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 (≤ 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 ≥ 1.51 mm) is a lower proportion than that reported by the 1990 Surveillance, Epidemiology and End Result Registry. The rate of thickest lesions (≥ 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.     

Practical considerations of melanoma/skin cancer screening clinics.

In 1989 a voluntary melanoma/skin cancer screening clinic was held in Oss, the Netherlands. The campaign was carried out according to the free clinics conducted since 1985 in the USA. Our experiences with the first clinic urged us to improve on the organization of the screen. This produced a better yield of the second screen, conducted in 1990 in Arnhem. In this paper we present the practical and organizational implications of melanoma/skin cancer screening based on both screening exercises. It is emphasized that only dermatologists should screen. Concomitant public education will enhance self-selection of people at risk for melanoma/skin cancer. There should be ample provider time, sufficient auxiliary personnel and abundant examination rooms. Total-body skin examination is optional. Follow-up of positive screenees is mandatory. It is concluded that melanoma/skin cancer screening is feasible, particularly in countries with a high dermatologist-to-patient ratio.     

Frequency of excisions and yields of malignant skin tumors in a population-based screening intervention of 360 288 whole-body examinations

OBJECTIVE To explore the frequency of excisions and yields of histopathologically confirmed skin cancer. DESIGN A population-based skin cancer screening intervention (the SCREEN project) in the German state of Schleswig-Holstein (July 1, 2003, to June 30, 2004). SETTING Physician offices. Participants could choose between nondermatologist physicians and dermatologists for their initial whole-body skin examination. All screening physicians received a mandatory 8-hour training course. PARTICIPANTS Inhabitants of Schleswig-Holstein 20 years or older with statutory health insurance (N?=?360?288). MAIN OUTCOME MEASURES Frequency of excisions and yields of malignant skin tumors (malignant melanomas [MMs], basal cell carcinomas [BCCs], and squamous cell carcinomas [SCCs]), stratified by sex and age. RESULTS Overall, 15?983 excisions were performed (1 of 23 screenees). A total of 3103 malignant skin tumors were diagnosed in 2911 persons: 585 MMs, 1961 BCCs, 392 SCCs, and 165 other malignant skin tumors. Overall, 116 persons (3103 of 360?288) had to be screened to find 1 malignant tumor, with 1 of 620 for MM, 1 of 184 for BCC, and 1 of 920 for SCC. Twenty excisions were performed to find 1 melanoma in men 65 years and older, but more than 50 excisions were required to find 1 melanoma in men aged between 20 and 49 years. CONCLUSIONS The results of SCREEN suggest a high yield of malignant skin tumors in a large-scale population-based screening project. We found that a high number of excisions was performed in the youngest screenees with an associated low yield, suggesting a need in screener training to emphasize a more conservative attitude toward excisions in young screenees.     

The Euromelanoma skin cancer prevention campaign in Europe: characteristics and results of 2009 and 2010

Background Euromelanoma is a skin cancer education and prevention campaign that started in 1999 in Belgium as ‘Melanoma day’. Since 2000, it is active in a large and growing number of European countries under the name Euromelanoma. Objective To evaluate results of Euromelanoma in 2009 and 2010 in 20 countries, describing characteristics of screenees, rates of clinically suspicious lesions for skin cancer and detection rates of melanomas. Methods Euromelanoma questionnaires were used by 20 countries providing their data in a standardized database (Belgium, Croatia, Cyprus, Czech Republic, FYRO Macedonia, Germany, Greece, Hungary, Italy, Lithuania, Luxembourg, Malta, Moldavia, Portugal, Serbia, Slovenia, Spain, Sweden, Switzerland and Ukraine). Results In total, 59 858 subjects were screened in 20 countries. Most screenees were female (64%), median ages were 43 (female) and 46 (male) and 33% had phototype I or II. The suspicion rates ranged from 1.1% to 19.4% for melanoma (average 2.8%), from 0.0% to 10.7% for basal cell carcinoma (average 3.1%) and from 0.0% to 1.8% for squamous cell carcinoma (average 0.4%). The overall positive predictive value of countries where (estimation of) positive predictive value could be determined was 13.0%, melanoma detection rates varied from 0.1% to 1.9%. Dermoscopy was used in 78% of examinations with clinically suspected melanoma; full body skin examination was performed in 72% of the screenees. Conclusion Although the population screened during Euromelanoma was relatively young, high rates of clinically suspected melanoma were found. The efficacy of Euromelanoma could be improved by targeting high‐risk populations and by better use of dermoscopy and full body skin examination.     

The use of targeted and non-targeted advertising to enrich skin cancer screening samples

Summary Tbe purpose of this study was to determine whether tbe risk factor profile of persons attending skin cancer screening clinics could be enriched by appropriate advertising prior to tbe screening events. Eleven screening clinics were held in eight rural and three suburban communities, Matched communities were randomly assigned to either a target or non-target condition. Targeted communities received an advertisement designed to attract bigh-risk individuals. The advertisement listed a number of risk factors and encouraged readers witb one or more of the listed risk factors to attend the screening. Non-targeted communities received a general advertisement requesting individuals who felt they were at risk of skin cancer to attend the clinic. Risk factor profiles of all participants were measured on the factors listed in the targeted advertisement. The risk factor profiles of screenees and the referral rates for skin lesions requiring attention were significantly higher in the targeted communities than in the non-targeted communities. Lesions suspicious of malignant melanoma or Hutchinson's meianotic freckie also were higher, but not statistically significant, in the targeted communities. Population samples attending community-based skin cancer screening ciinics can be enriched by appropriate targeted advertising prior to the screening events, This has important impiications for determining the potentiai cost-effectiveness of population screening programmes.     

Effectiveness of skin cancer screening for individuals age 14 to 34 years

Background: Approximately 15 % of all cases of melanoma are diagnosed before age 35 years. In Germany, individuals ≥ 35 years are eligible for the national skin cancer screening program. The effectiveness of a population‐based skin cancer screening in general and in particular for young adults is unclear. Objectives: Assessment of the effectiveness of a skin cancer screening program and of risk factors for detection of a melanoma/atypical nevus in the setting of a screening for the age group 14 to 34 years. Methods: A total of 12 187 individuals age 14 to 34 years were screened in Saxony for skin cancer by a dermatologist in the program “Haut‐Check 14–34 Jahre” of the AOK PLUS, a large German health insurance, between January and July 2009. Demographic, clinical and histopathological data and UV‐exposure data were collected from each participant. Multivariate logistic regression models were used to assess risk factors for the detection of a (histopathologically confirmed) melanoma or atypical nevus. Results: 2.8 % of the eligible individuals participated in the skin cancer screening program with women being more likely to do so. In 1 072 individuals (8.8 %) screening included at least one excision of a skin lesion leading to the diagnosis of melanoma in two participants, melanoma in situ in four persons, and atypical nevus in 641 persons. Use of tanning beds, higher age, number of nevi, and previous cutaneous excision were independent risk factors for the detection of a melanoma or atypical nevus. Conclusions: In 5.5 % of all cases skin cancer screening resulted in the excision of a malignant or atypical melanocytic lesion. It remains unclear what proportion of these cases would have been detected in routine care. The rate of excisions per newly diagnosed melanoma was 179 : 1. Further investigations are necessary to explore the reasons for this low diagnostic specificity. This study highlights the possibilities and limitations of routine data to evaluate screening programs and indicates the need to collect additional information on healthcare utilization behaviour.     

Follow-up and evaluation of skin cancer screening in British Columbia.

BACKGROUND: Skin cancer screening is thought to be a useful public health tool for the early detection of skin cancers. However, few studies have reported on follow-up and outcome of subjects who have a positive screen. OBJECTIVE: The aims of this study were to evaluate attendance at skin cancer screening clinics in British Columbia for the period 1994 and 1995 and to assess follow-up outcome among participants who were identified to have a potentially serious skin lesion that warranted further medical review. METHODS: A self-administered questionnaire was sent to participants screening positive for skin cancer and to their attending physicians. RESULTS: Five hundred twenty people were screened. Of these, 105 were referred for evaluation of a potential malignancy or precursor lesion. One melanoma, 3 basal cell carcinomas, 4 atypical nevi, and 1 actinic keratosis were histologically confirmed in 76 referred participants for whom follow-up information was available. The positive predictive values ranged from 17% to 89% depending on the screening diagnosis. Several false-positive results and one false-negative result were observed. Reasons for not seeking recommended follow-up were addressed. CONCLUSIONS: Our yield and positive predictive values for different screening diagnoses were virtually identical to those previously reported in larger US studies. Improved communication between screening physicians and screening participants may improve follow-up rates in those people who would benefit from further medical care.     

Visual screening for malignant melanoma: a cost-effectiveness analysis

OBJECTIVE: To evaluate the cost-effectiveness of various melanoma screening strategies proposed in the United States. DESIGN: We developed a computer simulation Markov model to evaluate alternative melanoma screening strategies. PARTICIPANTS: Hypothetical cohort of the general population and siblings of patients with melanoma. Intervention We considered the following 4 strategies: background screening only, and screening 1 time, every 2 years, and annually, all beginning at age 50 years. Prevalence, incidence, and mortality data were taken from the Surveillance, Epidemiology, and End Results Program. Sibling risk, recurrence rates, and treatment costs were taken from the literature. MAIN OUTCOME MEASURES: Outcomes included life expectancy, quality-adjusted life expectancy, and lifetime costs. Cost-effectiveness ratios were in dollars per quality-adjusted life year (US dollars/QALY) gained. RESULTS: In the general population, screening 1 time, every 2 years, and annually saved 1.6, 4.4, and 5.2 QALYs per 1000 persons screened, with incremental cost-effectiveness ratios of US dollars 10,100/QALY, US dollars 80,700/QALY, and US dollars 586,800/QALY, respectively. In siblings of patients with melanoma (relative risk, 2.24 compared with the general population), 1-time, every-2-years, and annual screenings saved 3.6, 9.8, and 11.4 QALYs per 1000 persons screened, with incremental cost-effectiveness ratios of US dollars 4000/QALY, US dollars 35,500/QALY, and US dollars 257,800/QALY, respectively. In higher risk siblings of patients with melanoma (relative risk, 5.56), screening was more cost-effective. Results were most sensitive to screening cost, melanoma progression rate, and specificity of visual screening. CONCLUSIONS: One-time melanoma screening of the general population older than 50 years is very cost-effective compared with other cancer screening programs in the United States. Screening every 2 years in siblings of patients with melanoma is also cost-effective.     

Development of a targeted risk‐group model for skin cancer screening based on more than 100 000 total skin examinations

Background Skin cancer screening aims to detect potentially metastasizing skin cancers at an early and surgically curable stage. This may take the form of mass screening, as currently occurs in Germany, or of targeted screening of those at greatest risk. Objective To develop a model to identify patients at high risk of developing skin cancer who would benefit from regular skin cancer screening. Methods This was an open prospective point‐prevalence study of consecutive patients presenting to dermatologists for a total skin check. Demographic and skin cancer risk factors were recorded and, for the first time, histology of skin lesions was documented. Results were analysed by univariate and multivariate analyses and, after logistic regression with stepwise forward selection, a risk‐group model was developed. Results The results of 108 281 total skin examinations were available for analysis. 142 definite melanomas, 108 severely dysplastic naevi/cannot‐exclude‐melanoma, 491 basal cell carcinomas (BCC) and 93 squamous cell carcinomas (SCC) were excised. A risk model was developed for melanoma and SCC based on mathematical e‐functions. The model had >92% sensitivity for melanoma and SCC and an overall 67.24% specificity for melanoma, SCC and BCC. This targeted risk model identified one‐third of the study population as being at risk for the development of melanoma and SCC. Conclusions Using the risk calculator developed from this study, targeted screening of the identified at‐risk population reduces the numbers needed to be screened regularly by 50%, yet has better sensitivity for melanoma and similar sensitivity for SCC compared to the current mass screening programme in Germany.     

Skin cancer day in Italy: method of referral to open access clinics and tumor prevalence in the examined population

Education campaigns to encourage self-examination coupled with rapid access to specialized dermatological clinics is considered the key strategy in the realization of early detection of cutaneous melanoma and non-melanoma skin cancer (NMSC). An alternative to an initial visit to the family doctor is open access to a skin cancer clinic at the decision of the individual. This approach has been followed mainly in countries with high melanoma incidence where the majority of the population is of northern European origin. However, the efficacy of this system has not been well established because there are few studies involving systematic follow up of individuals with positive screening through pathological confirmation of the diagnosis. We report the follow up data focussed on melanoma and NMSC detection rates in more than 1,000 subjects examined at numerous 1-day, open access clinics on the occasion of the Italian nation-wide "Skin Cancer Day" campaign promoted by the Federation of Italian Dermatological Societies. Total body skin examination was performed on all subjects, and surgical excision of a lesion was recommended in 41 of the 1042 subjects (3.9 %). Histologic diagnosis, available for 39/41 lesions, evidenced 3 superficial spreading melanomas (1 in situ, one "thin" lesion, ie. 0.30 mm in thickness, and one "thick" lesion, with a thickness of 4.53 mm) and 6 NMSC (5 BCC and 1 SCC). Thus, the prevalence of skin cancer (melanoma and NMSC) in this group was 0.8 % (9/1042), and the prevalence of melanoma was 3/1042, 0.2 %, rather similar to that found in populations of northern European origin. Open access to skin cancer clinics may represent an alternative approach to melanoma prevention also in southern European populations. Increased public awareness regarding skin cancer probably represents the main effect of this type of campaign.     

Skin cancer prevention and detection practices among siblings of patients with melanoma

BACKGROUND: Family members of patients with melanoma have an increased risk of the disease, and families with multiple affected members account for about 10% of melanoma cases. These statistics suggest that first-degree relatives of patients with melanoma, who are at particularly high risk, warrant targeted public health action. OBJECTIVE: We sought to document rates for dermatologist examinations for cutaneous lesions, the practice of skin self-examination, and sunscreen use in this at-risk group. METHODS: Before participation in a randomized trial, 404 siblings of recently diagnosed patients with melanoma completed a survey on beliefs and practices regarding skin cancer prevention and detection. RESULTS: Sixty-two percent of participants had carefully examined their skin, 54% routinely used sunscreen, and 27% had received a skin cancer examination by a dermatologist during the past year; 47% had never received a dermatologist examination. Multivariate analysis found modifiable positive predictors for skin self-examination and dermatologist examinations, including having a clinician with whom to talk about melanoma and believing in the importance of regular skin examinations by a physician. Significant modifiable negative predictors included enjoyment of being tanned, not being sure what to look for when examining moles, and feeling uncomfortable having others look at their skin. CONCLUSIONS: Skin self-examination rates among these high-risk siblings are markedly higher than in population-based studies. However, many siblings were not screened for skin cancer by a dermatologist despite having strong risk profiles, being nearly fully insured, and being under care of primary care physicians. Improvements in communication between physicians and high-risk families and changes in office systems to assess family history of melanoma could increase screening rates for the estimated 1 million siblings of patients with melanoma.     

Melanoma/skin cancer screening in a Mediterranean country: results of the Euromelanoma Screening Day Campaign in Greece

Background Since the year 2000 a melanoma/skin cancer screening campaign has been organized annually in Greece in the context of the Euromelanoma Screening Day Campaign. Objectives We aimed to analyse the characteristics of the screened population, to recognize relevant risk factors and to identify the cases of histologically confirmed malignant melanoma (MM) in individuals with suspicious skin lesions. Methods An analysis of the completed screening forms from the years 2000–2004 was performed with respect to relevant demographic, epidemiological and clinical data. Results A total of 9723 individuals were screened, most of whom where below the age of 50 years (71%), female (59%), and of skin phototype II and III (76%). Sunburn during childhood was reported in 47% of participants, while 5% of the screened population had a personal or family history of melanoma. On clinical examination, 14.4% had actinic keratoses, 31.2% had dysplastic nevi, while 6.4% carried a presumptive diagnosis of non‐melanoma skin cancer. In the 2003–2004 screening campaign, 19 out of the 171 clinically suspicious lesions were histologically proven to be MM, the majority of which (58%) were ‘thin’ melanomas (Breslow's thickness of ≤ 1 mm) of the superficial spreading type. Conclusions Our study suggested that, a melanoma/skin cancer screening programme in a Mediterranean country, supported by an intense publicity campaign, attracted many individuals at risk for skin cancer and detected mostly thin melanomas of the superficial spreading type.     

[Translated article] Current State of Skin Cancer Prevention: A Systematic Review

Skin cancer deaths continue to rise despite the implementation of numerous preventive campaigns and programs. The aim of this systematic review was to evaluate reviews of primary and secondary skin cancer prevention strategies as reported over the past 10 years. We analyzed 63 systematic reviews and meta-analyses: 30 (46.6%) addressing primary interventions and 35 (55.6%) addressing secondary interventions. Two of the reviews covered both. The most widely reported primary prevention approaches were education programs (63.3%), followed by risk modeling to identify individuals at high risk for melanoma (17.6%), and the promotion of sunscreen use (11.8%). The most widely reported secondary prevention measures concerned imaging systems for early skin cancer detection (40%), smartphones and new technologies (22.9%), and visual diagnosis in population-based screening (17.4%). The most effective measures were primary prevention education programs to improve sun protection habits.     

Can screening for melanoma and skin cancer save lives?

Although screening for melanoma and skin cancer is theoretically appealing, too few data exist to evaluate its effectiveness. The rising incidence and mortality rates of melanoma and the continued incurability of metastatic disease underscore the desperate need for effective screening. The extraordinary incidence of NMSC is a public health problem, but the value of screening for NMSC has not been established. The AAD screening program offers an opportunity to obtain critical data. Further research must make our screenings more effective and efficient. We need rigorous design and evaluation of all screening efforts. In the absence of a randomized controlled trial, other design measures, with careful tracking of incidence and mortality, are critical to assessing whether screening for melanoma and skin cancer can reduce morbidity and save lives.     

Results of the 'Euromelanoma Day' screening campaign in Sweden 2008

Background  The 'Euromelanoma Day' skin cancer screening campaign is organized annually in several European countries since the year 2000. The national results have not been analysed in a Scandinavian country.
Objective  Our objective was to analyse the demographic characteristics and risk factors of the screened population during the 'Euromelanoma Day' in Sweden 2008. We also aimed to describe the clinical diagnoses found, the melanomas confirmed histopathologically and the treatments performed.
Methods  A public health education campaign to promote awareness of skin cancer risk factors and warning signs was carried out. Patients with suspicious lesions were advised to attend the screening. Questionnaires were used to collect relevant demographic, epidemiological and clinical data.
Results  In total, 2659 patients were screened. Women accounted for 62.3% of all patients; the median age was 57 years (range: 5–100 years); and 91.2% had skin phototypes II–III. Previous skin cancer was reported by 18.4% of all patients and 14.8% had a family history of melanoma. In total, 456 patients were diagnosed clinically with non-melanoma skin cancer. Twenty-four patients had histopathologically confirmed melanomas. Ten were in situ and 8 of the 14 invasive melanomas had a Breslow thickness that was less than 1 mm. Treatment or future medical care was carried out in 45.4% of all patients.
Conclusion  The 'Euromelanoma Day' campaign attracted many individuals at risk for skin cancer. The detection rate of non-melanoma skin cancer and melanoma was relatively high compared to similar campaigns in other European countries. Most melanomas found had a favourable prognosis.     

Situación actual de la prevención del cáncer de piel: una revisión sistemática

Skin cancer deaths continue to rise despite the implementation of numerous preventive campaigns and programs. The aim of this systematic review was to evaluate reviews of primary and secondary skin cancer prevention strategies as reported over the past 10 years. We analyzed 63 systematic reviews and meta-analyses: 30 (46.6%) addressing primary interventions and 35 (55.6%) addressing secondary interventions. Two of the reviews covered both. The most widely reported primary prevention approaches were education programs (63.3%), followed by risk modeling to identify individuals at high risk for melanoma (17.6%), and the promotion of sunscreen use (11.8%). The most widely reported secondary prevention measures concerned imaging systems for early skin cancer detection (40%), smartphones and new technologies (22.9%), and visual diagnosis in population-based screening (17.4%). The most effective measures were primary prevention education programs to improve sun protection habits.     

Cyclosporine and skin cancer: an international dermatologic perspective over 25 years of experience. A comprehensive review and pursuit to define safe use of cyclosporine in dermatology

Cyclosporine A (CsA), a powerful immunosuppressant drug effective in treating a variety of dermatologic diseases, is often avoided due to potential adverse side effects such as skin cancer. CsA-induced skin cancers are well documented in organ transplant literature. This association is less clear when dermatologic guidelines are followed (e.g., low dose, healthy patients, time-limited use, no other immunosuppressive agents, etc.). Marcil and Stern estimated increased risk of squamous cell carcinoma (SCC) after CsA treatment equivalent to 200 PUVA treatments while the original data collected by Sandoz Ltd. reported a significantly less skin malignancies at doses of 5 mg/kg/day or less. Reviewing 60 studies and over 1700 patients in 25 years of existing US and international multicenter studies revealed 63 patients (less than 1%) with skin cancer. No skin cancers were reported with 6 months continuous use or up to 2 years of intermittent therapy. PUVA phototherapy overwhelmingly preceded CsA use in reported cases. Overall, 14 case reports were found suggesting CsA-induced skin cancers with the majority either having violated accepted dermatologic safety guidelines or enrolling patients with significant pre-existing carcinogenic risk factors. When reviewing over 25 years of dermatologic experience worldwide, it is not clearly substantiated that skin cancer risk is necessarily increased in patients using CsA.     

Educational outcomes regarding skin cancer in organ transplant recipients: Randomized intervention of intensive vs standard education

OBJECTIVE: To determine whether an intensive educational program focused on the risk of skin cancer in organ transplant recipients, a population at high risk for development of skin cancer because of immunosuppression, produced measurable improvement in patient knowledge and sun-protective behavior. DESIGN: Patients were randomly assigned to receive standard episode-of-care-based education or intensive repetitive written education about skin cancer after organ transplantation. Preintervention knowledge was assessed and documented through a self-administered educational assessment tool. Retention of knowledge and the effect on sun-protective behavior were assessed with a follow-up questionnaire at 3 and 10 months. SETTING: Transplant center of an academic medical center. PATIENTS: Two hundred two patients presenting for transplant dermatologic consultation.Intervention Randomized intensive, repetitive written educational reinforcement. MAIN OUTCOME MEASURES: Retention of knowledge and the effect on sun-protective behavior were assessed with a follow-up questionnaire at 3 and 10 months. RESULTS: Both intervention groups had similarly high baseline and 3- and 10-month scores on the knowledge portion of the surveys, and they had similar scores on the behavioral assessment portion of the surveys at baseline. Subjects receiving intensive education scored significantly better on the behavioral assessment at 3 and 10 months, although an improvement in knowledge was not documented. CONCLUSIONS: This cohort of transplant recipients was well educated about skin cancer prevention before educational intervention and retained this knowledge. Patients who received the intensive educational intervention were significantly more compliant with recommendations for sun-protective behavior than those who received standard education, although differences in knowledge were not apparent. Lack of time and hassle were the most commonly cited barriers to behavioral compliance with sun protection.     

Self-detected cutaneous melanomas in Italian patients

Self-detection of suspicious pigmented skin lesion combined with rapid referral to dermatologic centres is the key strategy in the fight against melanoma. The investigation of factors associated with pattern of detection of melanoma (self- vs. nonself-detection) may be useful to refine educational strategies for the future. We investigated the frequency of melanoma self-detection in a Mediterranean population at intermediate melanoma risk. A multicentric survey identified 816 consecutive cases of cutaneous melanoma in the period January to December 2001 in 11 Italian clinical centres belonging to the Italian Multidisciplinary Group on Melanoma. All patients filled a standardized questionnaire and were clinically examined by expert dermatologists. Self-detected melanomas were 40.6%, while the remaining lesions were detected by a dermatologist (18.5%), the family physician (15.2%), other specialists (5%), the spouse (12.5%), a friend or someone else (8.2%). Variables associated with self-detected melanomas were female sex, young age, absence of atypical nevi, knowledge of the ABCD rule, habit of performing skin self-examination. Self-detected melanomas did not differ from nonself-detected tumours in term of lesion thickness; however, patients with self-detected melanomas waited a longer period before having a diagnostic confirmation (patient's delay) (> 3 months: odds ratio, 3.89; 95% confidence interval, 2.74-5.53). In order to reduce the patients' delays, educational messages should adequately stress the need for a prompt referral to a physician once a suspicious pigmented lesion is self-detected.