The diagnosis and initial management of melanoma in Australia: findings from the prospective, population-based QSkin study

Laryngeal Squamous Cell Carcinoma and Diathermy Plume

Plume from surgical diathermy systems is recognised as a hazard to healthcare providers but is often ignored during ambulatory care procedures. The development of a squamous cell carcinoma of the larynx in a dermatologist, despite the absence of recognised risk factors, prompted this review and recommendations for change in procedural practices.

Factors Influencing the Use of Shave Biopsy for Lesions Suspicious of Melanoma in Australia: An Exploratory Mixed-Methods Study

BACKGROUND

Recent Australian trends indicate that shave biopsies for diagnosing lesions suspicious of melanoma are increasing, yet reasons for this remain relatively unknown. We sought to understand which factors influence Australian clinicians' use of shave biopsy for managing thin lesions suspicious of melanoma in sites of low cosmetic sensitivity.

METHODS

We used a convergent, exploratory mixed-methods design, with a cross-sectional online survey (n = 59) and semi-structured qualitative interviews (n = 15). We recruited clinicians working in skin cancer medicine across Australia, mostly general practitioners (> 80%) with some dermatologists (n = 7 survey and n = 1 interview participant). Survey participants indicated how frequently they used shave biopsies and rated the importance of factors when considering the use of a shave biopsy. Interview participants elaborated on the motivating factors for using different biopsy techniques. Qualitative data were professionally transcribed and analysed with content analysis.

RESULTS

Most survey participants (95%) reported that identifying fewer signs of locally advanced melanoma was 'very important' for using shave biopsy. Fifty per cent of survey participants also reported that faster procedure speed and greater convenience were 'very important' reasons for using shave biopsy. Procedure speed was particularly important for using shave biopsy among clinicians self-identifying as time-poor. Interview participants noted (a) the risk of transecting the lesion base or (b) incomplete lesion removal from shave biopsies as reasons against their use.

CONCLUSIONS

The relative speed and convenience of shave biopsies in clinical practice are strong motivators for their use. Further evidence on patient outcomes with widespread use of shave biopsy is required to inform clinical guidelines.

Estimating the magnitude and healthcare costs of melanoma in situ and thin invasive melanoma overdiagnosis in Australia

BACKGROUND

Research suggests that a high proportion of melanoma in situ (MIS) may be overdiagnosed, potentially contributing to overtreatment, patient harm and inflated costs for individuals and healthcare systems. However, Australia-wide estimates of the magnitude of melanoma overdiagnosis are potentially outdated and there has been no estimation of the cost to the healthcare system.

OBJECTIVES

To estimate the magnitude and cost of overdiagnosed MIS and thin invasive melanomas in Australia.

METHODS

Using two different methods to calculate lifetime risk, we used routinely collected national-level data to estimate overdiagnosed MIS and thin invasive melanomas (stage IA) in Australia in 2017 and 2021, separately for men and women. We multiplied the number of overdiagnosed melanomas by the estimated annual cost of a MIS or thin invasive melanoma, to quantify the financial burden of melanoma overdiagnosis to the Australian healthcare system in the year following diagnosis.

RESULTS

We estimated that 67-70% of MIS were overdiagnosed in 2017, rising to 71-76% in 2021, contributing to between 19 829 [95% confidence interval (CI) 19 553-20 105] and 20 811 (95% CI 20 528-21 094) cases of overdiagnosed MIS. In 2021, the estimated costs in Australia ranged between $17.7 million Australian dollars (AUD; 95% CI 17.4-17.9 million) and AUD$18.6 million (95% CI 18.3-18.8 million). We estimated that 22-29% of thin invasive melanomas were overdiagnosed in 2017, rising to 28-34% in 2021, contributing to between 2831 (95% CI 2726-2935) and 3168 (95% CI 3058-3279) overdiagnosed thin invasive melanomas. In 2021, the estimated costs from thin invasive melanoma overdiagnoses ranged between AUD$2.5 million (95% CI 2.4-2.6 million) and AUD$2.8 million (95% CI 2.7-2.9 million).

CONCLUSIONS

Melanoma overdiagnosis is a growing clinical and public health problem in Australia, producing significant economic costs in the year following overdiagnosis. Limiting melanoma overdiagnosis may prevent unnecessary healthcare resource use and improve financial sustainability within the Australian healthcare system.

Patients poorly recognize lesions of concern that are malignant melanomas: is self-screening the correct advice?

Background

Australia is known for its outdoor culture, with a large percentage of its population engaging in outdoor recreational activities, aquatic, non-aquatic and outdoor occupational activities. However, these outdoor enthusiasts face increased exposure to ultraviolet radiation (UVR), leading to a higher risk of skin cancer, including malignant melanoma (MM). Over the past 40 years, there has been a significant rise in skin cancer rates in Australia, with two out of three Australians expected to develop some form of skin cancer by age 70. Currently, skin cancer examinations are not endorsed in asymptomatic or low-risk individuals in Australia, with only high-risk individuals recommended to undergo regular skin examinations. Notably, the Melanoma Institute Australia suggests that one-half of patients identify MMs themselves, although this claim appears to be based on limited Australian data which may not reflect contemporary practice. Therefore this study sought to determine the percentage of patients who were able to self-identify MMs as lesions of concern when presenting for a skin cancer examination.

Methods

Multi-site, cross-sectional study design incorporating a descriptive survey and total body skin cancer screening, including artificial intelligence by a skin cancer doctor.

Results

A total of 260 participants with suspect MM lesions were biopsied, with 83 (31.9%) found to be melanomas. Of the true positive MMs only a small percentage of participants (21.7% specificity) correctly had concerns about the suspect lesion being a MM. These MMs were located primarily on the back (44.4%), shoulder (11.1%) and upper leg (11.1%). There was no significant difference in the size between those participants aware of a MM versus those who were not (P = 0.824, 24.6 vs 23.4 mm2). Significantly more males identified lesions of concern that were MMs as compared to females (P = 0.008, 61.1% vs 38.9%, respectively). With regard to true negatives males and females were similar (52.1% vs 47.9%, respectively). With regard to false negatives (n = 65), a greater percentage of males than females did not recognize the MM as a lesion of concern (66.2% vs 33.8%, respectively). Participants were more likely to correctly identify an invasive MM as opposed to an in situ MM (27.3% versus 21.3%).

Conclusions

Only a small percentage of participants in this study were able to self-identify either in situ or invasive MM as a lesion of concern with a tendency to identify the more advanced, thicker MMs. Given that MM is associated with a high mortality and cost of treatment, particularly when invasive, the inability of lay persons to identify these cancerous lesions will likely lead to delayed treatment and a possible adverse outcome. We believe the current melanoma screening practices in Australian general practice should be revisited to improve patient outcomes with regard to MM. Additionally, prevention campaigns should include images and primary risk factors for MM.

Performance of Commercial Dermatoscopic Systems That Incorporate Artificial Intelligence for the Identification of Melanoma in General Practice: A Systematic Review

BACKGROUND

Cutaneous melanoma remains an increasing global public health burden, particularly in fair-skinned populations. Advancing technologies, particularly artificial intelligence (AI), may provide an additional tool for clinicians to help detect malignancies with a more accurate success rate. This systematic review aimed to report the performance metrics of commercially available convolutional neural networks (CNNs) tasked with detecting MM.

METHODS

A systematic literature search was performed using CINAHL, Medline, Scopus, ScienceDirect and Web of Science databases.

RESULTS

A total of 16 articles reporting MM were included in this review. The combined number of melanomas detected was 1160, and non-melanoma lesions were 33,010. The performance of market-approved technology and clinician performance for classifying melanoma was highly heterogeneous, with sensitivity ranging from 16.4 to 100.0%, specificity between 40.0 and 98.3% and accuracy between 44.0 and 92.0%. Less heterogeneity was observed when clinicians worked in unison with AI, with sensitivity ranging between 83.3 and 100.0%, specificity between 83.7 and 87.3%, and accuracy between 86.4 and 86.9%.

CONCLUSION

Instead of focusing on the performance of AI versus clinicians for classifying melanoma, more consistent performance has been obtained when clinicians' work is supported by AI, facilitating management decisions and improving health outcomes.

Extracellular vesicle-derived non-coding RNAs in remodeling melanoma

Melanoma is one of the most lethal cutaneous malignancies. Despite great advances in radiotherapy, chemotherapy, and immunotherapy, the survival rate and prognosis of patients with melanoma remain poor. The abundant and sophisticated reciprocal communication network between melanoma cells and non-tumor cells contributes to the high heterogeneity of the melanoma microenvironment and is intimately related to varying treatment responses and clinical courses. Extracellular vesicles (EVs) are membrane structures generated by nearly all cell types. EVs contain biologically active molecules, mainly comprising proteins, lipids, and RNAs, and undoubtedly play multifaceted roles in numerous diseases, represented by melanoma. Non-coding RNAs (ncRNAs) mainly encompass long non-coding RNAs, microRNAs, and circular RNAs and constitute the majority of the human transcriptome. Multiple ncRNAs encapsulated in EVs coordinate various pathophysiological processes in melanoma. This review summarizes the mechanisms by which EV-ncRNAs modulate biological behaviors and immunity, and their potential diagnostic and therapeutic applications in melanoma. Undoubtedly, further insight into EV-ncRNAs and their functions in melanoma will contribute to the clinical treatment of melanoma and the implementation of precision medicine.

Relationship between climate change and skin cancer and implications for prevention and management: a scoping review

OBJECTIVES

This study aimed to explore the published research on the relationship between climate change and skin cancer and the implications for prevention, management and further research.

STUDY DESIGN

Scoping review.

METHODS

This scoping review following JBI methodology reviewed English articles identified in searches of MEDLINE, Embase, CINAHL, Web of Science and Scopus on 14 April 2023. The screening of articles was completed by two independent reviewers. Data were extracted by a single reviewer and checked by another. A causal pathway diagram was iteratively developed throughout the review and was used to categorise the findings.

RESULTS

The search identified 1376 papers, of which 45 were included in the final review. Nine papers reported primary research, and 36 papers were reviews, perspectives, commentaries, editorials, or essays. The papers examined climate change influencing behaviours related to ultraviolet exposure (30 papers), ambient temperature (21 papers) and air pollution (five papers) as possible risk factors; occupational, rural, and contextual factors affecting skin cancer (11 papers); and prevention and access to health care in the context of climate change (seven papers). Most papers were published in journals in subject areas other than health.

CONCLUSIONS

This review identified ultraviolet radiation, occupation, rising temperature, individual behaviour and air pollution as possible influences on skin cancer rates. Furthermore, it highlights the complexity and uncertainties in the relationship between climate change and skin cancer and the need for further research on this relationship, including primary epidemiological research and reviews that follow recognised review guidelines and include assessment of health services and social determinants in the causal pathways of this relationship.

Protocol for a systematic review of reviews on training primary care providers in dermoscopy to detect skin cancers

INTRODUCTION

Globally, incidence, prevalence and mortality rates of skin cancers are escalating. Earlier detection by well-trained primary care providers in techniques such as dermoscopy could reduce unnecessary referrals and improve longer term outcomes. A review of reviews is planned to compare and contrast the conduct, quality, findings and conclusions of multiple systematic and scoping reviews addressing the effectiveness of training primary care providers in dermoscopy, which will provide a critique and synthesis of the current body of review evidence.

METHODS AND ANALYSIS

Four databases (Cochrane, CINAHL, EMBASE and MEDLINE Complete) will be comprehensively searched from database inception to identify published, peer-reviewed English-language articles describing scoping and systematic reviews of the effectiveness of training primary care providers in the use of dermoscopy to detect skin cancers. Two researchers will independently conduct the searches and screen the results for potentially eligible studies using 'Research Screener' (a semi-automated machine learning tool). Backwards and forwards citation tracing will be conducted to supplement the search. A narrative summary of included reviews will be conducted. Study characteristics, for example, population; type of educational programme, including content, delivery method, duration and assessment; and outcomes for dermoscopy will be extracted into a standardised table. Data extraction will be checked by the second reviewer. Methodological quality will be evaluated by two reviewers independently using the Critical Appraisal Tool for Health Promotion and Prevention Reviews. Results of the assessments will be considered by the two reviewers and any discrepancies will be resolved by team consensus.

ETHICS AND DISSEMINATION

Ethics approval is not required to conduct the planned systematic review of peer-reviewed, published articles because the research does not involve human participants. Findings will be published in a peer-reviewed journal, presented at leading public health, cancer and primary care conferences, and disseminated via website postings and social media channels.

PROSPERO REGISTRATION NUMBER

CRD42023396276.