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.     

Factors associated with thorough skin self-examination for the early detection of melanoma

BACKGROUND: Regular thorough skin self-examination (TSSE) has potential for detecting melanoma early and reducing melanoma mortality. OBJECTIVES: We sought to model factors associated with skin self-examination (SSE) and test whether efficacy and attitudes about SSE mediated these relationships. PATIENTS/METHODS: The Check-It-Out project is a randomized trial of an intervention to encourage TSSE; 2126 participants were recruited from the practices of primary care physicians. Correlates predicting baseline TSSE included demographic variables, skin cancer risk, physician advice to examine skin, and appropriate conditions for conducting SSE (availability of partner to assist with self-examination, availability of a wall mirror, and use of contact lenses/glasses). RESULTS: Those who were given physician advice, had a wall mirror, and had a partner available were more likely to perform TSSE. LIMITATIONS: We identified the factors associated with concurrent TSSE practices. Further research is needed to determine if these same factors predict future behaviour. Our findings may not be applicable in geographical areas other than our recruitment area. CONCLUSIONS: Primary care providers can recommend SSE and provide materials to increase ability to recognize skin problems. Providing instructions and aids for conducting TSSE may increase self-efficacy.     

Fundamentals of skin cancer/melanoma screening campaigns

There is increased world-wide concern about the rising incidence of melanoma and non-melanoma skin cancer. Screening theoretically reduces death and morbidity from skin cancer/melanoma. Visual examination of the skin is a rapid, safe and inexpensive screening tool. In this review the fundamentals of early disease detection before implementation of a public-health screening programme are critically analysed with reference to the skin cancer/melanoma, epidemic. It is concluded that skin cancer/melanoma fulfils, for the most part, the criteria enunciated by Wilson and Jungner in 1968. However, information about the effect of screening on reducing incidence and mortality is still lacking. Future research should focus on methods of improving compliance and on the costs and benefits of such screening programmes.     

Nationwide hospitalization costs of skin melanoma and non-melanoma skin cancer in Germany

Introduction Non‐melanoma skin cancer (NMSC), in contrast to skin melanoma (MEL), is considered a negligible health problem because mortality of NMSC is low. The aim of this study was to provide insights into the burden of NMSC and MEL by analysing nationwide skin cancer hospitalization data and data from a dermatologist panel of Germany. We wanted to estimate hospitalization costs due to skin cancer in Germany. Material and methods We analysed the most recent nationwide hospitalization data from 2003 and estimated hospitalization costs due to MEL and NMSC. We estimated the annual number of private dermatologist practice visits in Germany due to skin cancer. Results In 2003, 20 455 melanoma‐related and 41 929 NMSC‐related hospitalizations occurred in Germany. Age‐standardized hospitalization rates for NMSC were 2.5‐fold and 1.8‐fold higher among men and women than the rates for MEL, respectively. The age‐specific proportions of hospitalizations for NMSC in relation to all cancer‐related hospitalizations increased within the age range of 65 years and more. Among people aged 90 years and more, 14% of all cancer‐related hospitalizations were due to NMSC. Estimated annual hospitalization costs for MEL were €50 to 60 million, and those for NMSC were €105 to 130 million. The estimated number of private dermatologist practice visits in Germany 2003 is considerably higher for NMSC than MEL Conclusions Analyses of hospitalizations data and data from private dermatologists give NMSC higher public health relevance than can be obtained from consideration of death statistics.     

Efficacy of skin self‐examination for the early detection of melanoma

The National Cancer Institute's “Melanoma Action Plan” calls for reduction of melanoma mortality through early detection. Routine skin self‐examination (SSE) has the potential to increase chances of early detection and treatment and may be the key to melanoma survival. We provide a focused review of the accuracy of SSE for detecting premalignant lesions and cutaneous risk factors for melanoma, with suggestions for future directions for enhancing measurement of SSE accuracy and ways in which to improve the public's perceptions of melanoma efficacy. We examined published data on the efficacy of skin self‐examination for the early detection of melanoma. We searched the MEDLINE database for publications between January 1, 1987 and June 1, 2007 using search terms for “melanoma” and “self‐examination.” We found that sensitivity of skin self‐examination is low, ranging from 25% to 93%, while specificity is generally higher (83% to 97%). Attempts to increase improve the lay public's perceptions of the early signs of melanoma have proved effective, while those aimed at increasing accuracy of SSE with targeted interventions have been moderately successful. SSE's insensitivity for detection of pigmented lesions should prompt further investigation of educational interventions to enhance its accuracy and lead to its adoption as a cheap, simple screening tool. Assessment of the accuracy and efficacy of SSE should proceed using standardized definitions and measurements such that it is easier to pool data on the overall value of SSE as a screening modality.     

Total body skin imaging as an aid to melanoma detection

Total body skin imaging (TBSI) is being increasingly used as an aid to melanoma detection in high-risk individuals. In this article, we review the rationale, techniques, advantages, and potential pitfalls of TBSI as an aid to melanoma detection. We highlight the technical and clinical considerations relevant to implementation of TBSI in clinical practice.     

Oxidative stress in malignant melanoma and non-melanoma skin cancer

BACKGROUND: Solar ultraviolet (UV) radiation is considered to be a major aetiological factor in melanoma and non-melanoma skin cancer. A growing body of evidence indicates that oxidative stress is involved in photocarcinogenesis. However, in vivo data for human skin are still lacking. Reactive oxygen species participate in a number of pathophysiological processes including DNA damage and lipid peroxidation (LPO) and are considered to be a key factor in tumour progression. OBJECTIVES: We hypothesized that in human skin cancer the natural redox balance is disturbed and that this imbalance may result in an accumulation of LPO products. METHODS: To test this, skin biopsies of superficial spreading melanoma were compared with age-matched benign melanocytic naevi and young healthy controls. Additionally, non-melanoma skin cancers (basal cell carcinoma, squamous cell carcinoma) and actinic keratosis were investigated (n = 18 each). Expression of the antioxidant enzymes, copper-zinc superoxide dismutase, manganese superoxide dismutase and catalase was analysed by immunohistochemical techniques. To detect LPO products, protein-bound malondialdehyde (MDA) was visualized. RESULTS: In human melanoma biopsies, a significant overexpression of the antioxidant enzymes was found when compared with surrounding non-tumour tissue, benign melanocytic naevi, and young controls. Intriguingly, the LPO marker MDA was significantly increased in melanoma tissue. MDA was located not only in typical melanoma cells, but also occurred in surrounding keratinocytes. In contrast, a severely disturbed antioxidant balance with diminished antioxidant enzymes was found in non-melanoma tumours, whereas MDA was elevated only in squamous cell carcinomas. CONCLUSIONS: These findings indicate that oxidative stress may play different roles in the pathogenesis of human skin cancers. In non-melanoma skin cancer, a diminished antioxidant defence caused by chronic UV exposure might contribute to multistep carcinogenesis, whereas melanoma cells exhibit increased oxidative stress which could damage surrounding tissue and thus support the progression of metastasis.     

Total skin examination during screening for malignant melanoma does not increase the detection rate

Summary Total skin examination during public screening for malignant melanoma is often advocated, but the benefit of this approach has not been established properly. We assessed the yield of examination of the entire skin, in addition to examination of intentionally shown skin lesions, in people attending melanoma screening clinics in southern Limburg, the Netherlands, in 1993. Of the 4146 attenders, 2910 (70%) showed a specific skin spot. Additional examination of the entire skin was offered to 1385 people. There were 1221 evaluable cases. Fourteen presumptive diagnoses of malignancies were encountered: seven malignant melanomas, all with low clinical suspicion, and seven basal cell carcinomas. Histology revealed three basal cell carcinomas. No malignant melanomas were confirmed by histology. It is concluded that additional total skin examination during screening for malignant melanoma is not worthwhile, except perhaps for persons presenting lesions that are suspicious of melanoma or dysplastic naevi.     

Quality of life in non‐melanoma skin cancer

Basal cell carcinoma and squamous cell carcinoma are the most common malignancies and are classified under the umbrella of non‐melanoma skin cancer (NMSC). NMSC exerts a small but appreciable decrement in quality of life (QOL). The impact posed may arise from the tumour itself or as a result of treatment, and through symptoms, functional limitations, cosmetic burden and auxiliary considerations such as cost and disturbance to the activities of daily living. Researchers have evaluated this burden using a variety of outcome measures including generic, dermatology‐specific and disease‐specific instruments. The skin cancer index represents a promising disease‐specific patient‐reported outcome measure in this setting. To overcome some of the constraints inherent to disease‐specific instruments, and to allow comparisons with other diseases, utility weightings have been developed. Utility weightings represent a cardinal measure for a specific health status and are established through methods such as the standard gamble, willingness‐to‐pay and time trade‐off, and have also been employed to generate utility weightings for NMSC. Utilities are becoming increasingly important as a means of comparing health states across medicine and are of particular importance from a health‐care policy perspective as they are used for resource allocation. The small but definite impact on the individual's QOL posed by NMSC should be a clinical consideration for physicians and it should be recognised by researchers as a potential outcome measure.     

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.