Population-based analysis of prognostic factors and survival in familial melanoma.

PURPOSE: Familial melanoma patients are reported to present with thinner melanomas, to be younger at the time of diagnosis, and to have a greater likelihood of developing multiple primary tumors. We sought to determine whether melanomas that occur in a familial setting demonstrate different prognostic and survival statistics relative to sporadic melanoma. PATIENTS AND METHODS: This population-based study used the Utah Cancer Registry and Utah Population Database to objectively evaluate prognostic and survival statistics of the familial melanoma population. From 1973 to 1999, there were 7,785 cases of invasive melanoma identified through the Utah Cancer Registry. These were linked to the Utah Population Database, resulting in 2,659 subjects with family-history information from which a familiality score could be calculated. Cases scored in the top ninth percentile were assigned as high familial risk, and the remaining 91% were considered low familial risk. RESULTS: Multivariate logistic-regression analysis found no association between sex, Breslow depth, Clark level, or survival and the familial status. Age at first diagnosis of invasive melanoma was slightly lower in the high-familial-risk group (57 v 60 years; P = .03). High-familial-risk subjects had more melanomas diagnosed at age 30 or younger (12% v 6%; P < .001). A significant difference in the overall number of individuals with two or more primary malignant melanomas was not detected among the groups (P = .2). CONCLUSION: These data suggest that melanomas occurring in the context of an underlying inherited susceptibility do not have a significantly different biologic behavior.     

Trends in incidence of ocular malignant melanoma in Denmark 1943-1982

All records of ocular malignant melanoma notified to the Danish Cancer Registry between 1943 and 1982 were re-coded, and 1,624 out of 1,650 cases were verified and included in this investigation. The annual number of incident cases increased from about 30 to 50, but the age-standardized incidence rate remained stable at 0.75 per 100,000 in males and 0.60 in females. There was no predilection for one or the other eye in either sex. About 80% of the tumours were located in the choroid, 10% in the ciliary body and iris, 5% in the conjunctiva, and 5% in "multiple regions". The histopathology of the tumours was: epithelioid cell type in 12%, spindle-cell type in 36%, and mixed-cell type in 51%. The stable incidence rates of ocular malignant melanomas were in marked contrast to the 5- and 6-fold increase observed for cutaneous melanomas during the same time period. Possible differences in risk factors are discussed. Similarities and differences between the present data and results from other countries are highlighted.     

Conditional survival of malignant melanoma in The Netherlands: 1994–2008

BackgroundCutaneous malignant melanoma causes the majority of skin cancer related deaths and features increasing incidence and mortality rates in the Netherlands. Conditional survival analysis is performed on patients who survived the preceding year(s).MethodsPatients with invasive melanoma, as recorded in the population-based Netherlands Cancer Registry, were included. To assess prognosis of melanoma survivors according to gender and Breslow thickness, conditional five-year relative survival was calculated for lymph node negative melanoma patients and conditional one-year relative survival was analysed for melanoma patients with and without nodal involvement.FindingsBetween 1994 and 2008, 40,050 patients developed a melanoma (stage I–III, of whom 6% with nodal involvement). Six to 8 years after diagnosis, survival of patients with a 1–2 mm (T2) thick melanoma equalised the general population. Conditional five-year relative survival for patients with >4 mm thick (T4) melanomas increased from about 60% at diagnosis to 90% at 7 years after diagnosis. Largest improvements were found in patients with thick melanomas and female patients with nodal involvement.InterpretationThe prognosis for melanoma survivors improved with each additional year of survival after diagnosis, except for patients with a ⩽1 mm thick melanoma, who never had any excess mortality during follow-up. Conditional survival of melanoma was better amongst females, amongst those with lower Breslow thickness and nodal stage.     

Malignant melanoma of the vulva in a nationwide, 25-year study of 219 Swedish females: clinical observations and histopathologic features.

BACKGROUND: Because the clinical and histopathologic features of vulvar melanoma had not been characterized completely in a large, homogeneous population, the authors retrospectively analyzed all such patients recorded in Sweden during a 25-year period. METHODS: The Swedish National Cancer Registry opened its records to the authors for review of all 219 females with primary vulvar melanoma reported from 1960 to 1984. Histopathologic specimens and clinical histories of the 198 patients who qualified for this study were reanalyzed and the tumors rigorously subtyped. RESULTS: Macroscopically amelanotic tumors were observed in 27% of patients, predominantly in glabrous skin; the clitoral area and labia majora were the most common primary sites. Of all melanomas, 46% emerged in glabrous skin, 12% emerged in hairy skin, and 35% extended to both areas. On average, approximately 2.5 times more melanomas appeared in the vulva than on the whole body surface. Overall, 57% were of the mucosal lentiginous (MLM) type, 22% were nodular melanomas (NMs), 12% were unclassified, and only 4% were superficial spreading melanomas (SSMs); this was the reverse of the order observed for cutaneous melanoma. Almost all vulvar melanomas underwent a vertical growth phase; other common features were marked thickness and ulceration, particularly in the glabrous skin. Preexisting nevi occurred in 11 cases, all in hairy skin, and 71% in conjunction with SSM but only 4% with MLM. CONCLUSIONS: Several clinical and histopathologic features indicated that the natural history of vulvar melanomas is at variance with that of cutaneous melanomas. Because preexisting nevi, which are often considered a precursor to melanoma, were significantly linked to SSM and only in the vulvar hairy skin, melanomas in the glabrous skin apparently emerged de novo.     

Natural history and treatment of mucosal melanoma

Forty-three patients with primary mucosal melanomas seen between 1960 and 1987 were reviewed. There were 17 patients with tumors arising from the head and neck, 17 from the vulva and/or vagina, 8 from the anorectum, and 1 from the esophagus. Twenty-one patients were resected with curative intent. In patients with head and neck tumors, local recurrence was the initial cause of failure in the majority of cases, whereas with tumors arising from the anorectum, vulva, and vagina, systemic recurrence was more common. There were four long-term survivors, and three of these had melanomas less than 1 mm thick with negative regional lymph nodes; no patients with mucosal melanoma less than 1 mm thick developed recurrent disease. Overall, actuarial survival was 64% after 1 year and 23% after 5 years. Mucosal melanoma has a poor prognosis, and adequate resectional surgery affords the only chance of long-term survival.     

Immunohistochemical diagnosis of malignant melanoma of the conjunctiva and uvea: comparison of the novel antibody against melan-A with S100 protein and HMB-45

A novel antibody A103, which recognizes melan-A/MART-1, has been found to be more sensitive than the antibody HMB-45, which recognizes gp100, in melanocytic lesions of the skin and might therefore also be useful in the diagnosis of uveal and conjunctival melanocytic lesions. In this study we compared the staining characteristics of anti-melan-A, anti-S100 protein and HMB-45 in 13 conjunctival, 11 iris and 37 ciliary and choroidal malignant melanomas. The ciliary and choroidal melanomas comprised 13 spindle cell (10 spindle B and three spindle A), 14 mixed cell and 10 epithelioid cell tumours. In the conjunctival melanomas the diagnostic sensitivity was 100% for anti-S100 and anti-melan-A and 85% for HMB-45. In the iris melanomas the sensitivity was 100% for anti-S100 and anti-melan-A and 55% for HMB-45. A high staining intensity of anti-melan-A was particularly noticed in iris melanomas. In the choroidal malignant melanomas, the spindle cell and mixed cell types showed a sensitivity of only 69-79% with all three antibodies. In the epithelioid cell type the sensitivity was 80% for anti-S100 and 100% for HMB-45 and anti-melan-A. In conclusion, anti-melan-A was found to be a useful addition to antibody panels for ocular melanocytic lesions. Anti-melan-A has a higher sensitivity than HMB-45 in conjunctival and iris melanomas, but the sensitivity is similar to HMB-45 in choroidal melanomas. Anti-melan-A stains in a very similar pattern to anti-S100, but the staining intensity of anti-melan-A is higher than that of anti-S100 in iris melanoma.     

Malignant solitary fibrous tumor

BACKGROUND:

Malignant solitary fibrous tumors (SFTs) are extremely uncommon and poorly understood mesenchymal neoplasms. There are only rare published accounts of the cytopathologic features of these tumors, prompting the current study.

DESIGN:

All cases of malignant SFT with preoperative fine‐needle aspirations (FNAs) from 1999 to 2008 were retrieved from the archives of 3 large teaching hospitals. FNA smears and cell block material including immunoperoxidase stains were reviewed, and the cytologic characteristics were described.

RESULTS:

Thirteen cases of malignant SFT were identified in 11 patients. Mean age was 58 years, with a men:women ratio of 1:2.6. The tumors were generally large, with a mean size of 13.4 cm. Cytomorphologic features included mostly hypercellular smears with tissue fragments of monotonous, plump spindled cells with blunt‐ended and indented nuclei and fragile, wispy cytoplasm. Also seen were bare nuclei, occasional mitoses, and rare necrosis. Some cases showed a predominance of epithelioid cells, whereas others displayed a loose myxomatous matrix. There was a general lack of single cells. None of the cases was diagnosed accurately as malignant SFT on FNA, and only 6 cases were called malignant or suspicious for malignancy.

CONCLUSIONS:

The FNA diagnosis of malignant SFT is extremely difficult and needs histologic material for accurate interpretation. Predominant FNA diagnoses were SFT or spindle cell neoplasm. Malignant SFT must be included in the differential diagnosis of a spindle cell neoplasm of any anatomic site, particularly if it displays features not typical of benign SFT. Immunoperoxidase staining has some utility, mainly in ruling out other neoplasms in the differential diagnosis. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society.     

Cutaneous malignant melanoma in Swedish children and teenagers 1973-1992: a clinico-pathological study of 130 cases

To assess whether there has been a change in histological features and prognostic factors of primary cutaneous malignant melanoma (CMM) in young individuals in Sweden, an unselected, population-based study was undertaken; 177 cases of primary CMM in persons below 20 years of age were reported to the Swedish National Cancer Registry between 1973 and 1992. In 87% of the cases, original tumor tissue was available for histo-pathological review. The original diagnosis was verified in 88% (n = 126) of these cases. All tumors had histological features similar to adult CMM; 17% had an associated precursor lesion. Superficial spreading melanoma (SSM) was the most common sub-type, constituting 20/36 cases in the first decade and 59/90 in the second. Corresponding figures for nodular melanoma (NM) were 11/36 and 23/90. Only 5 melanomas in situ were diagnosed. In girls, the mean thickness of SSM decreased from 1.5 to 0.6 mm (p < 0.001). Overall mortality was 10%, 22% in the group with CMM diagnosed 0-15 years of age and 8% in individuals 15-19 years. Fatal CMM cases diagnosed below 15 years of age (n = 4) were NM > 1.6 mm thick and in subjects 15-19 years (n = 9) 44% of fatal tumors were NM with a mean thickness of 2.2 mm. Breslow index was the single most important prognostic factor. However, when known prognostic factors were adjusted for in a Cox regression analysis, young age remained an independent risk factor, with a relative death rate of 0.21 for individuals aged 15-19 compared with children < 15 years of age.     

Melanoma burden by melanoma stage: Assessment through a disease transition model

BackgroundThe total burden of melanoma has already been studied but little is known about the distribution of this burden amongst localised, node metastatic and distant metastatic stages.MethodsDisability-adjusted life years (DALY) assesses disease burden, being the sum of years of life with disability (YLD) and years of life lost (YLL). A melanoma disease model was developed in order to predict the evolution of patients from diagnosis until death. The model was applied to a large cohort of 8016 melanoma patients recorded by the Belgian Cancer Registry for incidence years 2009–2011. DALYs were calculated for each American Joint Committee on Cancer stage, considering stage at diagnosis on the one hand and time spent in localised, node metastatic and visceral metastatic stages on the other. Probabilistic sensitivity analyses and scenario analyses were performed to explore uncertainty.FindingsOur analyses resulted in 3.67 DALYs per melanoma, 90.81 per 100,000 inhabitants, or 32.67 per death due to melanoma. The total YLL accounted for 80.4% of the total DALY. Stages I, II, III and IV patients at diagnosis generated, respectively, 27.8%, 32.7%, 26.2% and 13.3% of the total YLL. For the time spent in each stage, localised melanomas, node metastatic melanomas, and distant metastatic accounted, respectively, for 34.8%, 52.6% and 12.6% of the total YLD. Parametric uncertainty was very limited, but the influence of using pre-2010 Global Burden of Disease approaches was substantial.InterpretationThe total DALY for melanoma was consistent with the previous studies. Our results in terms of proportions of DALY/YLL/YLD per stage could be extrapolated to other high-income countries. YLDs generated by localised melanoma which will never metastasize were inferior to YLLs resulting from stage IA melanomas. This result supports the hypothesis that efforts for an earlier diagnosis of melanoma are important.FundingNone.     

The incidence of second primary invasive melanoma in Queensland, 1982–2003

OBJECTIVE: To describe the incidence of second primary invasive melanoma. METHODS: Data describing 52,997 subjects with melanoma notified to The Queensland Cancer Registry between 1982 and 2003. We calculated incidence rates of second primary invasive melanoma (per 1,000 person-years) by sex, age, and characteristics of the first primary. RESULTS: The rate of second primary invasive melanoma was relatively constant over 20 years of follow-up at 6.01 per 1,000 person-years indicating a high, constant lifetime risk of second primary invasive melanoma. Rates were 62% higher in males than in females and increased with age at first diagnosis with the rate in older patients (80+ years) more than double the rate observed in younger patients (40-49 years). Rates in patients with melanomas thicker than 2 mm were over 50% higher than in patients with thinner melanomas. CONCLUSIONS: Melanoma patients are at high risk of a second primary invasive melanoma. This risk does not diminish with time and does not differ significantly between patients first diagnosed with lentigo maligna, in situ melanoma or invasive melanoma. These results indicate that all melanoma patients require lifetime surveillance. Current treatment guidelines should be modified to reflect this.     

Diagnostic challenges of metastatic spindle cell melanoma on fine‐needle aspiration specimens

BACKGROUND

Spindle cell melanoma is a morphologic variant of melanoma that can be difficult to diagnose on specimens obtained via fine‐needle aspiration (FNA). Published cytology studies concerning this entity were based for the most part on small series. In the current study, a large series of metastatic spindle cell melanoma is described and the diagnostic pitfalls present in FNA samples addressed.

METHODS

The authors retrospectively reviewed the cytologic features of 81 metastatic spindle cell melanoma specimens obtained from 67 patients. Corresponding primary tumors or metastatic tumors taken elsewhere from the same patient were also evaluated.

RESULTS

The cytologic smears were mostly cellular and comprised of predominantly spindle tumor cells that frequently formed cohesive fascicles or whorls intermingled with scattered epithelioid tumor cells. The classic cytologic characteristics of conventional melanoma (predominantly dyshesive cellular distribution, cytoplasmic melanin pigments, intranuclear pseudoinclusions, macronucleoli, and binucleation or multinucleation) were noted infrequently or, if present, were more readily found in coexisting epithelioid cells. Remarkably, 9% of the cases failed to demonstrate any of the above classic characteristics. In addition, spindle cells demonstrated a wide range of cytologic atypia, from deceptively bland cells resembling reactive fibroblasts to those indistinguishable from pleomorphic high‐grade sarcomatous neoplasms. When the morphologic features were compared with those of the primary tumor or metastatic melanoma taken elsewhere from the same patient, cell type discrepancy was found in 20% of the cases in that the previous counterparts demonstrated the epithelioid cell type. Spindle cells also tended to lose immunoexpression of melanoma markers.

CONCLUSIONS

Spindle cell melanoma infrequently demonstrates the diagnostic cytologic features and immunoreactivity of conventional melanoma. Varying degrees of cytologic atypia and possible cell type differences from the primary counterpart or metastatic melanoma occurring elsewhere are additional sources of diagnostic challenges, especially in the metastatic setting. Familiarity with cytologic features, combined with clinical and immunoperoxidase findings, is required to avoid misinterpretation. Cancer (Cancer Cytopathol) 2008. © 2008 American Cancer Society.     

Up-to-date survival estimates and historical trends of cutaneous malignant melanoma in the south-east of The Netherlands.

BACKGROUND: We present survival outcomes of patients registered in the Dutch population-based Eindhoven Cancer Registry (ECR). PATIENTS AND METHODS: Data on patients diagnosed with a melanoma between 1980 and 2002 were obtained from the ECR. Data on vital status up to 1 January 2005 were obtained, up-to-date survival rates were calculated using period analysis. Multivariate analyses were carried out using Cox proportional hazards model. RESULTS: Ten-year crude survival rates were 82% for women and 60% for men (P < 0.05). Thin melanomas (Breslow thickness 74%, for melanomas >4.0 mm these rates were <65% (P < 0.05). In the early 1980s, 5-year relative survival rates were 84% and 62% for young (<60 years) women and men, and 66% and 69%, respectively, for the elderly (aged 60+). In the period 2000-2002, these rates had improved to >90% for females and to >72% for males. Multivariate analyses showed increased hazard ratios with increasing age and Breslow thickness, being male, having a melanoma on the trunk or unknown sites and having a nodular melanoma. CONCLUSIONS: Despite the absence of improvements in treatment options for melanoma, survival improved significantly, except for elderly males.     

Prognosis for patients with thin cutaneous melanoma: long-term survival data from New South Wales Central Cancer Registry and the Sydney Melanoma Unit

BACKGROUND: Estimates of long-term survival for patients with thin (< or = 1 mm) primary cutaneous melanomas vary widely. Two separate methods were used to study the survival of patients with melanoma from New South Wales (NSW), Australia, and from the Sydney Melanoma Unit (SMU). METHODS: The NSW Central Cancer Registry (NSWCCR) provided data on all patients who were diagnosed with cutaneous melanomas that measured < or = 1 mm thick between 1983 and 1998, inclusive. Patients with metastases at the time of diagnosis were not included, leaving 18,088 patients for analysis. The SMU data base was analyzed to extract data for all patients with thin melanomas who met the same criteria from 1979 to 1998, inclusive. All patients who had their primary tumors treated definitively elsewhere were excluded, leaving 2746 patients for analysis. Ten-year Kaplan-Meier survival rates were calculated, and significant differences were determined using log-rank analysis. Prognostic factors were evaluated with Cox proportional hazards analysis. RESULTS: The NSWCCR analysis revealed a 10-year survival rate of 96.4%. The 10-year survival rate for patients at SMU was 92.7%. Among the patients at SMU who died, the median time to recurrence was 49.8 months, and the median time to death was 65.9 months. The 10-year survival for patients at SMU who had lesions that measured < or = 0.75 mm was 96.9% compared with 84.3% for patients who had lesions that measured 0.76-1.0 mm. For patients who had ulcerated melanomas measuring < or = 1 mm thick, the 10-year survival rate was 83%, compared with 92.3% for patients who had nonulcerated melanomas. CONCLUSIONS: The results of the current study confirmed the excellent survival rate for patients with thin melanomas. Higher-risk subsets of patients who may warrant consideration for aggressive investigation and treatment are identifiable.     

Long-term deaths from melanoma according to tumor thickness at diagnosis

There is little long-term follow-up information about how the number of melanoma deaths and case fatality vary over time according to the measured thickness of melanoma at diagnosis. This population-based longitudinal cohort study examines patterns and trends in case fatality among 44,531 people in Queensland (Australia) diagnosed with a single invasive melanoma (International Classification of Diseases for Oncology, third revision [ICD-O-3], C44, Morphology 872–879) between 1987 and 2011, including 11,883 diagnosed between 1987 and 1996, with up to 20 years follow-up (to December 2016). The 20-year case fatality increased by thickness, with the percentage of melanoma deaths within 20 years of diagnosis being up to 4.8% for melanomas with measured thickness <0.80 mm, 10.6% for tumors 0.8 to <1.0 mm and generally more than 30% for melanomas measuring 3 mm and more. For melanomas <1.0 mm, most deaths occurred between 5 and 20 years after diagnosis, whereas for thicker melanomas the reverse was true with most deaths occurring within the first 5 years. Five-year case fatality decreased over successive calendar time periods for melanomas <1.0 mm, but not for melanomas ≥1.0 mm. These findings demonstrate that the time course for fatal melanomas varies markedly according to tumor thickness at diagnosis. Improved understanding of the patient factors and characteristics of melanomas, in addition to tumor thickness, which increase the likelihood of progression, is needed to guide clinical diagnosis, communication with patients and ongoing surveillance pathways of patients with potentially fatal lesions.     

Maximizing local tumor control and survival after proton beam radiotherapy of uveal melanoma

PURPOSE: This study reports local tumor control and survival after proton beam radiotherapy (PBRT) of uveal melanoma. It identifies the risk factors for local tumor-control failure and for ocular tumor-related death. It presents the improvements implemented to increase the rate of local tumor control, and compares the survival rate of patients with locally controlled tumors to those of patients who had to receive a second treatment. PATIENTS AND METHODS: We have treated 2,435 uveal melanomas with PBRT between March 1984 and December 1998. Data were analyzed as of September 1999. Patients' age ranged from 9 to 89 years; there were 1,188 men and 1,247 women. The largest tumor diameter ranged from 4 to 26 mm, and tumor thickness from 0.9 to 15.6 mm. Median follow-up time was 40 months. RESULTS: Local tumor control probability at 5 years was improved from 90.6 +/- 1.7% for patients treated before 1988, to 96.3 +/- 0.6% for patients treated between 1989 and 1993, and became 98.9 +/- 0.6% for patients treated after 1993. Among 2,435 treated patients, 73 (3%) had to receive a second treatment because of tumor regrowth. Cause-specific survival at 10 years was calculated to 72.6 +/- 1.9% for patients with controlled tumors compared to 47.5 +/- 6.5% for those with recurrent tumors. CONCLUSION: Reduced safety margins, large ciliary body tumors, eyelids within the treatment field, inadequate positioning of tantalum clips, and male gender were identified to be the main factors impairing local tumor control. The improvement of local tumor control rate after 1993 is attributed to changes implemented in the treatment procedure. Our data strongly support that the rate of death by metastases is influenced by local tumor control failure: improvement of the local tumor control rate results in a better survival rate.     

Multiple primary cutaneous melanomas.

BACKGROUND. Development of multiple primary cutaneous melanomas is a well-recognized phenomenon. As with single primary melanoma, personal and family histories of melanoma and dysplastic nevi (DN) are considered important risk factors. The natural history and impact of regular follow-up evaluation of this entity were examined. METHOD. Through a search of the computerized data bank of the Pathology Department and the Melanoma Registry of the Pigmented Lesion Clinic at Massachusetts General Hospital, 41 patients with multiple cutaneous melanomas were identified. RESULTS. Mean (+/- standard error) age at first diagnosis was 49 +/- 2 years (range, 21-75 years). The male to female ratio was 2:1. The median number of primary melanomas was two (88%). Three patients had three and one had five. Melanoma types included superficial spreading (70%), nodular (8%), lentigo maligna (2%), and unclassified (10%), and in 7% the type was unknown. Nineteen (46%) patients had histologic and/or clinical evidence of DN. For the group with DN, the mean age at first diagnosis (44 +/- 3 years) was significantly less than that of patients without DN (54 +/- 3 years) (P less than 0.05). Family history of melanoma was found in 10 patients (24%). Multiple melanomas were diagnosed concurrently in 16 patients (39%), whereas in 25 (61%) diagnosis was sequential. For the latter group, the mean tumor thickness from the first (1.21 +/- 0.28 mm) to the second melanoma (0.51 +/- 0.08 mm) decreased significantly (P less than 0.05); the median time interval was 36 months (range, 2-372 months). CONCLUSION. These data confirm the need for complete skin examination for patients with newly diagnosed melanoma; and, with subsequent melanomas appearing as long as 31 years after the first melanoma, continued follow-up with complete skin examinations seems prudent.     

Cutaneous malignant melanoma in children and adolescents in Sweden, 1993-2002: the increasing trend is broken

The incidence of cutaneous malignant melanoma rose rapidly in teenagers in Sweden during 1973-1992, while it remained low in younger children. To study the further trends and characteristics of melanoma in this young population, data on all cases in individuals under 20 years of age reported to the Swedish Cancer Registry during 1993-2002, and the corresponding pathology reports were examined. Seventy-nine cases were reported to the Registry. There were 24 males and 55 females. Most melanomas occurred on the trunk followed by the legs in both genders. The median tumor thickness was 0.8 mm. Children under age 15 had thicker melanomas than individuals aged 15-19. Superficial spreading melanoma was the most common histological subtype (43/78, 55%). The melanoma-specific 5-year survival rate was 90%. During 1993-2002, the age-standardized incidence fell to 3.6/million from 5.0/million in 1983-1992 (RR 0.74, 95% CI 0.58-0.92). The most pronounced decrease was for melanomas on the trunk in boys and on the legs in girls. The incidence for 15-19-year-old boys peaked for the cohort born between 1968 and 1972 and for girls between 1973 and 1977. The decrease in incidence may be a result of public health campaigns aiming at reducing sun exposure in childhood. A contributing effect from an increased immigration of individuals with darker complexions and at a lower melanoma risk is probable.     

Trends of cutaneous melanoma in The Netherlands: increasing incidence rates among all Breslow thickness categories and rising mortality rates since 1989

BackgroundIt has been debated that the epidemic of melanoma is largely due to overdiagnosis, since increases in incidence were mainly among thin melanomas and mortality rates remained stable. Our objective was to examine this controversy in The Netherlands.Patients and methodsInformation on newly diagnosed melanoma patients was obtained from The Netherlands Cancer Registry. European Standardized Rates and estimated annual percentage change were calculated for the period 1989–2008. Cohort-based, period-based and multivariate survival analyses were carried out.ResultsThe incidence rate of melanoma increased with 4.1% (95% confidence interval 3.6–4.5) annually. Incidence rates of both thin melanomas (≤1 mm) and thick melanomas (>4 mm) increased since 1989. Mortality rates increased mainly in older patients (<65 years). Ten-year relative survival of males improved significantly from 70% in 1989–1993 to 77% in 2004–2008 (P > 0.001) and for females the 10-year relative survival increased from 85% to 88% (P > 0.01). Recently diagnosed patients had a better prognosis even after adjusting for all known prognostic factors.ConclusionSince incidence of melanomas among all Breslow thickness categories increased as well as the mortality rates, the melanoma epidemic in The Netherlands seems to be real and not only due to overdiagnosis.