Melanoma—Part 1: epidemiology, risk factors, and prevention

The recent and very interesting paper by Bataille et al. on the
melanoma prompts us to stress some aspects of the prevention of this
neoplasia.

The continuous increase of melanoma incidence throughout the world urges
us to deploy the most effective strategies, in view of diminishing
economic resources, to counter this neoplasia. It is early diagnosis
that constitutes our only weapon against this tumour. For these very
reasons there are more and more screening campaigns with random
dermatological exams 1.

This should lead us to reflect on the real utility of this type of
screening for melanoma, which involves high costs for low diagnostic
performances. It is well known that in non-screening conditions the ratio
between melanomas diagnosed and the number of subjects examined varies.

It is around 1:40/1:70 if a visit to the Pigmented Lesion Clinic follows
examination by the family doctor (as in the U.K. and in Italy)2, or 1:250
if the population has direct access to the dermatological centre, i.e.
the “skin cancer fairs” in the USA3. In both cases we have a better
diagnostic performance than with the screening carried out over the whole
population1 (table 1, added to response by BMJ on 4.12.08).

Table 1.
Ratio of melanoma detected in dermatological examination

Country	Ratio	                       Authors 	        Notes
U.K.	1:22-1:57	Gibbon KL. Clin Exp Dermatol 1998	G.P. filtered
Italy	1:64	        Carli P, Br J Dermatol 2002	G.P. filtered
U.S.A.	1:250	        Arundell FD.. JAMA. 1986. 
	      Not filtered
U.S.A.	1:625	        Koh HK. J Am Acad Dermatol. 1996. 	Not filtered.
        American Academy of Dermatology
        Screening Program
U.S.A.	1:6000	        Lamberg L.  JAMA.2002
	Not filtered. National
        Sports Skin Cancer
        Awareness Program (AAD)

Melanoma affects both sexes and all ages with the exception of pre-puberty
when it is a rare occurrence: thus prevention cannot be limited to certain
categories, as with other tumours, but should be extended to the entire
adult population. Even limited screening for subjects at risk
(familiarity, large numbers of nevi, atypical nevi) would produce
unsatisfactory results since the ratio of melanoma cases in subjects at
risk to the total number of melanomas is rather low.
Since annual check-ups for all adult subjects are not practical to
suggest, a dermatological examination for early diagnosis of melanoma
should thus be restricted to those subjects with potentially suspicious
pigmented lesions observed by the family doctor or identified through self
-examination using simple, but suppoted by evidence of reasonable
sensitivity and specificity, diagnostic criteria (“mole that changes”,the
ABCDE’s rule4). Clearly, informing the population and, above all,
involving the family doctor are fundamental in the fight against melanoma.

Indeed family doctors have two fundamental tasks:

1) ascertaining clinical suspicion arising from lesions identified by
patients, thus selecting the cases really requiring dermatological
evaluation(filter process);

2) looking for suspicious pigmented lesions when examining patients for
other reasons5.

Thus, in our experience2, a possible winning strategy is fully involving
family doctors, who control health care in entire areas. We must provide
them with the best training, using resources that are at present used for
screening or for other, not very successful initiatives.

Vincenzo De Giorgi 1, MD (corresponding author)

Ignazio Stanganelli 2, MD

Marta Grazzini, 1 MD

Torello Lotti 1 , MD

1 Department of Dermatology,
University of Florence

2 Skin Cancer Clinic,
Center for Cancer Prevention, Ravenna,
ITALY

REFERENCES

1. Lamberg L. “Epidemic” of Malignant Melanoma – True increase or
better detection? JAMA.2002.287(17):2201.

2. Carli P, De Giorgi V, Nardini P, Mannone F, Palli D, Giannotti B.
Melanoma detection rate and concordance between self-skin examination and
clinical evaluation in patients attending a pigmented lesion clinic in
Italy. Br J Dermatol 2002. 146: 261-266

3. Arundell FD. Screening for melanoma and skin cancer. JAMA. 1986.
255:2443-4

4. Abbasi NR, Shaw HM, Rigel DS, et al. Early diagnosis of cutaneous
melanoma: revisiting the ABCD criteria. JAMA. 2004 Dec 8;292(22):2771-6.

5. Epstein Ds, Lange JR, Gruber SB, et al. Is physician detection
associated with thinner melanomas? JAMA. 1999. 281:640-3

Competing interests:
None declared