Individual and ecological factors associated with early detection of nodular melanoma in the United States

Incidence and Mortality of Malignant Melanoma in Relation to Dermatologist Density in Bavaria

INTRODUCTION

Malignant melanoma is an aggressive skin tumor with a good prognosis when treated in an early tumor stage, but has a poor prognosis with distant metastases. The incidence of malignant melanoma has increased continuously over the last decades, with little change in mortality. One explanation for this is that melanomas are increasingly detected in early stages, especially after the establishment of statutory skin cancer screening in 2008, which allows a free skin examination every 2 years for people older than 35 years.

METHODS

In this study incidence and mortality of malignant melanoma were correlated with the dermatologist density in Bavarian administrative regions. In addition, the incidence data were compared before and after the introduction of statutory skin cancer screening.

RESULTS

There was a significant correlation between the incidence of malignant melanoma and dermatologist density (r = 0.258, p = 0.044), but no correlation between mortality and dermatologist density (r = 0.201, p = 0.121). Similarly, the increase of malignant melanoma incidence following the introduction of statutory skin cancer screening in 2008 was independent of dermatologist density (r = 0.021, p = 0.873).

CONCLUSION

The dermatologist density in Bavaria correlates positively with the incidence of malignant melanoma. Despite an increased incidence, mortality was not elevated in the respective administrative regions.

Late-Stage Melanoma in New York State: Associations with Socioeconomic Factors and Healthcare Access at the County Level

A diagnosis of late-stage melanoma is associated with significant mortality. From a public health perspective, the knowledge of geographic disparities in late-stage diagnoses can inform efforts to facilitate the diagnosis of the earlier stage, highly curable melanomas. We conducted a county-level analysis of melanoma in New York state to identify communities that may benefit from pilot health interventions to reduce the burden of late-stage melanoma. From 1995 to 2016, late-stage melanoma incidence increased from 1.5 to 2.8 cases per 100,000 in New York state. We found statistically significant associations between decreased county-level health system access (including physician density and resident educational status) and increased county incidence and proportion of late-stage disease among diagnosed cases (P < 0.001 for both). Increased county-level socioeconomic status, including measures of resident wealth and medical insurance status, was positively associated with greater late-stage incidence (P < 0.001). However, decreased county-level socioeconomic status was positively associated with a greater proportion of late-stage disease among cases at diagnosis (P = 0.009). Counties with reduced access to physician services and lower socioeconomic status may be suitable for pilot interventions promoting the recognition and diagnosis of early-stage melanomas to reduce late-stage diagnoses and associated mortality.

Patient-identified early clinical warning signs of nodular melanoma: a qualitative study

BACKGROUND

Nodular (NM) and superficial spreading melanoma (SSM) show different disease trajectories, with more rapid development in NM and fewer opportunities for early detection often resulting in worse outcomes. Our study described the patient-identified early signs of thin NM via comparisons to thin (≤ 2 mm) SSM and thick (> 2 mm) NM.

METHODS

We conducted semi-structured interviews with NM and SSM patients and analyzed the data using thematic analysis.

RESULTS

We enrolled 34 NM and 32 SSM patients. Melanoma early signs uniquely identified by patients with thin NM included white, blue or black coloration, "dot-like" size, fast changes in shape and color observed over 2 weeks, elevation and texture or "puffiness" over 6-12 months, and the sensation that the mole "did not feel right". Early signs reported by both thin NM and thin SSM patients included round or oblong shape, "jagged" border, pink/red, brown/reddish or dark coloration, "elevated like a pimple" or "tiny bump", fast color darkening, diameter growth, and border irregularity, and mole feeling "really itchy".

CONCLUSIONS

We found evidence that early signs of NM can be self-identified, which has important implications for the earlier detection of this most aggressive type of melanoma by both health professionals and patients.

A nomogram for predicting survival in patients with nodular melanoma: A population-based study

The use of traditional American Joint Committee on Cancer (AJCC) staging alone has limitations in predicting patient survival with nodular melanoma (NM). We aimed to establish a comprehensive prognostic nomogram and compare its prognostic value with the AJCC staging system.A nomogram was constructed to predict the 3-year and 5-year survival rates of NM patients by Cox regression. Several common model-validation parameters were used to evaluate the performance of our survival model.The multivariate analyses demonstrated that the age at diagnosis; being divorced, separated, or widowed; AJCC stages II, III, and IV; a regional SEER stage and the lymph-node density (LND) were risk factors for survival. The concordance index, the area under the time-dependent receiver operating characteristic curve, and calibration plots indicated that the nomogram performed well, while the net reclassification improvement and the integrated discrimination improvement showed that the nomogram performed better than the AJCC staging system. Finally, the decision curve analyses curves of the nomogram yielded net benefits that were higher than when using AJCC staging system with either the training or the validation cohort.The prognostic value of the nomogram is better than that of the AJCC staging system alone. In addition, we found that LND is an important risk factor for the survival of NM patients. The nomogram developed in this study may be a valuable tool for clinical practice when advising patients about their survival risk over the next 3 to 5 years.

Melanoma: clinical, evolutive and histopathological characteristics of a series of 136 cases

BACKGROUND

The incidence of melanoma has been increasing in Brazil and all over the world. Despite improvements in diagnosis and treatment, mortality remains unchanged.

OBJECTIVE

To associate clinical and histopathological aspects with the evolution of 136 cases of cutaneous melanoma.

METHODS

Retrospective cohort study that analyzed all patients diagnosed with melanoma during the period from 2003 to 2011, with at least 4 years follow up. Archived slides were analyzed to study histopathological variables (Breslow, ulceration, mitoses and histological regression). Medical records were used to retrieve clinical variables (age, sex, localization, time of appearance, diameter) and progression (metastases or death). Association measures were assessed by statistical analysis.

RESULTS

There was no statistically significant difference between groups according to age. Superficial spreading subtype showed lower Breslow (0.5mm) than acral lentiginous and nodular subtypes (2 and 4.6mm respectively), less ulceration and metastases (9.4% against 50 and 70.6%). Nodular subtype had higher mitoses' median (5.0/mm2) than superficial spreading and lentigo maligna (0.0/mm2, for both). Regression was more frequent in superficial spreading and lentigo maligna subtypes. There were only deaths by melanoma in the acral group, however, there were deaths for other reasons in groups superficial spreading one, acral lentiginous one and lentigo maligna two.

STUDY LIMITATIONS

Use of medical records as a source of data to the study.

CONCLUSIONS

Superficial spreading subtype presents better prognosis indicators. Histological subtype should be considered in follow-up and treatment protocols of patients with cutaneous melanoma.

Association of Skin Examination Behaviors and Thinner Nodular vs Superficial Spreading Melanoma at Diagnosis

Importance

Early melanoma detection strategies include skin self-examination (SSE), physician skin examination (PSE), and promotion of patient knowledge about skin cancer.

Objective

To investigate the association of SSE, PSE, and patient attitudes with the detection of thinner superficial spreading melanoma (SSM) and nodular melanoma (NM), the latter of which tends to elude early detection.

Design, Setting, and Participants

This cross-sectional, questionnaire-based, multicenter study identified patients with newly diagnosed cutaneous melanoma at 4 referral hospital centers in the United States, Greece, and Hungary. Among 920 patients with a primary invasive melanoma, 685 patients with SSM or NM subtype were included.

Interventions

A standardized questionnaire was used to record sociodemographic information, SSE and PSE practices, and patient perceptions in the year prior to diagnosis.

Main Outcomes and Measures

Data were analyzed according to histologic thickness, with a 2-mm cutoff for thinner SSM and NM.

Results

Of 685 participants (mean [SD] age, 55.6 [15.1] years; 318 [46%] female), thinner melanoma was detected in 437 of 538 SSM (81%) and in 40 of 147 NM (27%). Patients who routinely performed SSE were more likely to be diagnosed with thinner SSM (odds ratio [OR], 2.61; 95% CI, 1.14-5.40) but not thinner NM (OR, 2.39; 95% CI, 0.84-6.80). Self-detected clinical warning signs (eg, elevation and onset of pain) were markers of thicker SSM and NM. Whole-body PSE was associated with a 2-fold increase in detection of thinner SSM (OR, 2.25; 95% CI, 1.16-4.35) and thinner NM (OR, 2.67; 95% CI, 1.05-6.82). Patient attitudes and perceptions focusing on increased interest in skin cancer were associated with the detection of thinner NM.

Conclusions and Relevance

Our findings underscore the importance of complementary practices by patients and physicians for the early detection of melanoma, including regular whole-body PSE, SSE, and increased patient awareness.

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.

Impact of Socioeconomic Status and Ethnicity on Melanoma Presentation and Recurrence in Caucasian Patients

OBJECTIVES

The impact of ethnicity and the socioeconomic status (SES) among Caucasians is not well studied. Here, we examine the impact of income on melanoma presentation and prognosis within a Caucasian cohort, accounting for ethnicity, as some reports suggest increased melanoma incidence in Ashkenazi Jewish (AJ) BRCA mutation carriers.

METHODS

We studied prospectively enrolled primary melanoma patients at New York University. SES data were estimated using United States' Census Bureau data and patient zip codes. We evaluated associations between ethnicity, SES, and baseline characteristics using the χ² test and multivariate logistic regression. We compared survival distributions using Kaplan-Meier curves, log-rank tests, and Cox proportional hazard ratios.

RESULTS

Of the 1,339 enrolled patients, AJ represented 32% (n = 423). Apart from AJ being older at presentation (p < 0.001), no significant differences were observed in baseline characteristics between ethnic groups. Patients with a median household income (MHI) lower than the median of the cohort were significantly more likely to present with advanced stages (p < 0.001) compared to patients with a higher MHI. Shorter overall (p = 0.016) and post-recurrence survival (p = 0.042) was also observed in patients from lower-income households.

CONCLUSION

Data suggest that disparities in melanoma presentation in Caucasians stratify according to income independent of ethnic background.