A multicentre study of naevus-associated melanoma vs. de novo melanoma, tumour thickness and body site differences

BACKGROUND

Whether melanoma in histological contiguity with a naevus [naevus-associated melanoma (NAM)] is distinctly different from melanoma arising de novo remains unclear.

OBJECTIVES

To determine whether the characteristics of de novo melanoma differ from NAM and are not due to naevus obliteration in thicker tumours.

METHODS

We conducted a multicentre retrospective study of de novo melanoma and NAM in seven referral centres in Europe, Australia and the USA between 2006 and 2015.

RESULTS

In a total of 9474 localized melanomas, de novo melanoma was associated with thicker tumours and body site differences compared with NAM. In the subset of T1 melanomas (n = 5307), similar body site differences were found in multivariate analysis by body site. When compared with NAM, de novo melanoma was more likely to affect older individuals (≥ 70 years) when located on the head/neck [odds ratio (OR) 4·65, 95% confidence interval (CI) 2·55-8·46], the trunk (OR 1·82, 95% CI 1·40-2·36) or the upper extremity (OR 1·69, 95% CI 1·14-2·50), was more likely to affect female patients when located on the lower extremities (OR 1·36, 95% CI 1·03-1·80), and was more likely to be of the nodular melanoma subtype (OR 2·23, 95% CI 1·14-4·35) when located on the trunk. De novo melanoma was less likely to have regression present compared with NAM.

CONCLUSIONS

Clinicopathological and body site differences between de novo melanoma and NAM support the divergent pathway model of development. These differences were also found in thin melanomas, suggesting that de novo melanomas are different from NAM and their differences are not due to the obliteration of naevus remnants in thicker tumours.

Not all melanomas are created equal: a review and call for more research into nodular melanoma

Among the histogenic subtypes of melanoma, nodular melanoma (NM) is the major contributor for thicker and fatal melanomas and it has been associated with melanoma-specific death in thin tumours, highlighting an important subgroup of 'aggressive thin' melanomas. This review provides a synthesis of the distinct characteristics of NM, with respect to epidemiology and risk factors, clinical presentation, histopathology, molecular and dermoscopic aspects, and screening practices. The real challenges are to find better biomarkers of aggressiveness and to know whether the control of such aggressive melanomas can be influenced by targeted interventions such as early detection, drug interventions and preventive strategies.

Interval cancers after skin cancer screening: incidence, tumour characteristics and risk factors for cutaneous melanoma

BACKGROUND

The rate of interval cancers is an established indicator for the performance of a cancer-screening programme.

METHODS

We examined the incidence, tumour characteristics and risk factors of melanoma interval cancers that occurred in participants of the SCREEN project, which was carried out 2003/2004 in Schleswig-Holstein, Germany. Data from 350 306 SCREEN participants, who had been screened negative for melanoma, were linked to data of the state cancer registry. Melanoma interval cancers were defined as melanomas diagnosed within 4-24 months after SCREEN examination. Results were compared with melanomas of the pre-SCREEN era (1999-2002), extracted from the cancer registry.

RESULTS

The overall relative incidence of melanoma interval cancers in terms of observed/expected ratio was 0.93 (95% CI: 0.82-1.05; in situ: 1.61 (1.32-1.95), invasive: 0.71 (0.60-0.84)). Compared with melanomas of the pre-SCREEN era, the interval melanomas were thinner and had a slightly greater proportion of lentigo maligna melanomas whereas nodular melanomas were less frequent.

INTERPRETATION

The results indicate a moderate performance of the SCREEN intervention with an excess of in situ melanomas. In part, the findings might be due to specifics of the SCREEN project, in particular a short-term follow-up of patients at high risk for melanoma.

Factors driving the use of dermoscopy in Europe: a pan-European survey

BACKGROUND

When used correctly, dermoscopy is an essential tool for helping clinicians in the diagnosis of skin diseases and the early detection of skin cancers. Despite its proven benefits, there is a lack of data about how European dermatologists use dermoscopy in everyday practice.

OBJECTIVES

To identify the motivations, obstacles and modifiable factors influencing the use of dermoscopy in daily dermatology practice across Europe.

METHODS

All registered dermatologists in 32 European countries were invited to complete an online survey of 20 questions regarding demographic and practice characteristics, dermoscopy training and self-confidence in dermoscopic skills, patterns of dermoscopy use, reasons for not using dermoscopy and attitudes relating to dermoscopy utility.

RESULTS

We collected 7480 valid answers, of which 89% reported use of dermoscopy. The main reasons for not using dermoscopy were lack of equipment (58% of nonusers) and lack of training (42%). Dermoscopy training during residency was reported by 41% of dermoscopy users and by 12% of nonusers (P < 0·001). Dermatologists working in public hospitals were the least likely to use dermoscopy. High use of dermoscopy across the spectrum of skin diseases was reported by 62% of dermoscopy users and was associated with dermoscopy training during residency, the use of polarized light and digital dermoscopy devices, longer dermoscopy practice, younger age and female gender.

CONCLUSIONS

Expanding access to dermoscopy equipment, especially in public healthcare facilities and establishing dermoscopy training during dermatology residency would further enhance the substantially high dermoscopy use across European countries.

Cross-sectional analysis of the dermoscopic patterns and structures of melanocytic naevi on the back and legs of adolescents

BACKGROUND

Junctional (flat) naevi predominate on the extremities, whereas dermal (raised) naevi are found primarily on the head, neck and trunk. Few studies have investigated the anatomical site prevalence of melanocytic naevi categorized using dermoscopy.

OBJECTIVES

To identify the prevalence of dermoscopic patterns and structures of naevi from the back and legs of adolescents.

METHODS

Dermoscopic images of acquired melanocytic naevi were obtained from the back and legs of students from a population-based cohort in Framingham, Massachusetts. Naevi were classified into reticular, globular, homogeneous or complex dermoscopic patterns. Multinomial logistic regression modelling assessed the associations between dermoscopic pattern and anatomical location.

RESULTS

In total 509 participants (mean age 14 years) contributed 2320 back naevi and 637 leg naevi. Compared with homogeneous naevi, globular and complex naevi were more commonly observed on the back than the legs [odds ratio (OR) 29·39, 95% confidence interval (CI) 9·53-90·65, P < 0·001 and OR 6·8, 95% CI 2·7-17·14, P < 0·001, respectively], whereas reticular lesions were less likely to be observed on the back than on the legs (OR 0·67, 95% CI 0·54-0·84, P = 0·001). Naevi containing any globules were more prevalent on the back than on the legs (25% vs. 3·6%, P < 0·001). Naevi containing any network were more prevalent on the legs than on the back (56% vs. 40·6%, P < 0·001).

CONCLUSIONS

These findings add to a robust body of literature suggesting that dermoscopically defined globular and reticular naevi represent biologically distinct naevus subsets that differ in histopathological growth pattern, age- and anatomical-site-related prevalence, molecular phenotype and aetiological pathways.

Demographic, behavioural and physician-related determinants of early melanoma detection in a low-incidence population

BACKGROUND

Knowledge of the factors that influence early detection of melanoma is important in developing strategies to reduce associated mortality.

OBJECTIVES

To identify sociodemographic, behavioural and medical care-related factors associated with melanoma thickness in a low-incidence population but with a high case fatality.

PATIENTS AND METHODS

In a multicentre, retrospective, survey-based study of 202 patients with a recent diagnosis of invasive melanoma (< 1 year), we collected data on demographic and behavioural factors, attitudes towards prevention, access to medical care, frequency of skin self-examination (SSE) and physician skin examination (PSE) in relation to melanoma thickness.

RESULTS

Thinner tumours (≤ 1 mm, 80 melanomas) were associated with female sex (P ≤ 0.049), nonnodular (superficial spreading melanoma, lentigo maligna melanoma, acral lentiginous melanoma) histological subtypes (P < 0.001), absence of ulceration (P ≤ 0.001), and location other than lower extremity or trunk location (P ≤ 0.004). Patients married at the time of diagnosis or who performed SSE during the year prior to diagnosis were more likely to have thinner tumours than those who did not [odds ratio (OR) 3.45, 95% confidence interval (CI) 1.48-8.04 and OR 2.43, 95% CI 1.10-5.34, respectively]. Full-body skin examination by a physician was not significantly associated with thinner melanoma (OR 1.99, 95% CI 0.66-6.07).

CONCLUSIONS

SSE was shown to be an important factor in the detection of thin melanoma, in contrast to partial or full-body PSE, which did not show any statistically significant effect on tumour thickness.

Melanoma incidence and mortality in Europe: new estimates, persistent disparities

BACKGROUND

Melanoma incidence and mortality in Europe are high but there are significant gaps in the epidemiological information available across the continent.

OBJECTIVES

With the aim of enhancing the planning of educational programmes for reducing the melanoma burden in Europe, we analysed the most recent incidence and mortality data for Europe with a new focus on the regional disparities of melanoma reporting.

METHODS

GLOBOCAN 2008, the standard set of worldwide estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer for 2008, was used to provide the estimated age-standardized rates (world standard population) of melanoma incidence and mortality in European countries and regions.

RESULTS

The estimated age-standardized incidence of melanoma (measured per 100 000 person-years) varies widely from 19·2 in Switzerland to 2·2 in Greece. The incidence rate of 4·3 of Central and Eastern Europe (CEE) is less than half of that of Western Europe. Melanoma mortality rates of 1·5 are similar in CEE and Western Europe, although rates vary with a high of 3·2 in Norway and a low of 0·9 in Greece. Over 20 000 deaths from melanoma were estimated in Europe in 2008, with CEE having the largest share (35·5%) among the four geographical European regions. Population-based data are lacking for significant parts of CEE, which must rely on estimates.

CONCLUSIONS

The most recent estimates of melanoma incidence and mortality in Europe reveal sharp differences between European countries, possibly related to missed opportunities for early diagnosis and incomplete reporting of melanoma in Eastern Europe.

Skin cancer screening participation and impact on melanoma incidence in Germany--an observational study on incidence trends in regions with and without population-based screening

BACKGROUND

The SCREEN (Skin Cancer Research to provide Evidence for Effectiveness of Screening in Northern Germany) project involved population-wide skin cancer screening with whole-body examination by general physicians and dermatologists. It was conducted in the German state of Schleswig-Holstein (July 2003-June 2004), but not in the German state of Saarland.

METHODS

The population-based registries of Schleswig-Holstein and Saarland provided data on melanoma incidence before, during, and after SCREEN to assess the association of skin cancer screening with incidence.

RESULTS

Approximately 19% of the Schleswig-Holstein population participated in SCREEN (women: 27%, men: 10%). A total of 52% of all melanomas diagnosed during SCREEN in Schleswig-Holstein were detected as part of the project. Melanoma incidence increased during SCREEN (invasive melanoma in women: +8.9 per 100,000 (95% confidence intervals (CI): 6.1; 11.7); men: +4.0 per 100,000 (95% CI: 1.6; 6.4)) and decreased afterwards (women: -10.6 per 100,000 (95% CI: -13.3; -7.9); men: -4.1 per 100,000 (95% CI: -6.5; -1.7)). Similar changes were not observed in Saarland that had no such project. The differences between the two states were greatest among women, the group with the greater SCREEN participation.

CONCLUSION

The SCREEN project had a substantial impact on melanoma incidence. This is consistent with the impact of effective screening for other cancers.

Sun exposure and risk of melanoma

BACKGROUND

As skin cancer education programmes directed to children and adolescents continue to expand, an epidemiological basis for these programmes is necessary to target efforts and plan for further evaluation.

AIMS

To summarise the epidemiological evidence on sun exposure during childhood and adolescence and melanoma risk.

METHODS

A literature review was conducted using Medline (1966 to December 2004) to identify articles relating to sun exposure and melanoma. The review was restricted to studies that included sun exposure information on subjects 18 years of age or younger.

RESULTS

Migrant studies generally indicate an increased melanoma risk in individuals who spent childhood in sunny geographical locations, and decreasing melanoma risk with older age at arrival. Individuals who resided in geographical locations close to the equator or close to the coast during childhood and/or adolescence have an increased melanoma risk compared to those who lived at higher latitudes or never lived near the coast. The intermittent exposure hypothesis remains controversial; some studies indicate that children and adolescents who received intermittent sun exposure during vacation, recreation, or occupation are at increased melanoma risk as adults, but more recent studies suggest intermittent exposure to have a protective effect. The majority of sunburn studies suggest a positive association between early age sunburn and subsequent risk of melanoma.

CONCLUSION

Future research efforts should focus on: (1) clarifying the relation between sun exposure and melanoma; (2) conducting prospective studies; (3) assessing sun exposure during different time periods of life using a reliable and quantitative method; (4) obtaining information on protective measures; and (5) examining the interrelations between ability to tan, propensity to burn, skin type, history of sunburns, timing and pattern of sun exposure, number of nevi, and other host factors in the child and adolescent populations.

Clinical and Dermoscopic Changes in Common Melanocytic Nevi in School Children: The Framingham School Nevus Study

BACKGROUND

Nevi are potential precursors of malignant melanoma and are important risk factors for the development of the disease. Childhood may be a critical time for the formation and evolution of nevi.

OBJECTIVES

To document the development of new nevi and to document the clinical and dermoscopic changes in index nevi in school children during a 1-year follow-up.

METHODS

Digital photographs and dermoscopic images of the back of subjects were compared at baseline and 1-year follow-up to assess changes in nevi counts and in clinical and dermoscopic features of index nevi.

RESULTS

Overall participation rate was 81% (42/52). 56.4% of study participants were found to have an increased number of nevi at 1-year follow-up. All nevi were small and clinically insignificant. Fifty percent of study participants were found to have dermoscopic changes in their index nevi at 1-year follow-up. Eighty-five percent of these changes were classified as subtle and 15.0% as obvious.

CONCLUSIONS

A significant portion of students developed new nevi over the course of 1 year. Most index nevi remained stable in pattern and structure. Benign dermoscopic changes occurred in 50.0% of index nevi. However, none of the dermoscopically changed nevi revealed any major changes and the overall nevus pattern remained unchanged. The relevance of these changes is uncertain and further follow-up may elucidate their significance.

Utilization of colorectal cancer screening tests: a 1997 survey of Massachusetts internists

BACKGROUND

Physician noncompliance with screening recommendations has been a major barrier to effective colorectal cancer control. The overall objectives of this study were to assess the current attitudes and screening behavior of primary care physicians in light of new efficacy data, revised guidelines, improved technology, and more widespread insurance coverage.

METHODS

Questionnaires inquiring about knowledge, beliefs, and practice patterns related to colorectal cancer screening were mailed in mid-1997 to 700 randomly selected Massachusetts internists.

RESULTS

The overall response rate was 63%. Nearly 60% of respondents reported an increase in screening behavior during the past 5 years. Most (80%) were aware of at least one set of screening guidelines and 90% reported utilizing one or more recommended screening strategies. Fecal occult blood testing (FOBT), alone (47%) or in combination with flexible sigmoidoscopy (50%), was the preferred strategy for most respondents. Colonoscopy was rarely utilized (5%) despite high perceived effectiveness. Concern about patient compliance was a significant determinant of FOBT utilization, whereas perceived effectiveness, concerns about time or efficacy data, prior procedural training, date of licensure, and use of instructional materials were independent determinants of sigmoidoscopy utilization.

CONCLUSION

Massachusetts' internists report high rates of utilization of select colorectal cancer screening strategies. Future studies must validate self-reported compliance and explore barriers to screening colonoscopy.

Impact of skin cancer prevention on outdoor aquatics staff: the Pool Cool program in Hawaii and Massachusetts

BACKGROUND

Aquatic staff, including lifeguards, are exposed to intense sunlight for many hours each day and are likely to be at a relatively high risk for developing skin cancer. However, no interventions have been specifically directed to staff at outdoor swimming pool sites.

METHODS

We conducted a randomized controlled trial among aquatic staff at 28 outdoor pool sites in Hawaii and Massachusetts. Intervention pools received sun protection education and control pools received education on child injury prevention. Staff in both arms received orientation sessions and led instruction during swim lessons. Analysis of covariance was used to compare and test for changes in outcome variables (sun protection habits and sunburning rates of aquatic staff) and pool protection policies. Surveys were completed at the beginning and end of the summer.

RESULTS

Surveys were completed by 220 aquatics staff at baseline; 194 surveys were completed at posttest. Compared with staff at control pools, sun protection policies (P < 0.04) and sunburning rates (P < 0.05) improved at sun protection pools from baseline to posttest. However, the difference in the mean score of all sun protection habits between the two study groups was nonsignificant.

CONCLUSION

The Pool Cool sun protection intervention had significant effects on lifeguards' sunburn rates and pool sun safety policies but did not improve reported sun protection behaviors. More intensive strategies may be needed to influence aquatics workers who have already begun to adopt skin cancer prevention practices.

Cancer skills laboratories for medical students: a promising approach for cancer education

BACKGROUND

Most medical students graduate without the skills necessary to assist patients in cancer control. To address this problem, the authors developed a cancer skills laboratory for second-year medical students.

METHODS

The skills laboratory consists of two hours of training, with 15 minutes allotted per station (six to eight students assigned per station). Faculty and fellows lead the stations on prostate cancer, breast cancer, colorectal cancer, skin cancer, counseling for smoking cessation, and a discussion of anti-tobacco advertisements. Students completed pre- and post-laboratory surveys consisting of ten brief questions.

RESULTS

Overall, 94% of eligible students in 1997 and 1998 completed the surveys. Using a five-point scale, self-rated skill level increased from 2.12 to 3.83 when all modalities were averaged (p < .001).

CONCLUSIONS

Cancer skills laboratories are a promising new means for cancer education.

Screening for malignant melanoma: A cost-effectiveness analysis

BACKGROUND

Skin cancer is the most common cancer in the United States. Increasing evidence suggests that screening for malignant melanoma is effective, but its cost-effectiveness has not been determined.

OBJECTIVE

We attempted to determine the effectiveness and costs of a visual screen to diagnose malignant melanoma in high-risk persons.

METHODS

We developed a decision analysis comparing no skin cancer screen with a single screen by a dermatologist. Clinical outcomes included malignant melanoma, nonmelanoma skin cancer, or no skin cancer. Life expectancy and costs of care were projected on the basis of clinical findings.

RESULTS

Skin cancer screening increased average discounted life expectancy from 15.0963 years to 15.0975 years. Based on the prevalence of malignant melanoma, however, this translates into an increased discounted life expectancy of 0.9231 years for each person with diagnosed melanoma. Using a cost of $30 per screen, total skin cancer-related costs for a cohort of 1 million people increased from $826 million with no screen to $861 million with screening, with an increase of 1200 years of life. This results in an incremental cost-effectiveness ratio of $29,170 per year of life saved (YLS) with screening. Sensitivity analysis showed that the cost-effectiveness ratio for screening remained below $50,000/YLS if the prevalence of melanoma in the screened population was at least 0. 0009, the probability that a melanoma detected in screening was localized was at least 94.8%, or the cost of each screen was below $57.

CONCLUSION

Skin cancer screening in high-risk patients is likely to be associated with a small increase in discounted life expectancy and is reasonably cost-effective compared with other cancer screening strategies.

Public knowledge, awareness, and perceptions of the association between skin aging and smoking

BACKGROUND

Although the tobacco industry promotes images of glamour, 2 decades of epidemiologic research have concluded the opposite: smokers have enhanced facial aging and skin wrinkling compared with nonsmokers.

OBJECTIVE

The purpose of this study was to obtain information on the public's awareness of the association between cigarette smoking and skin aging.

METHODS

In the spring of 1994, the Maine-wide Cooperative Telephone Survey conducted telephone interviews in 678 randomly selected, nonseasonal dwelling units in Maine. From each dwelling unit, one randomly selected adult resident was interviewed to assess awareness of the association of skin aging with smoking.

RESULTS

Fifty-eight percent of those persons interviewed had smoked at least 100 cigarettes, and among them, 24% were current smokers (28% men, 21% women). After adjusting for sex, age, and education, current smokers remained less likely to be aware of this association compared with former (prevalence ratio, 0.78; 95% confidence interval, 0.64-0.95) and never smokers (prevalence ratio, 0.87; 95% confidence interval, 0.70-1.07). However, nearly one fourth of smokers in this study believed that most or some smokers would consider this information in their decision to quit, with slightly higher findings in young smokers.

CONCLUSION

These findings are of public health importance. While strategies for framing messages about the association between smoking and facial aging await further study, this association deserves to be considered in all tobacco control and counter-advertising campaigns.

The Falmouth Safe Skin Project: evaluation of a community program to promote sun protection in youth

A multidimensional community-based skin cancer prevention program was conducted in Falmouth, Massachusetts, combining community activism with publicity campaigns and behavioral interventions to improve sun protection knowledge; attitudes; and practices in parents, caregivers, and children. The program was associated with improvements in target outcomes, based on two telephone surveys of random samples of parents (n = 401, 404). After program implementation, fewer parents reported sunburning of their children, particularly among children 6 years old or younger (18.6% in 1994 vs. 3.2% in 1997), and more parents reported children using sunscreen, particularly continuous use at the beach (from 47.4% to 69.9% in younger children). Hat and shirt use did not increase. Improvements also were seen in parent role modeling of sun protection practices, parents' self-efficacy in protecting children from the sun, and sun protection knowledge. While these findings must be interpreted cautiously, they do suggest that this project was effective in promoting sun protection.

The New Moms Project: educating mothers about sun protection in newborn nurseries

Sun protection habits should begin early in life and be taught as part of routine preventive health care. Early teaching of parents aims to introduce an easily achieved means of sun protection with the goal of instilling these practices as habits in the parents and their young children. We developed a maternity nurse-led intervention for 187 mothers at newborn nurseries in Falmouth, Massachusetts, combining educational material and personal discussions. One year after the intervention we successfully contacted 73% of the mothers. Nearly 90% recalled the informational program and equal numbers stated that receiving educational materials in the newborn nursery was timely. Nearly two-thirds of mothers reported that this was the only sun protection information received from a provider in the past year.

Participant satisfaction and value in American Academy of Dermatology and American Cancer Society skin cancer screening programs in Massachusetts

BACKGROUND

More than 1 million Americans have attended the American Academy of Dermatology's Melanoma/Skin Cancer Screening Programs since 1985. However, there have been no reports of the participants' perceived value, satisfaction, and benefits of skin cancer screening.

OBJECTIVE

We attempted to measure the benefits and subsequent screening practices of persons with presumptive positive screening diagnoses.

METHODS

A self-administered questionnaire was sent to participants with positive screening diagnoses in Massachusetts.

RESULTS

Of the 643 respondents, 81% rated their satisfaction as high and 84% had similar ratings for the value of the screening. Screenings apparently led to an increase in self-screening (60% before screening compared with 84% after screening).

CONCLUSION

Although screening appears to have relatively strong benefits, further studies should be conducted nationally.

Medical students' knowledge, attitudes, skills, and practices of cancer prevention and detection

BACKGROUND

Surveys of U.S. physicians show deficiencies in cancer detection and counseling skills. Thus, there is a compelling need to provide skills teaching during medical school for cancers with preventable mortality and for counseling techniques for smoking prevention and cessation.

METHODS

In advance of the integration of initiatives for cancer education into the medical school curriculum, the authors conducted a baseline survey of students' knowledge, attitudes, skills, practices, observation, and training (KASPOT) related to cancer education. Eighty-one percent of Boston University School of Medicine students (n = 499) completed surveys.

RESULTS

The students reported higher levels of KASPOT for breast and cervical cancers, compared with skin cancer examination or tobacco use cessation or prevention counseling. More than half of third- and fourth-year students reported that too little emphasis was given to cancer control education.

CONCLUSIONS

It appears that students' practice and skills for detection of the most common cancer (skin cancer), and for cancers with the greatest mortality (tobacco-related cancers) are deficient. Revisions in medical students' curricula should seek to address these shortcomings.

Creating statewide tobacco control programs after passage of a tobacco tax: executive summary

The tobacco control leaders of four states that have successfully passed tobacco tax ballot initiatives (California, Massachusetts, Arizona, and Oregon) were brought together to this conference to discuss what happens after the passage of such an initiative, how to defend tobacco control funds against diversion for other purposes by a state's legislature, and how to use the revenues maximally to reduce the health and economic toll taken by tobacco use. At the conference, the attendees from each state presented reports that will undoubtedly be useful to other states seeking to pass their own tobacco tax legislation or initiatives.

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

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

Factors associated with smoking among children and adolescents in Connecticut

INTRODUCTION

The age of smoking initiation has dropped over the past four decades. Since behaviors and attitudes adopted in late childhood or early adolescence predict future smoking, it is important to understand the smoking and other risk-taking behaviors and attitudes of children aged 12 and younger. The goal of the analyses presented here was to describe behavioral and attitudinal factors associated with smoking among elementary school (grades 4-6), middle school (grade 7-8), and high school (grades 9-12) students in Connecticut.

METHODS

We have used data from 8 years (1988-1996) of an anonymous, self-administered health risk appraisal survey given to children and adolescents in self-selected public and private schools. We compared the proportion of smokers and nonsmokers who reported various behaviors and attitudes and compared them with the chi-square test.

RESULTS

Fifteen percent (n = 4,884) of the total population (n = 31, 861) were current smokers. At all grade levels, current smokers were more likely than nonsmokers to engage in risk-taking behaviors, and to report more stress and depression. Indicators of risk-taking and stress were also associated with the intent to smoke among children in grades 4-6.

CONCLUSIONS

Smoking occurs within the context of other risk-taking behavior and psychological distress, among both children and older adolescents. Our data provide support for the idea of early identification and targeting of children at high risk of smoking in elementary school, possibly as early as grade four.

Do pediatricians counsel families about sun protection?: a Massachusetts survey

BACKGROUND

Pediatric visits during summer months may be especially opportune times for sun protection counseling for children and their parents. Few data exist on the extent of such counseling.

OBJECTIVE

To begin to assess this, we surveyed practicing Massachusetts pediatricians to examine current attitudes and practices of sun protection counseling.

DESIGN AND SETTING

Surveys mailed to Massachusetts pediatricians.

RESULTS

We received surveys from 756 (60%) of 1263 eligible Massachusetts pediatricians. Almost 70% indicated that they recommended safe sun practices to more than 50% of their patients and their parents during the summer months. Counseling regarding seat belt use, bicycle helmet use, and smoking prevention were ranked higher in priority than sun protection counseling by pediatricians; nutritional guidelines were noted by pediatricians to be a parent's most frequent concern. Four variables were independently associated with a practitioner's providing safe sun recommendations to more than 50% of parents and children: (1) private setting and health maintenance organization practitioners as opposed to academic physicians, (2) high ranking of patients' safe sun knowledge, (3) high priorities of both parents and physicians for sun protection counseling and parental knowledge of safe sun practices relative to other recommendations, and (4) pediatrician interest in receiving instructional materials.

CONCLUSIONS

For the most part, summer sun protection counseling among Massachusetts pediatricians seems well integrated into standard practice. Most pediatricians rated their confidence level as high for discussing sun protection and only a few cited inadequate training or poor reimbursement as barriers toward improved counseling. Small steps, such as providing more instructional materials to patients and using office-based reminder systems, may improve the quality of sun protection counseling practices. Incorporating sunburn prevention into the list of routinely recommended injury prevention guidelines for pediatricians should be considered.

Evaluation of the Ultraviolet Index: media reactions and public response

BACKGROUND

In response to the increasing rate of skin cancer, particularly melanoma in the United States, the Environmental Protection Agency, the National Weather Service, the Centers for Disease Control and Prevention, National Association of Physicians for the Environment, and the American Academy of Dermatology, developed the Ultraviolet Index (UVI) to inform the public of the strength of the sun's rays and advise on methods for sun protection.

OBJECTIVE

Our purpose was to evaluate the extent to which television stations and newspapers reported the UVI and assess the public's response to it.

METHODS

To evaluate the effect of this effort, we surveyed television weather forecasters at 185 stations and examined weather pages in 54 newspapers in 58 cities that received the UVI reports. We also conducted a population probability telephone survey of 700 white adults (18 years of age and older) in these 58 cities.

RESULTS

Seventy-one percent of the 169 stations that provided survey data for both 1994 and 1995 broadcast the UVI; 61% of newspapers reported the UVI. Nearly 64% of the 700 respondents (n = 445) had heard of the UVI. Of these respondents, 38% (n = 170) stated that they or their family changed their sun protection practices as a result of the UVI.

CONCLUSION

The majority of television weather forecasters and newspapers reported the UVI. Most of the public was aware of the UVI, causing some to change sun protection practices. Further evaluation is required to maximize the effect of the UVI on sun protection practices.

Sunbathing habits and sunscreen use among white adults: results of a national survey

OBJECTIVES

This study assessed current levels of sunbathing and sunscreen use in the United States.

METHODS

From a general-population telephone survey of aquatic activities among adults in 3042 US households, we examined responses by the 2459 Whites.

RESULTS

Most adults (59%) reported sunbathing during the past year, and 25% reported frequent sunbathing. Of the subsample who reported sunbathing during the month before the interview, 47% routinely used sunscreen. Of these individuals, almost half did not use sunscreens with a solar protection factor of 15 or higher.

CONCLUSIONS

About a quarter of US White adults report frequent sunbathing, and only about a quarter of sunbathers use sunscreens at recommended levels. These results should help focus future sun protection educational efforts.

Full proceedings from the National Conference to Develop a National Skin Cancer Agenda. American Academy of Dermatology and Centers for Disease Control and Prevention, Washington, D.C., April 8-10, 1995

National efforts to reduce skin cancer incidence and mortality require scientifically coordinated efforts. This report summarizes the first American Academy of Dermatology/Centers for Disease Control and Prevention national conference to develop a skin cancer agenda. Leading experts in dermatology, public health, medicine, health education, nursing, behavioral sciences, environmental health and epidemiology identified and prioritized skin cancer control issues in five key areas. Discussion centered around strategies for reducing UV exposure and increasing public and professional awareness of skin cancer. Panelists in five sessions developed consensus on several public and professional recommendations and a series of research strategies.

Melanoma awareness and self-examination practices: results of a United States survey

BACKGROUND

Skin cancers are common and there has been a dramatic increase in their incidence, particularly melanoma. However, little is known about awareness of melanoma and early detection practices in the general U.S. population.

OBJECTIVE

In 1995, the American Academy of Dermatology increased their efforts to promote awareness of melanoma. This study was conducted to document current knowledge of melanoma and self-examination practices.

METHODS

In February 1995, a telephone survey was conducted in a nationally representative sample of 1001 persons at least 18 years of age (3% margin of error) that included questions on knowledge, attitudes, and practices regarding early detection of melanoma.

RESULTS

Almost 42% of those surveyed were unaware of melanoma, and only 26% of those who were aware could identify its specific signs. Most recognized at least one common risk factor for melanoma (e.g., sun exposure, fair skin). However, many did not distinguish melanoma from other skin cancers in terms of risk factors, signs of early disease, and body site distribution. The lowest measures of melanoma knowledge and attitudes were found among those who are male, nonwhite, and parents, and those with the lowest level of education and income. More than half (54%) did not conduct a self-examination. This practice was most frequently reported by women, white persons, and the elderly, as well as those with a greater knowledge of melanoma.

CONCLUSION

Our research documents deficiencies in knowledge and practices related to early detection of melanoma in the general U.S. population and supports the need for public education about melanoma.

Evaluation of the American Academy of Dermatology's National Skin Cancer Early Detection and Screening Program

BACKGROUND

Increasing incidence and mortality rates from cutaneous melanoma are a major public health concern. As part of a national effort to enhance early detection of melanoma/skin cancer, the American Academy of Dermatology (AAD) has sponsored an annual education and early detection program that couples provision of skin cancer information to the general public with almost 750,000 free skin cancer examinations (1985-1994).

OBJECTIVE

To begin to evaluate the impact of this effort, we determined the final pathology diagnosis of persons attending the 1992-1994 programs who had a suspected melanoma at the time of examination.

METHODS

We directly contacted all such persons by telephone or mail and received pathology reports from those who had a subsequent biopsy.

RESULTS

We contacted 96% of the 4458 persons with such lesions among the 282,555 screenings in the 1992-1994 programs. We obtained a final diagnosis for 72%, and the positive predictive value for melanoma was 17%. Three hundred seventy-one melanomas were found in 364 persons. More than 98% had localized disease. More than 90% of the confirmed melanomas with known histology were in situ or "thin" lesions (< or = 1.50 mm thick). The median thickness of all melanomas was 0.30 mm. The 8.3% of AAD cases with advanced melanoma (metastatic disease, regional disease, or lesions > or = 1.51 mm) is a lower proportion than that reported by the 1990 Surveillance, Epidemiology and End Result Registry. The rate of thickest lesions (> or = 4 mm) and late-stage melanomas among all participants was 2.83 per 100,000 population. Of persons with a confirmed melanoma, 39% indicated (before their examination) that without the free program, they would not have considered having a physician examine their skin.

CONCLUSION

The 1992-1994 free AAD programs disseminated broad skin cancer educational messages, enabled thousands to obtain a free expert skin cancer examination, and found mostly thin, localized stage 1 melanomas (usually associated with a high projected 5-year survival rate). Because biases impose possible limitations, future studies with long-term follow-up and formal control groups should determine the impact of early detection programs on melanoma mortality.

Cutaneous melanoma mortality among the socioeconomically disadvantaged in Massachusetts

OBJECTIVES

To identify groups for melanoma prevention and early detection programs, this study explored the hypothesis that survival with cutaneous melanoma is disproportionately lower for persons of lower socioeconomic status.

METHODS

Massachusetts Cancer Registry and Registry of Vital Records and Statistics data (1982 through 1987) on 3288 incident cases and 1023 deaths from cutaneous melanoma were analyzed. Mortality/incidence ratios were calculated and compared, predictors of late stage disease were examined with logistic regression analysis, and a proportional hazards regression analysis that used death registration as the outcome measure for incident cases was performed.

RESULTS

Lower socioeconomic status was associated with a higher mortality/incidence ratio after adjustment for age and sex. For education, the mortality/incidence ratio was 0.37 in the lower group vs 0.25 in the higher group (rate ratio = 1.48, 95% confidence interval [CI] = 1.08, 2.03). Late stage disease was independently associated with lower income (rate ratio for lowest vs highest tertile = 1.64, 95% CI = 1.20, 2.25), and melanoma mortality among case patients was associated with lower education (rate ratio = 1.52, 95% CI = 1.09, 213).

CONCLUSIONS

Melanoma patients of lower socioeconomic status may be more likely to die from their melanoma than patients of higher socioeconomic status. Low- SES communities may be appropriate intervention targets.

Melanoma and Skin Cancer Control: An International Perspective

Approximately one million Americans are diagnosed with skin cancer each year. Since melanoma and skin cancer are amenable to prevention, education, and early detection, efforts to reduce the incidence of and death from melanoma have developed in many countries. Programs promoting behavioral changes and the incorporation of skin cancer control into national health care agendas have begun in a number of countries. Additional programs for the at-risk and general populations require further development and evaluation.

The current status of melanoma early detection and screening

Multiple strategies are required to combat the increasing incidence and mortality of cutaneous melanoma. Major questions about melanoma and skin cancer are reviewed, with particular attention to education and early detection.

The early detection of and screening for melanoma. International status

Cutaneous melanoma is an increasingly common public health problem in industrialized nations. In theory, education and early detection should decrease melanoma morbidity and mortality, because the lesion is external and visible, risk factors are known, and thin tumors are associated with a high 5-year survival rate. The efficacy of early detection and screening programs, however, remains untested by randomized trials. Some early data are available from melanoma prevention and control efforts that have begun in many nations over the past decade. Textbook definitions of cancer screening are particularly challenging when applied to skin cancer control. Although some propose that there are rigid differences among screening, education, and early detection of skin cancer, the visible nature of this cancer makes early detection through education and screening inextricably intertwined. This article discusses the intermediate measures of education and screening within the context of the American Academy of Dermatology programs. Over the next few decades, screening and education for melanoma and other skin cancer will receive increasing worldwide attention. Multiple strategies will be required to combat increasing incidence and mortality rates. Screening and educational programs have been implemented worldwide, but data on their effects are only just being collected. Future collaborative work in melanoma/skin cancer prevention, education, and early detection holds promise as a way to decrease mortality and save lives.

Melanoma control in the United States: current status

Screening and education for melanoma/skin cancer are receiving increasing worldwide attention. In an attempt to improve melanoma control in the United States, where incidence and mortality rates continue to increase, the American Academy of Dermatology (AAD) has provided free skin cancer screenings to more than 600,000 Americans and prevention messages to millions more. This chapter reviews and summarizes ongoing melanoma control activities in the United States, including prevention, education, and early detection/screening. We also address outcome measures in melanoma control and suggest that the unique external and visible nature of skin cancer blurs the distinction between screening and education. Measuring and evaluating the benefits of international melanoma control activities presents many challenging tasks. Future collaborative work must include complementary strategies in melanoma/skin cancer prevention, education, and screening to combat the worldwide increase in melanoma incidence and mortality.

Etiology of melanoma

Although the precise etiology of melanoma remains unknown, much data link sunlight to melanoma. The imperfect evidence associating sun exposure (particularly UVB radiation) with melanoma emerges from human data, obviating problems inherent in extrapolation from animal and other models. However, the mechanism by which sunlight might possibly initiate or promote melanoma remains obscure. Some clarification should emerge from the potential isolation of genes that carry susceptibility to melanoma in families prone to the disease; such work could serve as a basis to distinguish genetic and environmental influences in melanoma [167]. Continued studies of faulty DNA repair in XP patients may elucidate the steps in mutagenesis and carcinogenesis. Future case-control studies must address the limits on the accuracy of recall and the limits on statistical methods to separate the cluster of phenotypic risk needed in determining biologically effective dose. Animal and in vitro studies must contribute more insight. Further research in the South American opossum models appears promising [72]. Although ozone depletion has been documented, there has been little definitive evidence of subsequent increase of UVB at the Earth's surface. Nevertheless, the threat posed by ozone depletion deserves continued environmental action and public education. The role of precursor lesions, particularly dysplastic nevi/atypical moles, must be clarified with future research. The distribution of melanoma among various work forces suggests that occupational risk factors may play an important role in the etiology of this disease [168-170]. The consistent reports of excess melanoma among accountants, clerical workers, professional workers, and teachers deserve further study. Furthermore, evidence of excesses in printing and press, petrochemical, and the telecommunications industries require follow-up. Carefully planned studies that account for nonoccupational risk factors are recommended. Research over the last four decades has brought much information about melanoma etiology. More work is needed to learn the precise cause and ultimately to prevent avoidable mortality from malignant melanoma.

Who discovers melanoma? Patterns from a population-based survey

BACKGROUND

Melanoma is external and potentially detectable by many persons but little is known about who first discovers these lesions. An understanding of discovery patterns can shape future public and professional education programs.

OBJECTIVE

Our purpose was to assess patterns of melanoma discovery and to determine the patients' role in finding their own lesions.

METHODS

With a written, mailed questionnaire, we conducted a population-based statewide survey of 216 incident cases of melanoma in Massachusetts.

RESULTS

Approximately half (53%) of melanomas were self-discovered, whereas the remainder were detected by medical providers (26%), family members (17%), and others (3%). Nearly one third of persons said they could not see their own lesions easily. Compared with men, women were more likely to discover their own lesions (66% vs 42%, p = 0.001) and those on their spouses (23% vs 2%, p less than 0.001).

CONCLUSION

Improving early detection and reducing mortality of melanoma will require both public and professional education programs, with particular emphasis on targeting men at highest risk of this disease.

Practices and beliefs concerning screening family members of patients with melanoma. Results of a survey of New England dermatologists

BACKGROUND

First-degree relatives of patients with melanoma are roughly two to eight times more likely than the general public to be diagnosed with melanoma. Several organizations recommend regular screening for these and other persons at high risk for melanoma. However, there are no data as to how frequently such persons receive skin cancer examinations.

OBJECTIVE

Our purpose was to determine the current screening recommendations and practices of dermatologists regarding family screening for melanoma.

METHODS

With a one-page questionnaire, we surveyed dermatologists attending a 1989 meeting of the New England Dermatological Society.

RESULTS

Seventy-three dermatologists completed the questionnaire. Most dermatologists (70%) reported that they encouraged screening of family members of patients with melanoma but also reported that family members infrequently appeared for skin examinations.

CONCLUSION

Although most dermatologists encouraged screening of first degree relatives of melanoma patients, there appears to be infrequent acceptance by the patient of these recommendations. Recording family screening in the patients' charts, reminders to patients, and distributing literature on familial melanoma may increase acceptance by the patient of these recommendations.

Use of health services before the diagnosis of melanoma: implications for early detection and screening

OBJECTIVE

To determine whether persons with melanoma were integrated into the health care system prior to diagnosis.

DESIGN

Population-based survey by mailed questionnaire.

PATIENTS/PARTICIPANTS

216 persons with malignant melanoma diagnosed in Massachusetts in 1986.

MAIN RESULTS

Of the 216 cases, 87% stated that they had regular physicians, 63% had seen those physicians in the year prior to diagnosis, but only 20% had regular dermatologists. Overall, only 24% had examined their own skin prior to diagnosis and 20% reported physician skin examinations.

CONCLUSIONS

Persons diagnosed with melanoma reported extensive contact with regular physicians in the year prior to diagnosis. However, most of these persons neither received skin examinations nor examined their own skin during that time. While additional study is necessary to confirm these findings, the authors suggest that physicians caring for patients at risk for melanoma integrate melanoma screening into routine care.

Occupation, smoking, and the risk of high-grade invasive bladder cancer in Missouri

Numerous epidemiological studies have established that occupational exposures and smoking are the two major known risk factors for the development of bladder cancer. Using data from the Missouri Cancer Registry, we investigated the hypothesis that individuals with occupationally-related bladder cancer are more likely to have a more invasive form of the disease. Data were analyzed for 2,893 white males diagnosed with primary bladder cancer in Missouri between 1984 and 1988. Of the 1,415 cases whose occupational status was recorded, 236 (17%) were employed in high-risk occupations. Cases with high-grade disease were more likely to have been employed in a high-risk occupation, after adjustment for age and smoking (adjusted odds ratio [AOR] = 1.7, 95% confidence interval [CI] = 1.1-2.6). High-risk workers under 60 years of age were most at risk for developing high-grade bladder tumors (AOR = 2.3, 95% CI = 1.0-5.3). There was no overall association between high-risk occupation and late-stage disease (AOR = 1.1, 95% CI = 0.7-1.5), but it was present in the men younger than 60 years of age (AOR = 2.0, 95% CI = 1.0-3.8). No association was found between tobacco use and grade (AOR = 1.1, 95% CI = 0.8-1.5), but cases with late-stage disease were more likely to be smokers (AOR = 1.5, 95% CI = 1.1-1.9). When occupations were examined individually, motor vehicle operators, truck drivers, vehicle mechanics, other mechanics, and janitors were among those most likely to be diagnosed with high-grade or late-stage tumors. Although further studies are necessary to confirm these results, they suggest that surveillance and targeted screening of workers in high-risk occupations may result in a greater yield of early invasive cancers and possibly decrease the mortality associated with this disease.