Cutaneous malignant melanoma in Scotland: incidence, survival, and mortality, 1979-94. The Scottish Melanoma Group

United States burden of melanoma and non-melanoma skin cancer from 1990 to 2019

BACKGROUND

Skin cancer is the most common cancer worldwide.

OBJECTIVE

To evaluate the burden of skin cancer in the US from 1990 to 2019.

METHODS

Age-standardized incidence, prevalence, disability-adjusted life years (DALY), and mortality rates from skin cancer in the US were evaluated from the Global Burden of Disease 2019.

RESULTS

Incidence, prevalence, DALY, and mortality rates for melanoma per 100,000 persons in 2019 were 17.0, 138, 64.8, and 2.2, respectively; for squamous cell carcinoma, rates were 262, 314, 26.6, and 0.8, respectively; and for basal cell carcinoma, rates were 525, 51.2, 0.2, and zero, respectively. Incidence and prevalence rates of melanoma and non-melanoma skin cancer (NMSC) have increased since 1990, while mortality rates have remained fairly stable. Males have had higher incidence, prevalence, DALY, and mortality rates from melanoma and NMSC every year since 1990. Incidence and prevalence of melanoma was relatively higher in the northern half of the US than in the southern half.

LIMITATIONS

Global Burden of Disease is derived from estimation and mathematical modeling.

CONCLUSIONS

Health care professionals can utilize differences and trends noted in this study to guide allocation of resources to reduce incidence and morbidity from skin cancer.

Immunotherapy for older patients with melanoma: From darkness to light?

Approximately 40% of malignant melanomas are diagnosed in patients older than 65 years. Elderly patients with melanoma present clinicopathological features related to a more aggressive biology, and they are often diagnosed with advanced stage of disease. Interestingly, in older patients the immune system can be altered with changes both in the innate system and in the adaptive immune system with the acquisition of a pro-inflammatory and immune suppressive phenotype. Immunotherapy with immune checkpoint inhibitors has reshaped the treatment strategies and prognosis of patients with melanoma, and particularly, older age should not be considered a contraindication for immunotherapy. However, data regarding efficacy and safety of immunotherapy in elderly population are still limited because frail older patients are generally excluded from clinical trials. Recently, real-world data have shed light on similar efficacy and safety of immunotherapy in older population compared with younger counterpart. The aim of the present review was to summarize the available knowledge on the underlying immune system in older patients with a diagnosis of melanoma and the immunotherapeutic approaches in this population.

Small Nodular Melanoma: The Beginning of a Life-Threatening Lesion. A Clinical Study on 11 Cases

Aims and background

Because of its high thickness, nodular melanoma often bears a poor prognosis. Thus, an earlier diagnosis of this type of lesion while it is still thin would be an important step in secondary prevention. The principal aim of the present study was to better define the initial clinical features of nodular melanoma to allow an early diagnosis. A secondary aim was to establish the prognosis of this type of lesion.

Methods

We retrospectively studied and illustrated the clinical features of 11 small (≤6 mm maximum diameter) cutaneous nodular melanomas seen and treated during a 10-year period. Prognostic characteristics of the various lesions were also described.

Results

The results of the study help to describe a small nodular melanoma as a dark and/or pink/red raised lesion, which may be evenly or unevenly colored, with well-defined borders, that often appears de novo. A correct clinical diagnosis was made in 7 of the cases. During a median follow-up of 6 years, none of the patients had local or distant relapses.

Conclusions

Detection of small nodular melanoma is feasible by accurate visual inspection, provided that physicians are aware of this type of lesion and maintain the index of suspicion at a high level to bring about curative surgery. Free full text available at www.tumorionline.it

Trends in the diagnosis and clinical features of melanoma in situ (MIS) in US men and women: A prospective, observational study

BACKGROUND

The incidence of melanoma in situ (MIS) is increasing, but little is known about its clinical and epidemiologic features.

OBJECTIVE

We sought to determine trends in diagnosis and clinical features of MIS.

METHODS

Incident cases of melanoma were collected prospectively from the Nurses' Health Study (1976-2010) and Health Professionals Follow-up Study (1986-2010).

RESULTS

MIS incidence increased from 2 to 42 per 100,000 person-year among women, and from 11 to 73 per 100,000 person-year among men, exceeding the rate of increase of invasive melanomas. Melanoma mortality initially increased during the follow-up period then plateaued. Men were more likely than women to develop in situ melanomas on the upper half of the body (P < .001). Invasive melanomas were diagnosed at a younger age than MIS (P < .001), and were more likely to be found on the lower extremities than MIS (P < .001).

LIMITATIONS

This is a strictly descriptive study without examination into mechanisms.

CONCLUSION

We found epidemiologic and clinical differences for in situ and invasive melanomas, which support further examination into the variations in etiologic pathways. The lack of improvement in mortality despite the increase in detection of in situ relative to invasive lesions further highlights the need to improve invasive melanoma-specific clinical screening features.

Trends in Invasive Cutaneous Melanoma in Saskatchewan 1970–1999

Background:

Melanoma incidence rates have increased dramatically in white populations worldwide during the past several decades. A more modest increase has been observed for melanoma-related mortality. Cause-specific and disease-free survivals are related to tumor characteristics, gender, age, and possibly anatomic site. It is difficult to accurately assess these trends without information on tumor thickness that is often unavailable.

Objective:

This study determines trends in melanoma incidence, mortality, and survival in Saskatchewan for a 30-year period, incorporating analysis of tumor thickness.

Methods:

Information about cases of primary cutaneous melanoma for the 30-year period 1970–1999 was obtained from the population-based Saskatchewan Cancer Registry. A 50% random sample of charts was reviewed to collect information about Breslow depth, Clark level, and other demographic data not available from the Registry. Multivariate regression analysis was used to determine the significance of prognostic factors on incidence and five-year relative survival rates.

Results:

The number of patients registered increased dramatically during the study period. The increase was greatest for thin lesions in all age groups. Anatomic site varied by gender. Head and neck tumors showed continual increase in risk with increasing age. Mortality rates in females have been stable over time but increased for males in the 1990s. The prognostic factors that predicted excess mortality at five years were tumor thickness, Clark level, and gender.

Conclusion:

The observed increase in melanoma appears to be real and not the result of increased surveillance or screening. Tumor characteristics (Breslow depth, Clark level) and gender were significant prognostic indicators of five-year excess mortality.

Sex differences in the incidence of skin and skin-related diseases in Olmsted County, Minnesota, United States, and a comparison with other rates published worldwide

Many skin and skin-related diseases affect the sexes unequally, with attendant implications for public health and resource allocation. To evaluate better the incidence of skin and skin-related diseases affecting males vs. females, we reviewed published population-based epidemiology studies of skin disorders performed utilizing Rochester Epidemiology Project data. Females had a higher incidence of the following diseases: connective tissue diseases (scleroderma, morphea, dermatomyositis, primary Sjögren syndrome, systemic lupus erythematosus [not in all studies]), pityriasis rosea, herpes progenitalis, condyloma acuminatum, hidradenitis suppurativa, herpes zoster (except in children), erythromelalgia, venous stasis syndrome, and venous ulcers. Males had a higher incidence of psoriasis and psoriatic arthritis, basal cell carcinoma (exception, females aged ≤40 years), squamous cell carcinoma, and lentigo maligna. Incidence rates were equal in males and females for cutaneous malignant melanoma (exception, higher in females aged 18-39 years), lower-extremity cellulitis, cutaneous nontuberculous mycobacterial infection, Behçet disease, delusional infestation, alopecia areata, and bullous pemphigoid. Many of the population-based sex-specific incidence rates of skin and skin-related diseases derived from the Rochester Epidemiology Project are strikingly different from those estimated elsewhere. In general, females are more commonly affected by skin and skin-related diseases. The reasons for this imbalance remain to be determined and are likely multifactorial.

Association of sentinel lymph node biopsy with survival for head and neck melanoma: survival analysis using the SEER database

IMPORTANCE

Sentinel lymph node biopsy (SLNB) provides prognostic information for melanoma; however, a survival benefit has not been demonstrated.

OBJECTIVE

To assess the association of SLNB with survival for melanoma arising in head and neck subsites (HNM).

DESIGN, SETTING, AND PARTICIPANTS

Propensity score-matched retrospective cohort study using the Surveillance Epidemiology and End Results (SEER) database to compare US patients with HNM meeting current recommendations for SLNB, treated from 2004 to 2011 with either (1) SLNB with or without neck dissection, or (2) no SLNB or neck dissection.

INTERVENTIONS

SLNB with or without neck dissection.

MAIN OUTCOMES AND MEASURES

Disease-specific survival (DSS) estimates based on the Kaplan-Meier method, and Cox proportional hazards modeling to compare survival outcomes between matched pair cohorts.

RESULTS

A total of 7266 patients with HNM meeting study criteria were identified from the SEER database. Matching of treatment cohorts was performed using propensity scores modeled on 10 covariates known to be associated with SLNB treatment or melanoma survival. Cohorts were stratified by tumor thickness (thin, >0.75-1.00 mm Breslow thickness; intermediate, >1.00-4.00 mm; and thick, >4.00 mm) and exactly matched within 5 age categories. In the intermediate-thickness cohort, 2808 patients with HNM were matched and balanced by propensity score for SLNB treatment; the 5-year DSS estimate for those treated by SLNB was 89% vs 88% for nodal observation (log-rank P = .30). The hazard ratio for melanoma-specific death was 0.87 for those undergoing SLNB (95% CI, 0.66-1.14; P = .31). In each of the other cohorts analyzed, including those with thin and thick melanomas, and cohorts with melanoma overall, no significant difference in DSS was demonstrated.

CONCLUSIONS AND RELEVANCE

This SEER cohort analysis demonstrates no significant association between SLNB and improved disease-specific survival for patients with HNM.

Efficacy of a general practitioner training campaign for early detection of melanoma in France

BACKGROUND

To date, no strategy for improving early diagnosis of melanoma has been evaluated on a population basis in France.

OBJECTIVE

To evaluate the efficacy of a general practitioner (GP) awareness and training campaign in a pilot French geographical region (Champagne-Ardenne), including 1.34 million inhabitants, 1241 GPs, 56 dermatologists and a population-based melanoma registry.

METHODS

All GPs received repeated awareness postal mailings in 2008 and 398 (32.1%) attended training sessions organized by 27 dermatologists. The pre- (2005-7) and post-campaign (2009-11) periods were compared for the following: primary endpoint - the world-standardized incidence of very thick melanomas (VTM) (Breslow thickness ≥ 3 mm); secondary endpoints--the mean Breslow thickness; the proportions of VTM and of thin (< 1 mm) melanomas among invasive cases; and the ratio of in situ/all melanoma cases. Similar measures were performed in the control area of Doubs/Belfort territory (655,000 ha), where no similar campaign was carried out.

RESULTS

The incidence of VTM decreased from 1.07 to 0.71 per 100 000 habitants per year (P = 0.01), the mean Breslow thickness from 1.95 to 1.68 mm (P = 0.06) and the proportion of VTM from 19.2% to 12.8% (P = 0.01). The proportion of thin and in situ melanomas increased from 50.9% to 57.4% (P = 0.05) and from 20.1% to 28.2% (P = 0.001), respectively. No significant variation was observed in Doubs/Belfort territory.

CONCLUSION

These results strongly support the efficacy of such a campaign targeting GPs and provide a rationale for a larger public health campaign in France, including training of GPs by dermatologists and encouraging patients to ask their GP for a systematic skin examination.

Malignant melanoma in the elderly: different regional disease and poorer prognosis

Purpose: Age is a poor prognostic factor in melanoma patients. Elderly melanoma patients have a different presentation and clinical course than younger patients. We evaluated the impact of age ≥70 years (yrs) on the diagnosis and natural history of melanoma.

Methods: Retrospective review of 610 patients with malignant melanoma entered into a prospective sentinel lymph node (SLN) database, treated from June 1997 to June 2010. Disease characteristics and clinical outcomes were compared between patients ≥70 yrs vs. <70 yrs of age.

Results: 237 patients (39%) were ≥70 yrs. Elderly patients had a higher proportion of head and neck melanomas (34% vs. 20%, p<0.001), and greater mean tumor thickness (2.4mm vs. 1.8mm, p<0.001). A greater proportion of T3 or T4 melanoma was seen in the elderly (p<0.001) as well as a greater mean number of mitotic figures: 3.6/mm² vs. 2.7/mm² (p=0.005). Despite greater mean thickness, the incidence of SLN metastases was less in the ≥70 yrs group with T3/T4 melanomas (18% vs. 33%, p=0.02). The elderly had a higher rate of local and in-transit recurrences, 14.5% vs. 3.4% at 5 yrs (p<0.001). 5 yr disease-specific mortality and overall mortality were worse for those ≥70 yrs: 16% vs. 8% (p=0.004), and 30% vs. 12% (p<0.001), respectively.

Conclusions: Elderly (≥70 yrs) melanoma patients present with thicker melanomas and a higher mitotic rate but have fewer SLN metastases. Melanoma in the elderly is more common on the head and neck. Higher incidence of local/in-transit metastases is seen among the elderly. Five-year disease-specific mortality and overall mortality are both worse for these patients.

[Melanoma: A protective role of pregnancy? A case report and review of literature]

Melanoma is actually one of the most common malignancies to be diagnosed during pregnancy. Nevertheless, the role of the pregnancy hormones on the melanoma course is not yet completely clear. We present the case of melanoma in a pregnant woman, with a particularly fulminant postpartum development. This raised the question of a possible protection by the pregnancy hormones against melanoma.

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.

Cutaneous melanoma in the elderly

The aim of this review was to analyze the difficulties in diagnosing and treating elderly patients with cutaneous melanoma. It focused on the main causes for late diagnosis and relatively poor prognosis in these patients. Early detection of melanoma is vital to reduce mortality in these patients and surgery is often curative. Adequate treatment of elderly patients with melanoma requires knowledge of the clinical features and histopathology of the disease, and the therapeutic options. This review also examined the main surgical procedures for primary melanoma and regional lymph node staging, and the curative and palliative procedures indicated for those elderly patients with advanced disease. It is expected that several molecular genetic factors will soon provide further prognostic information of possible benefit for elderly patients with melanoma.

Thin primary cutaneous melanoma in childhood and adolescence: report of 12 cases

Approximately, 1-4% of all new melanoma cases occur in patients younger than 20 years. The clinical presentation of melanoma in the young is often challenging. We report the experience of the Melanoma Unit of University Hospital Spedali Civili of Brescia, Italy. Study subjects were drawn from 1470 patients with histologically confirmed melanoma. From this group, melanoma developed in 12 patients younger than 19 years. For each melanoma diagnosed, histologic characteristics, treatment, and outcomes were evaluated. Of the 12 patients described in this study, four were men and eight were women. The average age was 15.6 years ranging from 11 to 18 years. Regarding invasive melanomas, Breslow thickness ranged from 0.15 to 0.66 mm with a mean thickness of 0.36 mm. Primary treatment of 12 patients included wide local excision of their primary lesions. In many cases reported in literature lesions are amelanotic, nodular, and resemble pyogenic granuloma. From our case studies it was found that the clinical characteristics detected in melanomas diagnosed in childhood and adolescence have been the same as those described in adults and that the ABCDE clinical criteria may be helpful basics of melanoma.

Melanoma prognostic factors found in the dermatopathology report

Significant prognostic information is available in a routine melanoma dermatopathology report. Features that are enumerated in the pathology report and that portend a potentially poorer prognosis are older age, site (acral, head, neck), male sex, increasing Breslow tumor thickness, increasing Clark's level, ulceration, increasing number of mitoses, vertical growth phase, regression, absence of a host inflammatory response, increased tumor vascularity, angiotropism, vascular invasion, neurotropism, marked atypia, and satellite metastasis.

Melanoma epidemiology and trends

Rising incidence rates of cutaneous melanoma have been observed during the last four decades in white populations worldwide. The cancer statistics in the United States have revealed 6 cases per 100,000 and year at the beginning of the 1970s and 18 cases per 100,000 inhabitants and year at the beginning of 2000, demonstrating a threefold increase in incidence rates. Incidence rates in central Europe increased in the same time period from 3 to 4 cases to 10 to 15 cases per 100,000 inhabitants and year, which is very similar to the increase in the United States. Cohort studies from several countries indicate that the trend of increasing incidence rates will continue in the future for at least the next 2 decades; thus, an additional doubling of incidence rates is expected. The highest incidence rates have been reported from Australia and New Zealand, from 40 to 60 cases per 100,000 inhabitants and year. Mortality rates likewise slightly increased in the United States and in Europe during the 1970s and 1980s. In the 1990 s, however, a leveling off of mortality rates was observed in many countries. Simultaneously, a clear decrease of Breslow tumor thickness was reported in the United States and European countries. This development indicates improved early recognition of cutaneous melanoma, which is presently the main factor for a more favorable prognosis.

Cutaneous melanoma mortality starting to change: a study of trends in Northern Ireland

Incidence and mortality of melanoma have increased among men and women in Europe. We analysed the incidence and mortality of cutaneous melanoma (CM) in Northern Ireland. Three thousand eight hundred and thirty-seven incident cases of CM were reported to the Northern Ireland Cancer Registry (NICR) from 1984 to 2006 and 1177 melanoma deaths occurred from 1955 to 2007. Trends were analysed using joinpoint regression and a negative binomial model was fitted to test the linear trends for incidence adjusted for calendar year, age, sex and Breslow thickness. Age-adjusted incidence rates of CM increased significantly in both men and women (estimated annual percent change (EAPC): 4.8% and 2.5%, respectively). The increase was essentially due to thin melanoma (<1mm). In contrast, there was a stabilisation of incidence of thick melanomas (4mm) in men and suggestion of a decrease in incidence of thick melanomas in women (EAPC: -1.5, 95% confidence interval (CI) -3.6;0.6). Mortality rates increased steadily in men over the whole period 1955-2004 (EAPC: 1.8%, 95% CI 1.1;2.5) whereas in women it increased until 1980 and decreased after (EAPC: -1.0%, 95% CI -2.5;0.6). We report for the first time a downward shift in all age mortality after steady increases but for women only. The plausibility of this shift is supported by similar downward trend in thick melanoma incidence in females only. Although there has been an active sun protection programme in Northern Ireland since 1990, the reason for the changes in female mortality which predates the programme remains to be fully understood.

Incidence of cutaneous malignant melanoma in the Ottawa region: 1996 to 2006

BACKGROUND

The incidence rates of invasive primary cutaneous malignant melanoma in Canada have shown a gradual tapering in recent years, after decades of increases. This trend suggests that the incidence of melanoma in Canada is stabilizing; however, knowledge of the recent trend for both in situ and invasive tumors was lacking.

OBJECTIVE

The purpose of this study was to examine the temporal trend of both in situ and invasive melanoma within the Ottawa region over a 10-year period.

METHODS

The histopathology of cutaneous melanomas diagnosed in the Ottawa region was obtained for the years 1996, 2001, and 2006 from the main diagnostic centers servicing the area; however, not all melanomas have been accounted for. All rates are expressed per 100,000 population per year.

RESULTS

Melanoma incidence decreased between 1996 and 2001 (-3.83) and increased between 2001 and 2006 (+7.46; p < or = .05). This increase is mainly attributable to in situ melanoma (+5.49; p < or = .05). There has been no statistically significant change in invasive melanoma.

CONCLUSIONS

Invasive melanoma incidence in the Ottawa region remained stable, whereas in situ melanoma incidence increased.

Socioeconomic inequalities in cancer survival in Scotland 1986-2000

We analysed trends in 5-year survival of the 18 commonest cancers in Scotland diagnosed between 1986 and 2000 and followed up to 2004 in each of five deprivation groups based on patients postcode of residence at diagnosis. We estimated relative survival up to 5 years after diagnosis, adjusting for the different background mortality in each deprivation group by age, sex and calendar period. We estimated trends in overall survival and in the deprivation gap in survival up to 2004. Five-year survival improved for all malignancies except bladder cancer and was associated with a widening in the deprivation gap in survival. For 25 of 30 cancer-sex combinations examined, 5-year survival was lower among more deprived patients diagnosed during 1996-2000, and the deprivation gap in survival had widened since 1986-1990 for 15 of these 25 cancers, similar to the trends seen in England and Wales.

Distribution of clinical-pathological types of cutaneous melanomas and mortality rate in the region of Passo Fundo, RS, Brazil

OBJECTIVE

To describe the characteristics of all cases of primary cutaneous melanoma during the period 1995-2001, registered at pathology departments in the region of Passo Fundo.

METHODS

The sample studied consisted of 229 primary cutaneous melanoma lesions, identified by anatomopathological reports, in 218 patients. The variables evaluated were: sex, age, anatomical site, histological type, level of invasion and tumor thickness. The rate of incidence, mortality and survival curve were calculated.

RESULTS

The most frequent tumor site was in the back of men (49.5%) and in the lower limbs of women (33.1%). The most frequent clinical-pathological type for both sexes was the superficial expansive type (superficial spreading) at 61.6%. The level of invasion was higher in men, using Clark level III (30.3%), than in women. In women the most frequent level of invasion was Clark level II (33.1%). Of the total number of lesions, 198 (47.2%) were </= 1 mm thick, and 23.2% of the men had thicker lesions (> 4 mm) than the women. The incidence was 5.67 per 100,000 patients-year during this period and the mortality rate was 2.16 per 100,000 patients-year.

CONCLUSIONS

In the sample studied the most common sites were in the back of men and in the legs of women. The predominant type clinical-pathological was superficial spreading.

Melanoma incidence and mortality in Scotland 1979-2003

We studied 12,450 cases of invasive melanoma diagnosed in Scotland in 1979-2003, by thickness, pathological type, and body site at ages under 40, 40-59, and 60 years and over. Melanoma incidence trebled in males from 3.57 to 10.93/10(5) per year, and increased 2.3-fold in females from 5.60 to 12.96/10(5) per year. The rate of increase fell in each successive 5-year period. The greatest increase was in males aged 60 years and over at diagnosis. Significant incidence increases were seen in melanomas < 1 mm in all three age groups, but those > 4 mm only increased significantly at ages 60 years and over. All histological types increased significantly at ages 60 years and over, and in this age group the greatest increase was seen on the head and neck. Five-year disease-free survival improved steadily. Survival figures for 1994-1998 ranged from 93.6% for males and 95.8% for females with tumours < 1 mm, to 52.4 and 48.3%, respectively, for those with tumours > 4 mm. Over the 25 years, melanoma mortality doubled in males from 1.1 to 2.4/10(5) per year, but was unchanged in females at 1.5/10(5) per year. Public education on melanoma is required both for primary prevention and earlier diagnosis, particularly for older males.

A profile of invasive cutaneous malignant melanoma in Malta: 1993–2002

BACKGROUND

The incidence of malignant melanoma of the skin has risen in every part of the world where reliable cancer registration data are found.

OBJECTIVE

Our study aims to describe the changing incidence of and survival from invasive cutaneous malignant melanoma in Malta, by analysing the data from the 211 cases that were registered at the Malta National Cancer Registry between 1993 and 2002.

RESULTS

The age standardized incidence rates for invasive cutaneous malignant melanoma rose from 3.7 per 100,000 population per year for males and 5.1 for females in the first 5-year period, to 8.0 per 100,000 population per year for males and 5.9 for females in the second 5-year period. In both sexes, numbers of thin (< or = 1.0 mm) invasive melanomas increased significantly between 1993 and 2002; males also registered a significant increase in intermediate-thickness (1.01-4.0 mm) melanomas. The increase in numbers of thin and intermediate-thickness melanomas between the two 5-year periods was greatest in patients aged 60 years and over. The overall absolute 5-year survival rate for the first period was 74% and for the second period 92%.

CONCLUSION

Numbers of reported cases of invasive cutaneous malignant melanoma in Malta have more than doubled during the 10-year study period. This is mostly due to a marked rise in the diagnosis of thin melanomas in both sexes, occurring mainly in patients aged 60 years and over. As thin melanomas are of low metastasizing potential, this has resulted in an increase in survival between the two 5-year study periods.

Epidemiología y supervivencia del melanoma cutáneo en España: estudio de 552 casos (1994-2003)

Studies on epidemiology and survival of patients diagnosed of cutaneous melanoma in our country are few. We described epidemiological, clinical, histopathologic and survival characteristics of patients diagnosed of cutaneous melanoma at Hospital Gregorio Marañón of Madrid during ten years (1994-2003). The incidence of melanoma has doubled in the last decade. An important proportion of melanomas continues to be diagnosed in advanced stages (III-IV; 14.5%). The following factors were associated with a poor global survival: Tumor thickness, ulceration, nodular type, masculine gender and age older than 65.

Recent trends in cutaneous malignant melanoma in the Yorkshire region of England; incidence, mortality and survival in relation to stage of disease, 1993-2003

The aim of this study was to investigate recent trends in incidence, mortality and survival in patients diagnosed with malignant melanoma (MM) in relation to stage (Breslow thickness). Cases of primary invasive and in situ MM diagnosed between 1st January 1993 and 31st December 2003 in the former Yorkshire Health Authority were identified from cancer registry data. Over the study period, the incidence of invasive MM increased from 5.4 to 9.7 per 100,000 in male subjects and from 7.5 to 13.1 per 100,000 in female subjects. Most of this increase was seen in thin tumours (< 1.5 mm). Thin tumours were more likely to be diagnosed in the younger age groups and be classified as superficial spreading melanoma. In situ melanoma rates increased only slightly. Over the same time period, mortality rates have been relatively constant in both male and female subjects. Five-year relative survival varied from 91.8% (95% CI 90.4-93.1) for patients with thin tumours to 41.5% (95% CI 36.7-46.3) for those with thick tumours. In multivariable analyses, Breslow thickness was the most important prognostic factor. Age, sex and level of deprivation were also identified as independent prognostic factors. The trends in incidence suggest that the increase is real, rather than an artefact of increased scrutiny, implying that primary prevention in the Yorkshire area of the UK has failed to control trends in incidence. Mortality, in contrast, appears to be levelling off, indicating that secondary prevention has been more effective.

Developing epidemic of melanoma in the Hispanic population of California

BACKGROUND

Hispanics comprise almost one-third of the population of California, are the most rapidly increasing racial/ethnic group in the state, and represent almost one-third of all Hispanics in the U.S. California has among the highest rates of melanoma in the world, yet little is known about trends in melanoma in its Hispanic population.

METHODS

Trends in invasive and in situ melanoma incidence data and melanoma mortality data, between 1988 and 2001, from the California Cancer Registry were analyzed. Trends in the Hispanic population were compared with those in the non-Hispanic white population. Time trends in tumors of differing thicknesses and histology were assessed.

RESULTS

There was a statistically significant 1.8% per year increase in incidence of invasive melanomas among Hispanic males and a similar but non-statistically significant increase in invasive melanoma among Hispanic females between 1988 and 2001. Among Hispanic males and females tumors thicker than 1.5 mm at presentation increased at 11.6% per year (95% confidence interval [CI], 8.1, 15.2) and 8.9% per year (95% CI, 4.7, 13.3), respectively.

CONCLUSION

Rates of invasive melanoma have increased markedly among Hispanics in California since 1988. In contrast to trends in the non-Hispanic white population, increases in melanoma in Hispanics have been confined to thicker tumors, whose prognosis is poor. We recommend that efforts be undertaken immediately to target both primary and secondary melanoma prevention messages to Hispanic communities.

Adolescent melanoma: Risk factors and long term survival

AIMS

To report the adolescent melanomas with focus on differences in clinical characteristics, prognostic factors, disease free (DFS) and overall survival (OS) in comparison with adults.

METHODS

A single institution retrospective study in which 49 adolescent patients were compared to an adult group of 972 patients. The 10-year DFS, 10-year OS and prognostic factors were calculated for both groups.

RESULTS

The median age for the adolescent patients was 17 (range 12-19) years and 49 (range 20-93) years for the adult patients. Median follow-up time was 92 (range 4-366) months. Adolescent patients presented more often with locally advanced melanoma (p<0.01). The median Breslow thickness was 1.6 vs 2.0mm for the adults (p=0.075). Increasing age, ulceration, Breslow thickness, tumour location, male gender and stage at diagnosis were calculated to be negative prognostic factors for the adult group. In the adolescent group, only the stage at diagnosis was a significant negative predictor. The 10-year DFS and OS for the adolescent patients and adult group were not significantly different regarding AJCC stages I-III.

CONCLUSION

Although adolescent patients presented more often with locally advanced disease, there are no significant differences in the 10-year DFS and OS between adolescent and adult patients. In our series, we could not confirm the prognostic factors found in the adult group for the adolescent patients, except for the stage at diagnosis.

Photoprotection in teenagers

BACKGROUND

It is very common to apply a 'template photoprotection' without taking into consideration the background of a specific population. In Lebanon, so far, no preliminary survey has been conducted before launching an educational photoprotection campaign, revealing the need of the people according to their background.

MATERIALS AND METHODS

In April 2004, a specific questionnaire was administered to 940 adolescents, aged from 14 to 18 years. The questionnaire comprised 18 multiple-choice questions that established the approximate phototype of teenagers, awareness of ultraviolet (UV) hazard, presence of sufficient information regarding the risk of sun exposure (school, doctor, media) and the use of measures of photoprotection (clothes, sunscreens).

RESULTS

The incidence of sunburn in teenagers was high (85.42%) despite their awareness of the risks of unprotected sun exposure. The information regarding sun damage seems to be insufficiently delivered at school and by doctors. The main source of information was television. It was obvious that our adolescents underestimated the value of clothing to protect themselves. The use of clothing comes at the second place after sunscreens. However, the application of sunscreen seems to be inadequate.

CONCLUSIONS

While solar protection has become part of routine beach behavior for adolescents, there is room for improvement with better application of sunscreen and more use of clothing, especially wearing hats, and seeking shade. However, it is difficult to appreciate the impact of publicity campaigns on the risks of sun exposure in reducing the incidence of melanoma.

Non-compliance with the re-excision guidelines for cutaneous melanoma in The Netherlands does not influence survival

AIM

To evaluate causes and consequences of not adhering to the clinical practice guideline for cutaneous malignant melanoma.

METHODS

We conducted a retrospective cohort study of the clinical records of 454 subjects whose pathological reports were obtained from a population-based cancer registry to assess determinants and effects of non-compliance of physicians with the excision policy and the related clinical practice guideline for patients with primary localized cutaneous malignant melanoma (CMM). A comparative analysis was performed of patients who did and did not undergo re-excision (compliance versus non-compliance with the guideline). Subjects diagnosed in 1988, 1993 and 1997, just 1 year after publication of the (adapted) guideline, were followed until death due to any cause or until July 1st 2003.

RESULTS

Old age was the most important determinant of non-compliance. After adjusting for age at diagnosis, gender, subsite and Breslow thickness there was no significant difference in overall survival between the compliance group and the non-compliance group.

CONCLUSIONS

Non-compliance to the guideline is more common in older patients and in patients with melanoma in the head and neck region. After adjusting for confounders, a significant effect of complying with the guidelines on overall survival could not be observed.

Cancer in adolescents and young adults aged 15-24 years: a report from the North of England young person's malignant disease registry, UK

BACKGROUND

Descriptions of population-based data have rarely been published specifically for adolescents and young adults with cancer.

PROCEDURE

Data on young adults (15-24 years) diagnosed with cancer in the North of England from 1968 to 1997 were obtained from the Northern Region Young Person's Malignant Disease Registry. Temporal changes in incidence and survival rates were investigated.

RESULTS

There were 2,329 first cancers diagnosed over the study period (M:F 1.22:1). Overall age standardized incidence was 174 cases per million 15-24 years old, per year, 190 for males and 157 for females. The most common cancers in young adults were Hodgkin disease (19%), carcinomas (15%), central nervous system tumors (14%), germ cell tumors (13%), and leukemia (11%). Comparing incidence for 1968-1977 with 1988-1997 there were significant increases in the incidence of bone tumors (rate ratio 1.72, 95% CI 1.10-2.68), testicular tumors (rate ratio 1.64, 95% CI 1.16-2.32), thyroid cancer (rate ratio 2.63, 95% CI 1.37-5.02), and malignant melanoma (rate ratio 2.04, 95% CI 1.36-3.08). Survival rates improved significantly (P < 0.001) over the study period; 5-year survival rates over the three time periods 1968-1977, 1978-1987, 1988-1997 for all cancers were 45% (95% CI 41%-49%), 62% (95% CI 58%-65%), and 74% (95% CI 71%-77%) respectively.

CONCLUSIONS

Survival rates improved and there were significant increases in incidence for specific cancers in young adults in the North of England. Further research is required to identify the reasons for changing incidence and to investigate the late effects of treatment among survivors.

Cutaneous melanoma: pathogenesis and rationale for chemoprevention

OBJECTIVE

To critically review aspects of melanoma pathogenesis that lend themselves to a chemoprevention strategy. To discuss potential candidate chemoprevention agents with an emphasis on the lipid lowering drugs, the statins, currently, the most promising agents.

DATA SOURCES

A retrospective review of the literature.

STUDY SELECTION

Studies included those relevant to melanoma pathogenesis, to the scientific rationale of chemoprevention, and pertinent epidemiologic, pre-clinical, and clinical studies. The referenced study designs and methodologies varied.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by two reviewers, and the main results are presented in a quantitative descriptive manner.

CONCLUSION

Melanoma is a preventable disease by altering behavior (sun exposure) among at-risk individuals. There is also considerable evidence to suggest that melanoma development may be prevented or delayed by drugs of sufficiently low toxicity to make clinical trials of chemoprevention feasible and potentially successful. Among potential candidate agents, statins have compelling data for long-term safety and sufficient pre-clinical and clinical evidence for efficacy to justify their evaluation in well-designed trials in high-risk individuals, incorporating intermediate biologic endpoints.

The photocarcinogenic risk of narrowband UVB (TL-01) phototherapy: early follow-up data

BACKGROUND

Limited information is available on the carcinogenic risk associated with narrowband TL-01 UVB phototherapy in humans.

OBJECTIVES

To determine the skin cancer incidence in a population treated with TL-01 phototherapy.

PATIENTS AND METHODS

All TL-01-treated patients were identified from the departmental computerized database. Patients with malignant melanoma (MM), squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) were identified by record linkage with the Scottish Cancer Registry. The incidence of each was compared with the normal Scottish population matched for age and sex.

RESULTS

Data were obtained from 1908 patients. The median follow-up duration was 4 years (range 0.04-13). The median cumulative number of TL-01 treatments and dose were 23 (1-199) and 13 337 (30-284 415) mJ cm(-2), respectively. No increased incidence of SCC or MM was observed. Ten patients developed BCC compared with an expected 4.7 in the Scottish population [standardized rate ratio 213 (95% confidence interval 102-391); P < 0.05].

CONCLUSIONS

A small but significant increase of BCC was detected in the TL-01 group. This could be explained by a number of factors, including ascertainment bias. To determine the true carcinogenic risk of TL-01 phototherapy, longer follow-up is essential.

Cancer Screening in Theory and in Practice

Improvements in technology have led to a number of tests that can be used to suggest that a patient has a cancer. Advances in cancer biology and medical imaging have led to a number of cancer screening tests. Cancer screening is commonly advocated, but its complexity is often lost in guidelines that have sound-bite quality. It is commonly viewed as of no harm, when in fact there are harms associated with every known screening test. Indeed, many screening experts believe a screening test should only be used when the potential for benefit clearly outweighs the potential for harm.

Cancer screening principles are classically within the realm of the epidemiologist. As more screening tests are developed, these principles have become more relevant to the practicing clinician. What is known and what is unknown about screening is distinctly different from what is believed by the public and many practicing clinicians.

Many tests have both screening and diagnostic uses, and it is only the context in which these are used that determines whether they are screening or diagnostic. A screening test is done on asymptomatic individuals who receive the test principally because they are of the age or sex at risk for the cancer. A diagnostic test is done on an individual because of clinical suspicion of disease.

Development of prognostic factors and survival in cutaneous melanoma over 25 years

BACKGROUND

Recent studies revealed that incidence rates of cutaneous melanoma (CM) were leveling off predominantly among younger people and patterns suggested birth-cohort effects. The current study analyzed the development of prognostic factors and survival in incident CM over 25 years.

METHODS

All 45,483 patients with incident CM diagnosed between 1976 and 2000 recorded by the German Central Malignant Melanoma Registry were considered. Linear and logistic regression analyses were used to judge time trends. Trends of survival rates were tested with the multivariate Cox model.

RESULTS

Median tumor thickness decreased from 1.81 mm in 1976 to 0.53 mm in 2000 (P < 0.0001). The percentages of in situ and level II CM increased, respectively (P < 0.0001). The percentage of ulcerated CM decreased (P < 0.0001). The percentage of superficial spreading melanoma increased, whereas the percentage of nodular melanoma decreased (P < 0.0001). These time trends were all significant in the strata of gender, however, male patients presented in general with more advanced disease. Between 1976 and 2000, the average patient got older (P < 0.0001). The percentage of patients diagnosed with the primary tumor alone increased (P < 0.0001). Across the 25 years of observation, adjusted survival rates did not increase for females (P = 0.1561) but they increased for males (P < 0.0001).

CONCLUSIONS

The data demonstrated a strong trend towards prognostically more favorable CM most likely due to earlier diagnosis. Men and older people should be the focus of health promotion activities as they presented with more advanced disease.

Trends in the presentation of cutaneous malignant melanoma over three decades at King's College Hospital, London

The aim of this study was to examine trends in the presentation of cutaneous malignant melanoma at King's College Hospital (KCH) over the last three decades (1970-2000). KCH was one of seven centres that participated in the 1987 Cancer Research Campaign (CRC) publicity campaign aimed at promoting earlier self-recognition of melanoma. Data included patient age at presentation, sex, tumour site, Breslow thickness and histological subtype. The late 1980s saw a threefold increase in the annual number of melanomas and an eightfold increase in thin melanomas compared to the 1970s. The increase occurred in both sexes and was particularly marked after the CRC campaign but numbers had already begun to increase prior to this. The increase has predominantly been thin (Breslow < 1.5 mm) tumours of the superficial spreading variety with a resultant fall in mean Breslow thickness. There has been a decline in the annual number of melanomas since the peak in 1992 which is not explained by increased proportion of in situ tumours. The CRC campaign may have contributed to the documented increase in thin tumours but this trend had begun prior to 1987 suggesting factors other than public awareness and earlier presentation are important. It is encouraging that the number of melanomas has declined over the last 5 years at KCH but it is yet to be seen whether this reflects a real decrease in the incidence of melanoma.

Diagnosis of melanoma in the elderly and surgical implications

The diagnosis of primary melanoma is mainly related to the precocity on which a patient is referred to the specialist, but in elderly patients this may present some peculiar characteristics, one is anatomical, a typical melanoma of the face, the lentigo maligna melanoma and the second is attitudinal, the fact that elderly patients often do not refer a changing cutaneous lesion to a doctor until becoming symptomatic. The therapeutic approach has to be discussed with an anaesthesiologist if the procedure has to be conducted under general anaesthesia or with a cardiologist if under local anaesthesia. Once there are no contraindications medically, a similar oncological approach should be proposed without any reduction in radicality due to the elderly age.

Comparison between ultraviolet-visible and near-infrared elastic scattering spectroscopy of chemically induced melanomas in an animal model

The work reported compares elastic scattering spectroscopy (ESS) for diagnosis of pigmented skin lesions in two spectral regions: UV-visible and near infrared (NIR). Given the known strong absorption by melanin in the near-UV to mid-visible range of the spectrum, such a comparison can help determine the optimum wavelength range of ESS for diagnosis of pigmented skin lesions. For this purpose, four South American opossums are treated with dimethylbenz(a)anthracene on multiple dorsal sites to induce both malignant melanomas and benign pigmented lesions. Skin lesions are examined in vivo with ESS using both UV-visible and NIR, with wavelength ranges of 330 to 900 nm and 900 to 1700 nm, respectively. Both portable systems use the same fiber optic probe geometry. ESS measurements are made on the lesions, and spectral differences are grouped by diagnosis from standard histopathological procedure. Both ESS datasets show strong spectral trends with the histopathological assignments, and the data suggest a model for the underlying basis of the spectral distinction between benign and malignant pigmented nevi.

Knowledge, attitudes and behaviour in the sun: the barriers to behavioural change in Northern Ireland

To inform future health promotion programmes, we studied the knowledge, attitudes and behaviour of the Northern Ireland population to sun care. An interviewer-administered questionnaire was applied to one adult per household from a random sample of 1242 addresses. Lower levels of knowledge were found among respondents who were male, aged under 25 years or over 65 years, in a manual occupation or living in the west where health promotion activity on this topic was less active than in the east. Younger adults, females and professional groups were more likely to indicate that a suntan was important, healthy or attractive. Use of high factor sunscreen was inversely proportional to perceived importance of a suntan. Sunburn was more common in younger adults but more men reported multiple episodes of burning. Regular skin checks were uncommon and self-assessment of skin type was unrealistic indicating that sun care advice based on self assessment should be avoided in this population. Future campaigns should target appropriate messages at specific population subgroups. The study highlights the importance of collecting baseline information before implementing health promotion programmes and suggests that repeat monitoring is essential to ensure that key messages remain relevant. This study also indicates that Care in the Sun campaigns here impacted on general awareness in the population even with limited resources. There is, therefore, potential for greater impact with high funding levels.

Improved survival for melanoma in Northern Ireland: a comparison of two 5-year periods (1984-88 and 1994-98)

BACKGROUND

The incidence of cutaneous malignant melanoma has been rising steadily in Caucasian populations for several decades, with a doubling time of 10-14 years. An increase in incidence of about 5% per year has been reported in most Caucasian populations since the early 1960s.

OBJECTIVES

This study was designed to determine the changing incidence of primary cutaneous malignant melanoma in Northern Ireland and to examine changes in survival rates from cutaneous malignant melanoma in two 5-year periods, 1984-88 and 1994-98.

METHODS

One thousand three hundred and twenty-six patients with invasive primary cutaneous melanoma were included in the study.

RESULTS

The age standardized rate of melanoma rose from 4.3 per 100,000 population per year in men and 8.6 per 100,000 population per year in women to 7.7 and 11.8, respectively, per 100,000 population per year in the 1994-98 period. Overall, the absolute 5-year survival for the 1984-88 period was 71.0% [95% confidence interval (CI) 66.9-75.1%] and 77.4% (95% CI 73.4-81.4%) for the 1994-98 period. Women consistently showed better survival at all ages and within almost all categories of thickness of primary tumour. Younger patients of both sexes showed better survival rates.

CONCLUSIONS

When survival rates between the 1984-88 and 1994-98 periods were compared using multivariate analysis, we found that patients diagnosed in the second period had a one-third lower risk of dying than those in the earlier period. Much of this reduction was explained by changes in the number of melanomas of thin Breslow depth and ulcerated melanomas.

A description of travel medicine in general practice: a postal questionnaire survey

BACKGROUND

Travel-related diseases are important aspects of public health. The number of UK residents traveling abroad is increasing at a rate of 16% a year, thereby increasing exposure to travel-related morbidity. Provision of comprehensive pretravel health advice is essential to reduce this trend. In the UK, pretravel health advice is predominantly provided through general practices.

METHODS

A postal questionnaire was sent to all 91 general practices in South Cheshire Health Authority. The questionnaires were to be completed by the lead advisor in travel medicine for each practice. Questions were asked on service provision, training and reference resources used, subjects advised on, and health promotion material used. Nonresponders were contacted and sent a further questionnaire.

RESULTS

A response rate of 86% (78/91) was achieved. Of the lead advisors, 97% were nurses and 3% general practitioners. Thirty-eight sources of advice were quoted, the commonest of which comprised wall immunization charts (72%). Duration of consultation ranged from less than 5 min to over 30 min, with a median and mode of 11 to 15 min. Most respondents reported advising on most travel-associated risks, 40% of practices lacked a protocol, and 83% of providers had attended a training course on travel medicine for 2 days or less.

CONCLUSIONS

This survey identified inadequacies of training and use of multiple sources of reference which may lead to inconsistencies in advice. Most practitioners could not define their workload in travel medicine. For effective protection of travelers, a careful risk assessment, clear risk communication and health education with detailed health promotion are necessary, but these are not likely to be provided within an average consultation time of 11 to 15 min. There is no evidence of consistent governance, planned training and monitoring of service quality of travel medicine practice. This may be due to lack of a national policy on best practice and guidance in this subject. National protocols with validated information resources, set standards of training, along with adequate consultation time for educating, advising, and prescribing, will lead to improved health of the traveling public.