in a prospective cohort of 498,455 participants who were 50-71 year old and without cancer at enrollment in 1995/96. During a maximum 8.2 years of follow-up we identified 40,443 cancers in men and 18,367 in women. In age-adjusted models, the least educated men (

CONCLUSIONS/SIGNIFICANCE

We found a higher risk of malignant disease, particularly smoking- related cancers, among those in the lowest educational attainment category. Only some of the educational gradient is attributable to smoking. The persistence of substantial education inequalities in cancer incidence poses a challenge for etiologic research and public health policy.

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Key Words Collapse

MESH Headings

• Aged
• Animals
• Educational Status
• Female
• Humans
• Male
• Middle Aged
• Neoplasms/epidemiology
• Prospective Studies
• Risk Factors
• Smoking
• United States/epidemiology

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Grants

• Intramural NIH HHS

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Affiliation(s)

Traci Mouw Division of Epidemiology, Public Health & Primary Care, Faculty of Medicine, Imperial College London, London, United Kingdom
Annemarie Koster Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, National Institutes of Health, Bethesda, Maryland, United States of America Faculty of Health, Medicine and Life Sciences, Universiteit Maastricht, Maastricht, The Netherlands
Margaret E. Wright Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, United States of America
Madeleine M. Blank Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
Steven C. Moore Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
Albert Hollenbeck AARP, Washington, D. C., United States of America
Arthur Schatzkin Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America

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Melanoma in Hispanic and Black Americans

Background

Although age-adjusted incidence rates (per 100,000) for melanoma are lower among Hispanics and blacks (4.5 and 1.0, respectively) compared with white non-Hispanics (21.6), melanomas among minority populations in the United States are more likely to metastasize and have poorer outcomes.

Methods

A review of the literature was conducted on melanomas affecting Hispanic and black Americans.

Results

Because of the low index of suspicion in both the medical community and these ethnic populations, diagnosis is often delayed, resulting in advanced presentation and a poorer prognosis.

Conclusions

More comprehensive medical training, expanded public educational campaigns, and increased awareness among patients of all skin types to perform self skin checks are recommended. Further studies elucidating the etiology and risk factors for melanoma among minority populations are warranted.

[Behaviors related to sunlight exposure versus protection in a random population sample from 15 Brazilian State capitals and the Federal District, 2002-2003]

This article examines region-specific relations between prevalence of protection against sunlight and socio-demographic and behavioral variables in Brazil. Data were derived from a cross-sectional population-based random sample. Information on sunlight exposure was available for a total of 16,999 individuals 15 years and older. Comparing the North and South of Brazil, crude differences between women and men in the use of "sunscreen" and "protective headwear" were +10.9% (95%CI: 7.1; 14.6) and -11.6% (95%CI: -17.0; -6.3) in the North and +21.3% (95%CI: 17.7; 24.9) and -16.0% (95%CI: -20.2; -12.5) in the South. Adjusted differences by selected variables confirmed that women use more sunscreen protection and less headwear protection as compared to men in both the North and South, but the difference was not homogeneous by region (interaction term p value < 0.05).

Factors associated with a high tumour thickness in patients with melanoma

BACKGROUND

Prognosis of patients with melanoma is strongly associated with tumour thickness at time of diagnosis. Therefore, knowledge of patient characteristics and behaviour associated with a high tumour thickness is essential for the development and improvement of melanoma prevention campaigns.

OBJECTIVES

The present study aimed to identify sociodemographic, clinical and behavioural factors associated with high tumour thickness according to Breslow.

METHODS

The study population consisted of 217 patients with histologically proven primary invasive cutaneous melanomas seen at the Department of Dermatology and Allergology at the Ludwig-Maximilian-University Munich, Germany, between January 1999 and January 2001. Personal interviews were conducted by two physicians to obtain information on sociodemographic characteristics and on patients' knowledge of melanoma symptoms, sun behaviour, delay in diagnosis and related factors. Multivariate linear and logistic regression analysis with stepwise variable selection was used to identify risk groups with a high tumour thickness. To assess possible effect modifications, interaction terms were included in the regression analysis.

RESULTS

The median tumour thickness was 0.8 mm (interquartile range 0.5-1.6). Fifty-seven patients (26%) had tumour thickness >1.5 mm. In a multivariate linear regression analysis, patients living alone and patients with a low educational level showed a significantly greater tumour thickness. The relation of melanoma knowledge to tumour thickness was modified by the melanoma subtype: whereas lack of melanoma knowledge led to an increased tumour thickness for the subtypes superficial spreading melanoma, lentigo maligna melanoma and unspecified malignant melanoma, no significant effect was estimated for the subtypes nodular melanoma (NM) and acrolentiginous melanoma (ALM). Sex, age, self-detection of melanoma, patient delay and professional delay were not significantly associated with the tumour thickness in multivariate linear regression. Similar results were found in multivariate logistic regression.

CONCLUSIONS

An increased tumour thickness was found in subjects living alone and having a low educational level. These subjects should be targeted in future prevention campaigns in a more focused way. Further efforts are necessary to improve knowledge and earlier detection of melanoma subtypes NM and ALM.

A randomized trial to improve early detection and prevention practices among siblings of melanoma patients

BACKGROUND

Identifying high-risk individuals for melanoma education and risk reduction may be a viable strategy to curb the incidence of melanoma, which has risen precipitously in the past 50 years. The first-degree relatives of melanoma patients represent a risk group who may experience a 'teachable moment' for enhanced education and risk reduction.

METHODS

We report a randomized trial testing an intervention that provided personalized telephone counseling and individually tailored materials to siblings of recently-diagnosed melanoma patients. The purpose of this study was to test whether an intervention could lead to improvements in siblings' skin cancer risk reduction practices. Intervention condition participants received the following: (1) an initial motivational and goal-setting telephone intervention session delivered by the health educator; (2) three sets of computer-generated materials specifically tailored to individual responses from the baseline survey; (3) three telephone counseling sessions with the health educator, timed to follow receipt of the mailed materials; and (4) linkages to free screening programs. Families in the usual care arm received the suggestion from the physician that patients diagnosed with melanoma notify the family members about their diagnosis and encourage the family members to be screened.

RESULTS

494 siblings were recruited to the study and 403 siblings remained in the study through at least 6 months. At 12 months, intervention siblings were more likely to examine all moles, including those on the back (OR, 1.76; 95% CI, 1.06-2.91). Compared with baseline, the number of participants in both groups that had received a skin cancer examination more than doubled, with no differences between groups. At 12 months, two-thirds of siblings in both groups reported routine use of sunscreen, but there were no differences in change over baseline between the two groups.

CONCLUSIONS

This study is the one of the first, to our knowledge, to address skin cancer risk-reduction strategies in a sample of individuals who have a recent family diagnosis of melanoma. Diagnosis of melanoma in a family member provides an important opportunity to intervene with others in that family. The components of the intervention may provide a useful foundation for future efforts to target the more than half million siblings at risk for melanoma, a lethal but preventable disease.

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

Background

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

Results

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

Conclusion

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

Slip! Slap! Slop! Cutaneous malignant melanoma incidence and social status in New Zealand, 1995-2000

Numerous studies have noted a strong social gradient in many types of ill health. In particular, people in more deprived areas tend to be less healthy than those in more affluent communities, even once the demographic and socio-economic differences of the people in those areas have been taken into account. The social gradient is evident for many types of health outcomes, including diseases such as cancer. However, this positive relationship is not evident for rates of melanoma incidence and mortality, with rates of the disease tending to decrease with measures of disadvantage. In this study, we assess the relationship between the incidence of melanoma and deprivation in New Zealand, a country with particularly high rates of the disease. In the light of greater public awareness of the risk factors associated with melanoma, through public awareness campaigns such as 'Slip! Slap! Slop' and 'No Suntan is Safe', we analyse small-area data on standardised rates of melanoma for the period 1995-2000. We found that melanoma rates increase with social status, even once other confounding factors are controlled for, but that the relationship is very small. Furthermore, the relationship between melanoma incidence and deprivation is context-dependent. Possible explanations for the relationship between melanoma and deprivation are discussed, including more frequent exposure to intermittent sunshine among less disadvantaged groups and the underreporting of melanoma incidence in the New Zealand cancer registry among individuals in lower social groups.

Non-Cancer Mortality among People Diagnosed with Cancer (Australia)

OBJECTIVE

To investigate whether people diagnosed with cancer have an increased risk of death from non-cancer causes compared to the general population.

METHODS

The non-cancer mortality of people diagnosed with cancer in Queensland (Australia) between 1982 and 2002 who had not died before 1 January 1993 was compared to the mortality of the total Queensland population, matching by age group and sex, and reporting by standardised mortality ratios.

RESULTS

Compared to the non-cancer mortality in the general population, cancer patients (all cancers combined) were nearly 50% more likely to die of non-cancer causes (SMR = 149.9, 95% CI = [147-153]). This varied by cancer site. Overall melanoma patients had significantly lower non-cancer mortality, female breast cancer patients had similar non-cancer mortality to the general population, while increased non-cancer mortality risks were observed for people diagnosed with cervical cancer, colorectal cancer, prostate cancer, non-Hodgkin lymphoma and lung cancer.

CONCLUSIONS

Although cancer-specific death rates underestimate the mortality directly associated with a diagnosis of cancer, quantifying the degree of underestimation is difficult due to various competing explanations. There remains an important role for future research in understanding the causes of morbidity among cancer survivors, particularly those looking at both co-morbid illnesses and reductions in quality of life.

Melanoma and ionizing radiation: is there a causal relationship?

This review was initiated in response to concerns that ionizing radiation could be a cause of melanoma. Studies presenting the relative risks for melanoma after external ionizing radiation exposure were in seven categories: (1) The Canadian Radiation Dose Registry, (2) nuclear industry workers, (3) subjects near nuclear test blasts, (4) survivors of the atomic bombings of Japan, (5) airline pilots and cabin attendants, (6) recipients of medical radiation, and (7) radiological technicians. Relative risks for leukemia in each of the studies were used to confirm the likelihood of exposure to ionizing radiation. When studies within a category were compatible, meta-analytic methods were used to obtain combined estimates of the relative risk, and a meta-regression analysis of melanoma relative risk compared to leukemia relative risk was used to examine consistency across exposure categories. Generally, exposure categories with elevated relative risks of leukemia had proportionately elevated relative risks of melanoma. This suggests that people exposed to ionizing radiation may be at increased risk of developing melanoma, although alternative explanations are possible. Future epidemiological studies of ionizing radiation effects should include melanoma as an outcome of interest.

Meta-analysis of risk factors for cutaneous melanoma: III. Family history, actinic damage and phenotypic factors

A systematic meta-analysis of observational studies of melanoma and family history, actinic damage and phenotypic factors was conducted as part of a comprehensive meta-analysis of all major risk factors for melanoma. Following a systematic literature search, relative risks were extracted from 60 studies published before September 2002. Fixed and random effects models were used to obtain pooled estimates for family history (RR = 1.74, 1.41-2.14), skin type (I vs. IV: RR = 2.09, 1.67-2.58), high density of freckles (RR = 2.10, 1.80-2.45), skin colour (Fair vs. Dark: RR = 2.06, 1.68-2.52), eye colour (Blue vs. Dark: RR = 1.47, 1.28-1.69) and hair colour (Red vs. Dark: RR = 3.64, 2.56-5.37), pre-malignant and skin cancer lesions (RR = 4.28, 2.80-6.55) and actinic damage indicators (RR = 2.02, 1.24-3.29). Sub-group analysis and meta-regression were carried out to explore sources of between-study variation and bias. Sensitivity analyses investigated reliability of results and publication bias. Latitude and adjustment for phenotype were two study characteristics that significantly influenced the estimates.

Sun Exposure, Phenotypic Characteristics, and Cutaneous Malignant Melanoma. An Analysis According to Different Clinico-Pathological Variants and Anatomic Locations (Italy)

OBJECTIVE

The aim of the study was to examine the relation between sun exposure and other selected risk factors and the development of different clinico-pathological variants of cutaneous malignant melanoma (CMM) at different body locations.

METHODS

We analysed data from a case-control study conducted in Italy between 1992 and 1994 on 542 cases of CMM and 538 hospital controls. Clinico-pathological variants included 391 superficial spreading (SSM), 72 nodular (NM) and 39 lentigo maligna (LMM) melanomas.

RESULTS

The risk of SSM increased for a high education level (odds ratio, OR = 1.5, 95% confidence interval, CI, 1.0-2.2), sunburn episodes before age 15 (OR = 1.8, 95% CI, 1.1-2.8), light eye colour (OR = 1.6, 95% CI, 1.1-2.4) and solar lentigines (OR = 1.4, 95% CI, 1.0-1.8). The ORs for total number of nevi >30 were 4.4 (95% CI, 2.9-6.7) for SSM, 5.7 (95% CI, 2.6-12.5) for NM and 2.2 (95% CI, 0.5-9.4) for LMM. The risk of CMM located on the trunk seemed to be higher for a high education level (OR = 1.6, 95% CI, 1.0-2.6) and propensity to sunburn (OR = 1.6, 95% CI, 0.8-3.2). The ORs for sunburn episodes, eye and skin colour, and solar lentigines tended to be higher for CMM located on the face/neck and on the upper limbs than the trunk. Total number of nevi was strongly associated with all anatomic locations.

CONCLUSIONS

Total number of nevi was the major risk factor associated with all melanoma variants and locations. A higher level of education and sunburn episodes in early childhood appeared to be more strongly related to SSM than to other variants.

Skin cancer prevention and detection practices among siblings of patients with melanoma

BACKGROUND

Family members of patients with melanoma have an increased risk of the disease, and families with multiple affected members account for about 10% of melanoma cases. These statistics suggest that first-degree relatives of patients with melanoma, who are at particularly high risk, warrant targeted public health action.

OBJECTIVE

We sought to document rates for dermatologist examinations for cutaneous lesions, the practice of skin self-examination, and sunscreen use in this at-risk group.

METHODS

Before participation in a randomized trial, 404 siblings of recently diagnosed patients with melanoma completed a survey on beliefs and practices regarding skin cancer prevention and detection.

RESULTS

Sixty-two percent of participants had carefully examined their skin, 54% routinely used sunscreen, and 27% had received a skin cancer examination by a dermatologist during the past year; 47% had never received a dermatologist examination. Multivariate analysis found modifiable positive predictors for skin self-examination and dermatologist examinations, including having a clinician with whom to talk about melanoma and believing in the importance of regular skin examinations by a physician. Significant modifiable negative predictors included enjoyment of being tanned, not being sure what to look for when examining moles, and feeling uncomfortable having others look at their skin.

CONCLUSIONS

Skin self-examination rates among these high-risk siblings are markedly higher than in population-based studies. However, many siblings were not screened for skin cancer by a dermatologist despite having strong risk profiles, being nearly fully insured, and being under care of primary care physicians. Improvements in communication between physicians and high-risk families and changes in office systems to assess family history of melanoma could increase screening rates for the estimated 1 million siblings of patients with melanoma.

An assessment of factors related to tumor thickness and delay in diagnosis of melanoma in southern Italy

BACKGROUND

Since survival of patients with melanoma is strongly correlated with the Breslow tumor thickness of the primary lesion, factors that influence stage at diagnosis and delay in diagnosis are considered to be crucial. To test the relationship between tumor thickness and some social and clinical variables (including diagnosis/treatment delay) and the relationship between the diagnosis/treatment delay and some clinical variables, we analyzed data on 530 patients with melanoma from our Institute.

METHODS

In the analysis, Breslow tumor thickness was categorized into two categories (< or =1.49, > or =1.5). Three time intervals were examined to evaluate diagnostic delay: patient delay, time from first symptom to seeking medical advice; medical delay, time from first medical consultation to hospital admission; total delay, time from first symptom to resection. The variables evaluated in the analysis were: age at diagnosis, education, occupational status, first symptom, visibility of tumor, anatomic site, and physician who made the initial diagnosis.

RESULTS

A significant risk of having a Breslow tumor thickness > or =1.5 mm was noted in patients who had a low level of education (odds ratio 3.0, 95% confidence interval 1.9-5.0) or who were unemployed (odds ratio 1.7, 95% confidence interval 1.1-2.8). With respect to patient delay, a delay >3 months for anatomic locations visible to patients was associated with significant risk (odds ratio 1.7, 95% confidence interval 1.1-2.6); with respect to medical delay, a delay >3 months was associated with a higher risk in patients examined by a dermatologist (odds ratio 2.0, 95% confidence interval 1.2-3.4).

CONCLUSIONS

Our results clearly indicate that in Southern Italy poorly educated and unemployed subjects are at risk of being diagnosed at a more advanced stage, and admission to an oncological hospital causes a delay (waiting list) in the time interval related to the doctor (medical delay).