Evidenz für ein Hautkrebsscreening

Background

In 2008 Germany was the first country to introduce a nationwide population-based skin cancer screening after a pilot project in Schleswig-Holstein had shown promising results.

Objectives

This article gives an overview of the current evidence for the effectiveness of a German skin cancer screening program.

Material and methods

The number needed to screen was derived from data of the pilot project. The impact of screening on melanoma incidence and mortality was analyzed based on cancer registry data and on mortality statistics from Schleswig-Holstein and adjacent regions.

Results

A malignant tumor of the skin was found in 1 out of 116 screening participants and a melanoma in 1 out of 620. The intensified search for skin cancer resulted in an increase in melanoma incidence during the pilot project and a subsequent decline, as expected. A reduction in melanoma mortality was observed in Schleswig-Holstein but not in any of the adjacent regions.

Conclusion

The current evidence suggests that a population-based skin cancer screening is feasible and effective; however, further research is urgently needed: Open questions concern the benefit-harm relationship of the skin cancer screening, interval carcinomas and cost-effectiveness.     

Screening and early detection of skin cancer

Skin cancer is the most common type of cancer in the United States. US incidence of malignant melanoma is increasing faster than any other type of cancer. To minimize increasing morbidity and mortality rates, it is imperative that appropriate screening and early detection of skin cancer become more widespread. All physicians who see patients clinically have the potential for detecting skin cancers. The scope of skin cancer as a health-care problem is discussed. Evidence for the effectiveness and necessity of skin cancer screening and early detection is presented. Costs of screening and detection are discussed in relation to impact on treatment costs and overall costs of skin cancer burden. Current methods and recommendations for skin cancer screening and detection are reviewed, especially with regard to individuals and populations that may require more specialized or intensive screening and follow-up. Newer approaches involving instrument-assisted screening and detection of skin cancer are under intense development, and these exciting emerging technologies are reviewed.     

The regulation of p53 function: Steiner award lecture

Although breast-cancer screening programmes are now being introduced it is still debated whether this is an appropriate policy for all European countries. Taking into account empirical data from 2 regional pilot screening projects, this study has evaluated the effects and costs of a nationwide breast-cancer screening programme in Germany. Special attention was paid to the decentralized German health-care system and to the influence of attendance, interval and age group. The recent results of the analysis of the Swedish randomized screening trials were used to estimate the improvement in prognosis after early detection of breast cancer. Our analysis shows that a programme providing for the screening of women aged 50-69 at 2-year intervals might be expected to result in a decrease in mortality from breast cancer estimated at 11% for the total German population, representing 2,100 deaths from breast cancer prevented each year. The cost per life-year gained was assessed at between DM 18,600 and DM 25,300 for this scenario; 2 to 3 times less favourable than in the UK and The Netherlands. The sensitivity of mammography was estimated to be 12% lower than in The Netherlands and the attendance rate was calculated at 47% on average. A greater effort to ensure the quality of the screening programme and to improve the invitation system might finally lead to much better results. The mortality reduction might be as much as 18% if the attendance and the sensitivity of the screening could be improved to the Dutch level.     

Does skin cancer screening save lives?

BACKGROUND:

From July 1, 2003 to June 30, 2004, a population‐based skin cancer screening project was conducted in Schleswig‐Holstein, Germany. In total, 360,288 individuals aged ≥20 years were screened by means of a whole‐body examination. In this report, the authors compare trends in melanoma mortality in Schleswig‐Holstein with those in all adjacent regions, none of which had population‐based skin cancer screening.

METHODS:

Trends in melanoma mortality rates for Schleswig‐Holstein and the adjacent regions (Denmark and the German federal states of Mecklenburg‐Vorpommern, Hamburg, and Lower Saxony) and in Germany excluding Schleswig‐Holstein were compared. Log‐linear regression was used to assess mortality trends.

RESULTS:

In Schleswig‐Holstein during the pre skin cancer screening period (1998‐1999), the age‐standardized melanoma mortality rate (World standard population) was 1.9 per 100,000 for men and 1.4 per 100,000 for women. Melanoma mortality declined by 47% to 1.0 per 100,000 men and by 49% to 0.7 per 100,000 women by 2008/2009. The annual percentage change in the most recent 10‐year period (2000‐2009) was ?7.5% (95% confidence interval, ?14.0, ?0.5) for men and ?7.1% (95% confidence interval, ?10.5, ?2.9) for women. In each of the 4 adjacent regions and in the rest of Germany, mortality rates were stable, and the decline in Schleswig‐Holstein was significantly different from the changes observed in all of the other areas studied.

CONCLUSIONS:

The current data represent strong evidence, but not absolute proof, that the skin cancer screening program produced a reduction in melanoma mortality in Schleswig‐Holstein. Cancer 2012. © 2012 American Cancer Society.     

The role of screening in the management of skin cancer

The incidence of skin cancer has been rising at an alarming rate for the past several years. This poses a significant public health problem in the United States. Detection and treatment of melanoma early in its course is critical for improved outcome. Of the approaches to cancer control that can reduce mortality from melanoma and nonmelanoma skin cancer, screening holds the greatest promise for a rapid and major impact. Prevention and early detection are crucial in reducing morbidity and mortality from skin cancer. For a number of reasons, however, the full effect of screening for both melanoma and nonmelanoma skin cancers has not been achieved. Controversy exists regarding who should perform screening, who should be screened, and whether screening should be performed at all. It is clear that melanoma and nonmelanoma skin cancer control programs combining primary prevention, education, and screening are in developmental stages. This review will discuss the advantages and disadvantages of screening for skin cancer.     

Monitoring and evaluation of a model demonstration project for the control of cervical cancer in Nakhon Phanom province, Thailand

Cancer of the uterine cervix is the second most common cancer in females in the world with about half a million new patients per year. Since the introduction by Papanicolaou of cervical smear screening, the incidence of cervical cancer has declined in many developed countries. The decrease in the incidence of and mortality from cervical cancer is mainly due to the organized mass screening using Pap smear programmes. Uterine cervical cancer is the leading cancer among women in Thailand with age-standardized incidence rates of 24.7 per 100,000 in 1999. Most cases present at advanced stages with poor prognoses of survival and cure. In the present study, cervical cancer screening programme with cervical cytology was organized for Nakhon Phanom province, Thailand. The specific objectives were: 1) to evaluate the reduction in incidence and mortality from cervical cancer in the province by means of an organised low-intensity cervical cytology programme. 2) to demonstrate the different aspects of programme implementation as a potential model for nationwide implementation. The screening activities were integrated in the existing health care system. Organized screening for women in the target population (aged 35-54 years) at 5-year intervals was free of charge. Sample taking was done by trained nurses (midwives) and primary health care personnel in the local health care centers. Sample quality was under continuous controlled by the cytology laboratories and pathologists. Confirmation and treatment were integrated into the normal health care routines. The screening results of the programme, including histologically confirmed diagnosis, were registered at the National Cancer Institute using PapReg and CanReg 4 programmes. A population-based cancer registry in Nakhon Phanom province was also set up in 1997. In the period 1999-2002, 32,632 women aged 35-54 years were screened. Women with low-grade lesions returned for routine follow-up smears. High-grade preinvasive disease was further evaluated by repeating Pap smear, conization or biopsy and subsequent treatment through surgical removal or ablation. This organized low-intensity cervical cytology programme showed a considerable increase in early carcinoma in situ and CIN II -III cases and should reduce incidence of and mortality from cervical cancer in Nakhon Phanom province in the future. Screening with the Papanicolaou smear plus adequate follow-up diagnosis and therapy can achieve major reductions in both incidence and mortality rates.     

Who attends skin cancer clinics within a randomized melanoma screening program?

BACKGROUND: Screening may reduce morbidity and mortality associated with melanoma, although in the absence of randomized-controlled trials, this remains unproven. METHODS: As part of a randomized community-based trial of melanoma screening in Queensland, Australia, sociodemographic characteristics, skin cancer risk factors and attitudes towards skin cancer associated with attendance at screening clinics and reasons for attendance or non-attendance were examined. A telephone survey was conducted among 743 attendees and 298 non-attendees. RESULTS: After adjustment, the following factors were associated with clinic attendance: age 40-49 years, having fair skin, a personal history of skin cancer or melanoma or concern about a specific spot or mole, and no recent whole-body skin examination by a doctor. The main reasons for attendance were "to see if I have melanoma", "to have a suspicious mole checked" or "to have a whole-body skin examination". The main reasons for non-attendance were lack of knowledge about the clinics, no time or being away while the clinics were held and having had a skin check in the recent past. Overall, 77% of non-attendees compared to 65% of attendees stated they planned to participate in future screening. CONCLUSIONS: The results suggest that we were able to attract both men and women equally to a skin screening clinic, along with those at all levels of education and indicate the importance of using well-designed promotional materials to attract community members to skin screening clinics. Future work should test strategies to remove barriers to participation in skin screening identified in this study.     

Increase in skin cancer screening during a community-based randomized intervention trial

Survival from cutaneous melanoma is mainly dependent on the thickness of the lesion at diagnosis. Skin screening may increase detection of thin lesions and hence improve survival. Within a community-based randomized controlled trial of a population screening program for melanoma in Queensland, Australia, 9 communities were randomly assigned to the 3-year intervention and 9 communities to the control group. Skin screening prevalence was monitored by cross-sectional surveys at baseline, 1, 2 and 3 years into the intervention and 2 years later. At baseline, prevalence of whole-body clinical skin examination was similar in intervention and control communities. In intervention communities, the prevalence of whole-body skin examinations increased to 29.2%, an absolute difference of 18% from baseline, with a peak of 34.8% 2 years after baseline, and began to decline again at the end of the intervention period. The largest increases were seen in men and women > or =50 years. Uptake of screening did not differ according to melanoma risk factors; however, the decline in screening was less in participants who reported a number of melanoma risk factors. The prevalence of skin self-examination remained stable during the intervention program. No changes were observed in the control communities. These results indicate that the intervention program significantly increased the prevalence of whole-body clinical skin examinations in intervention communities. Once the intervention program ceased, and particularly after skin clinics ceased, levels of skin screening began to decline. The provision of specialized skin screening clinics may be needed to achieve sufficient screening rates should population based screening for skin cancer be considered.     

Früherkennung von Hautkrebs und Screeninguntersuchungen

Background

From 1970 to 2010, the incidence of melanoma rose 7?fold and the incidence of epithelial skin cancer, which is by far the most common form of cancer, 13-fold, according to the Saarland cancer registry data. This was due to the steep increase in UV exposure because of changes in holiday and leisure habits. The significant rise in skin cancers has greatly increased the demand for surgical care and for clinical follow-up examinations, and has also led to a significant increase in melanoma mortality. Early detection can be conducive to a decrease in care expenditure and long-term mortality. It is in principle simple, because the majority of suspected tumors are recognizable without expenditure on equipment.

Aim

The possibilities of the clinical diagnosis of skin cancers will be presented, together with diagnostic algorithms, and improvement of diagnostic accuracy by applying dermoscopy is discussed, along with the current contribution of statutory skin cancer screening tests.

Method

Data were extracted from a selective literature search in the PubMed database.

Results and discussion

Early detection of skin cancer is possible in up to 90?% of cases with the aid of testing and dermatoscopy. Particular attention should be paid to suspected skin tumors of which the patient is aware. There are no data on whether new diagnostic methods increase diagnostic accuracy further. In July 2008, statutory skin cancer screening with reimbursement was introduced throughout Germany for individuals from the age of 35 years every 2 years, in which more than 30?% of the population participated. A survey conducted by the Federal Joint Committee accompanying the clinical screening examinations collected data of the garbage in, garbage out type; accordingly, questions about the benefit of the skin cancer screenings remain unanswered.

     

Cervical cancer screening in the Netherlands

The Netherlands is among the European countries with low incidence and almost lowest mortality from cancer of the uterine cervix. Screening started around 1970, being a combination of local and regional invitational programmes and opportunistic screening. In 1996 screening activities have been structured to a new national and nationwide programme. The restructuring concerned the management and financing of the programme, organisation, target age-ranges and interval, follow-up of abnormal test results, and evaluation. At the moment short-term results of implementation of the new screening programme are becoming available. It will take many more years before long-term effects of the new programme will emerge.     

Update on melanoma and non-melanoma skin cancer. Annual Skin Cancer Conference 2011, Hamilton Island, Australia, 5–6 August 2011

In this article, we will summarize some of the highlights of the third annual conference on skin cancer, with special emphasis on the the recent advances regarding melanoma and non-melanoma skin cancer epidemiology, diagnosis and treatment. Topics were particularly addressed to a newly developing medical branch in Australia, namely that of Primary Care Skin Cancer Practitioners, and focused on strategies to improve primary and secondary prevention and early detection of melanoma and non-melanoma skin cancer using dermoscopy. Controversies related to skin cancer screening programs and recent progresses for treating advanced melanoma were additionally discussed. Yet, besides its scientific goals, the conference aimed also to encourage research originating in primary care and relevant to primary care.     

Früherkennung und Primärprävention von Hautkrebs

Skin cancer is today the most frequent cancer in Caucasians, whereas it is nearly unknown in pigmented populations (Africans, Asians), a finding that hints at the etiologic role of ultraviolet radiation. Skin cancer comprises epithelial neoplasias, including basal cell carcinoma and squamous cell carcinoma, and the pigment-cell-derived melanoma. Skin tumors are particularly suitable for early recognition because they can be easily and accurately diagnosed in the early phase of their development, and thus the extent of therapeutic measures and the severity of the disease course can be effectively influenced. New diagnostic developments such as dermoscopy have markedly improved diagnostic accuracy over the last decades. It is mandatory to make skin cancer screening a part of governmental cancer prevention campaigns: In Germany, skin cancer screening examinations will be reimbursed every 2 years by health insurances for patients 35 years old and older beginning in the second half of 2008. During the last decades, an epidemic increase in skin cancer incidence occurred in the western industrial countries. In Germany, the incidence of epithelial skin cancer increased by a factor of 10 from 1970 to 2005, and the melanoma incidence increased during this period by a factor of five. Primary and secondary prevention are suitable measures to counteract this development and to lower morbidity and mortality as well as the enormous costs for the healthcare system.     

Systemic treatments for women with breast cancer: outcome with relation to screening for the disease.

Early detection and proper care of breast cancer are currently the best available approaches to the treatment of patients with the disease. In countries with a breast cancer screening programme, there has been a demonstrated reduction in breast cancer-related mortality. Such reduction has also been observed in Switzerland, a country in which no national programme of screening is available. Although there is no doubt that early diagnosis might have had a major role in reducing breast cancer mortality the magnitude of this effect is unknown. Research with tailored approaches on alternative imaging for early detection of breast cancer in high-risk women and on treatments offered according to proper criteria of responsiveness to therapies is warranted.     

Skin Cancer Concerns in People of Color: Risk Factors and Prevention

Background: Though people of color (POC) are less likely to become afflicted with skin cancer, they are much more likely to die from it due to delay in detection or presentation. Very often, skin cancer is diagnosed at a more advanced stage in POC, making treatment difficult.The purpose of this research was to improve awareness regarding skin cancers in people of color by providing recommendations to clinicians and the general public for early detection and photo protection preventive measures. Methods: Data on different types of skin cancers were presented to POC. Due to limited research, there are few resources providing insights for evaluating darkly pigmented lesions in POC. Diagnostic features for different types of skin cancers were recorded and various possible risk factors were considered. Results: This study provided directions for the prevention and early detection of skin cancer in POC based on a comprehensive review of available data. Conclusions: The increased morbidity and mortality rate associated with skin cancer in POC is due to lack of awareness, diagnosis at a more advanced stage and socioeconomic barriers hindering access to care. Raising public health concerns for skin cancer prevention strategies fo     

Cervical cancer screening in Germany

Cervical cancer is one of the target cancers covered by the statutory German cancer screening programme which was introduced in West Germany in 1971 and expanded to the eastern part of the country in 1991. Women covered by statutory health insurance (over 90% of the female population) are eligible to receive an annual cervical examination including a Papanicolaou (PAP) smear beginning at age 20 years. Annual uptake currently slightly exceeds 50% of the eligible population. Shortly after implementation of the national screening programme in the early 1970s the incidence of invasive cervical cancer decreased moderately and the incidence of cervical carcinoma in situ increased substantially in the state of Saarland. These observations would be expected as a result of a cervical cancer screening programme with substantial uptake. Although quality assurance guidelines for cervical cancer screening have been adopted and updated since the inception of the screening programme, only minor changes have been made in the cross-sectional programme documentation. Implementation of population-based documentation and evaluation of screening activities is currently being developed for the German cancer screening programme in pilot studies implementing the European guidelines on the quality assurance of mammography screening. After demonstration of feasibility and effectiveness, improvements in the quality management of breast cancer screening will subsequently be applied to the cervical cancer screening programme.     

Divergent coverage,frequency and costs of organised and opportunistic Pap testing in Finland

We evaluated the overall coverage, frequency and costs of Pap testing by screening modality and health care provider in Finland. Information about Pap testing in the Finnish female population of 2.7 million was obtained from nationwide population‐based registry data. Among women aged 25–69 years, 87% had had a Pap test taken within or outside the organised programme at least once during the last 5 years and half of those screened in the organised programme had also had at least one Pap test taken outside the programme. Of the annual average of 530,000 Pap tests taken, 84% were taken for screening purposes and 16% as follow‐up. Forty percent of the 446,000 annual screening tests were taken in the organised programme, 55% as opportunistic tests in public primary or student health care or by private providers and 5% in public secondary health care. One‐fifth of all opportunistic screening Pap tests were taken from women aged <25. The voluminous opportunistic Pap testing in public primary health care was concentrated in young women aged 25–29 whereas the bulk of opportunistic testing in private health occurred in age groups eligible for organised screening. The total cost of all screening Pap tests was €22.4 million, of which 71% incurred in opportunistic screening. Of the 84,000 annual follow‐up Pap tests and their €8.3 million total costs, ～60% incurred in organised screening or in secondary health care.     

Mass screening programmes and trends in cervical cancer in Finland and the Netherlands

With respect to cervical cancer management, Finland and the Netherlands are comparable in relevant characteristics, e.g., fertility rate, age-of-mother at first birth and a national screening programme for several years. The aim of this study is to compare trends in incidence of and mortality from cervical cancer in Finland and the Netherlands in relation to the introduction and intensity of the screening programmes. Therefore, incidence and mortality rates were calculated using the Cancer Registries of Finland and the Netherlands. Data on screening intensity were obtained from the Finnish Cancer Registry and the Dutch evaluation centre at ErasmusMC-Rotterdam. Women aged 30-60 have been screened every 5 years, in Finland since 1992 and in the Netherlands since 1996. Screening protocols for smear taking and referral to the gynaecologist are comparable. Incidence and mortality rates have declined more in Finland. In 2003, age-adjusted incidence and mortality in Finland were 4.0 and 0.9 and in the Netherlands 4.9 and 1.4 per 100,000 woman-years, respectively. Excess smear use in the Netherlands was estimated to be 24 per 1,000 women during a 5-year interval compared to 121 in Finland. The decline in mortality in Finland seems to be almost completely related to the screening programme whereas in the Netherlands it was initially considered to be a natural decline. Differences in risk factors might also play a role: the Netherlands has higher population density and higher percentages of immigrants and (female) smokers. The greater excess smear use in Finland might also have affected incidence.     

Pr?vention des malignen Melanoms

The incidence of cutaneous melanoma is rising steadily in Germany and worldwide. Primary prevention of melanoma comprises UV protection as the central environmental factor for melanoma development. A significant step forward in secondary melanoma prevention was seen with the inclusion of skin cancer screening in the standard benefits of public health insurances in Germany. Additionally, patients with a high melanoma risk should be examined using dermoscopy and, when indicated, with digital dermoscopic follow-up. This enables the early diagnosis of melanoma at a curable stage.     

Brustkrebsfrüherkennung

In 2004 Germany implemented a national screening program closing up to other European countries. The effect on breast cancer mortality reduction has been proven with the highest level of evidence. The goal of any secondary preventive strategy is always nil nocere, therefore risks and undesired side-effects should be critically addressed and continuously evaluated to offer the possibility of early control. The women participating need comprehensive, understandable information to give informed consent. This aspect needs further improvement as well as the quality assurance of early breast cancer detection beyond mammography screening and the recommendations of the National Guidelines on Early Breast Cancer Detection should be integrated into routine medical care.     

Früherkennung des Mammakarzinoms

In order to optimize early detection of breast cancer a comprehensive concept with a new structure which overcomes the existing traditional barriers in the German health system must be established. Mammographic screening alone represents just one part of an early detection and diagnosis program. Complete documentation of breast imaging performed in private practice must be connected with data from mammography screening and the results from breast cancer treatment in the hospitals. These data must be linked with nationwide cancer registries. Without sufficient documentation we will not be able to measure the effect of the screening system and quality adjustment is impossible, nor will we be able to react if necessary. The mammographic screening program initiated in Germany covers just a part of a national secondary preventive strategy and several aspects need to be corrected in order to improve the effectiveness.