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Discussion

Table 2 summarizes the literature review by describing the evidence for each link in the analytic framework. The quality of the evidence at each link ranged from poor to fair. The effectiveness of early detection in reducing melanoma mortality and other clinical outcomes is uncertain. Studies of early detection have not focused on screening and have not adequately linked it with reduced incidence of invasive disease.

Community trials of screening are underway in Australia, but will take many years to complete. In the meantime, observational studies should address the potential harms of screening, including mislabeling, unnecessary biopsies, and the direct and indirect costs of screening programs. Gaps in our knowledge of the progression to thick melanoma in the elderly should also be addressed. Better information is needed about the natural history of thick nodular melanoma, the type typically found in the elderly, since there is little evidence that lethal tumors in this group could be detected while still in a curable stage.

Future research is also needed to help the clinician identify primary care patients at high risk for melanoma. Skin cancer screening using a risk assessment technique to identify high-risk patients is the most promising strategy for addressing the excess burden of disease in the elderly. Observational studies should assess the validity, reliability, and feasibility of standardized, brief risk assessments used to identify these patients. These assessments should incorporate age, mole counts, and a count of atypical moles, the best established risk factors for the later development of melanoma. Trials of validated risk assessment programs in the primary care setting, as well as more data regarding the accuracy of skin examination conducted by specialists and primary care clinicians in routine clinical practice, are needed.

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Acknowledgements

This study was conducted by the Oregon Health Sciences University Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (contract no. 290-97-0018), Rockville, Maryland.

This article is based on a more comprehensive Systematic Evidence Review, which is available online at http://www.ahrq.gov/clinic/prevenix.htm. That document was reviewed by content experts, including Marianne Berwick, Ph.D., M.P.H., Memorial Sloan-Kettering Cancer Center; Allan C. Halpern, M.D., Memorial Sloan-Kettering Cancer Center; R. A. Swerlick, MD, Emory University School of Medicine; and professional organizations, including the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Preventive Medicine, and the American College of Physicians/American Society of Internal Medicine; and public health organizations, including the Canadian Task Force on Preventive Health Care; the Indian Health Service; the National Cancer Institute, the National Institutes of Health; and the Centers for Disease Control and Prevention. Review by these individuals and groups does not necessarily imply endorsement of this article or of the accompanying recommendations of the U.S. Preventive Services Task Force.

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References and Notes

1. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1999. CA Cancer J Clin 1999;49:8.

2. Ries LAG, Kosary CL, Hankey BF, Miller BA, Edwards BK. SEER Cancer Statistics Review, 1973-95. Bethesda, MD: National Cancer Institute, 1998.

3. Cress RD, Holly EA. Incidence of cutaneous melanoma among non-Hispanic whites, Hispanics, Asians, and blacks: an analysis of California cancer registry data, 1988-93. Cancer Causes Control 1997;8:246-252.

4. Kelly J. Melanoma in the elderly—a neglected public health challenge. Med J Aust 1998;169:403-404.

5. Dennis LK. Analysis of the melanoma epidemic, both apparent and real: data from the 1973 through 1994 surveillance, epidemiology, and end results program registry. Arch Dermatol 1999;135:275-280.

6. Breslow A. Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Ann of Surg 1970, 172:902-908.

7. Berwick M, Halpern A. Melanoma epidemiology. Curr Opin Oncol 1997;9:178-182.

8. Swerlick RA, Chen S. The melanoma epidemic: more apparent than real? Mayo Clin Proc 1997;72:559-564.

9. Burton R, Armstrong B. Recent incidence trends imply a nonmetastasizing form of invasive melanoma. Melanoma Res 1994, 4:107-113.

10. Swerlick RA, Chen S. The melanoma epidemic. Is increased surveillance the solution or the problem? Arch Dermatol 1996, 132:881-884.

11. Burton R. An analysis of a melanoma epidemic. Int J Cancer 1993;55:765-770.

12. Chuang TY, Popescu A, Su WP, Chute CG. Basal cell carcinoma: a population-based incidence study in Rochester, Minnesota. J Am Acad Dermatol 1990;22:413-417.

13. Chuang TY, Popescu NA, Su WP, Chute CG. Squamous cell carcinoma: a population-based incidence study in Rochester, Minnesota. Arch Dermatol 1990;126:185-188.

14. Karagas MR, Greenberg ER, Spencer SK, Stukel TA, Mott LA. Increase in incidence rates of basal cell and squamous cell skin cancer in New Hampshire, USA. New Hampshire Skin Cancer Study Group. Int J Cancer 1999;81:555-559.

15. Preston DS, Stern RS. Nonmelanoma cancers of the skin. N Engl J Med 1992;327:1649-1662.

16. Osterlind A, Hjalgrim H, Kulinsky B, Frentz G. Skin cancer as a cause of death in Denmark. Br J Dermatol 1991;125:580-582.

17. Weinstock MA. Death from skin cancer among the elderly: epidemiological patterns. Arch Dermatol 1997;133:1207-1209.

18. Greene MH, Clark WH Jr, Tucker MA, Kraemer KH, Elder DE, Fraser MC. High risk of malignant melanoma in melanoma-prone families with dysplastic nevi. Ann Intern Med 1985;102:458-465.

19. MacKie RM, McHenry P, Hole D. Accelerated detection with prospective surveillance for cutaneous malignant melanoma in high-risk groups. Lancet 1993; 341:1618-1620.

20. Rigel DS, Rivers JK, Kopf AW, et al. Dysplastic nevi: markers for increased risk for melanoma. Cancer 1989;63:386-389.

21. Corona R, Mele A, Amini M, et al. Interobserver variability on the histopathologic diagnosis of cutaneous melanoma and other pigmented skin lesions. J Clin Oncol 1996; 14:1218-1223.

22. Farmer ER, Gonin R, Hanna MP. Discordance in the histopathologic diagnosis of melanoma and melanocytic nevi between expert pathologists. Hum Pathol 1996;27:528-531.

23. Tucker MA, Halpern A, Holly EA, et al. Clinically recognized dysplastic nevi: a central risk factor for cutaneous melanoma. JAMA 1997;277:1439-1444.

24. Garbe C, Buttner P, Weiss J, et al. Risk factors for developing cutaneous melanoma and criteria for identifying persons at risk: multicenter case-control study of the Central Malignant Melanoma Registry of the German Dermatological Society. J Invest Derm 1994;102:695-699.

25. Bataille V, Bishop JA, Sasieni P, et al. Risk of cutaneous melanoma in relation to the numbers, types and sites of naevi: a case-control study. Br J Cancer 1996; 73:1605-1611.

26. Lawson DD, Moore DH II, Schneider JS, Sagebiel RW. Nevus counting as a risk factor for melanoma: comparison of self-count with count by physician. J Am Acad Dermatol 1994;31:438-444.

27. Little P, Keefe M, White J. Self screening for risk of melanoma: validity of self-mole counting by patients in a single general practice. BMJ 1995;310:912-916.

28. Titus-Ernstoff L, Thorn M, Tosteson TD, et al. The accuracy of skin self-examination for atypical nevi. Epidemiology 1996;7:619-623.

29. Berwick M, Begg CB, Fine JA, Roush GC, Barnhill RL. Screening for cutaneous melanoma by skin self-examination. J Natl Cancer Inst 1996;88:17-23.

30. English DR, Armstrong BK. Identifying people at high risk of cutaneous malignant melanoma: results from a case-control study in Western Australia. BMJ 1988;296:1285-1288. (Clin Res Ed)

31. Marrett LD, King WD, Walter SD, From L. Use of host factors to identify people at high risk for cutaneous malignant melanoma. Can Med Assoc J 1992;147:445-453.

32. Bliss JM, Ford D, Swerdlow AJ, et al. Risk of cutaneous melanoma associated with pigmentation characteristics and freckling: systematic overview of 10 case-control studies. The International Melanoma Analysis Group (IMAGE) Int J Cancer 1995;62:367-376.

33. Schneider JS, Moore DH II, Sagebiel RW. Risk factors for melanoma incidence in prospective follow-up: the importance of atypical (dysplastic) nevi. Arch Dermatol 1994;130:1002-1007.

34. Kelly JW, Crutcher WA, Sagebiel RW. Clinical diagnosis of dysplastic melanocytic nevi: a clinicopathologic correlation. J Am Acad Dermatol 1986;14:1044-1052.

35. Jackson A, Wilkinson C, Ranger M, Pill R, August P. Can primary prevention or selective screening for melanoma be more precisely targeted through general practice? A prospective study to validate a self administered risk score. BMJ 1998;316:34-38. (discussion 38-9)

36. Limpert GH. Skin-cancer screening: a three-year experience that paid for itself. J Fam Pract 1995;40:471-475.

37. Rampen FH, Casparie van Velsen JI, van Huystee BE, Kiemeney LA, Schouten LJ. False-negative findings in skin cancer and melanoma screening. J Am Acad Dermatol 1995;33:59-63.

38. Koh HK, Norton LA, Geller AC, et al. Evaluation of the American Academy of Dermatology's National Skin Cancer Early Detection and Screening Program. J Am Acad Dermatol 1996;34:971-978.

39. Federman DG, Concato J, Kirsner RS. Comparison of dermatologic diagnoses by primary care practitioners and dermatologists: a review of the literature. Arch Fam Med 1999;8:170-172.

40. Whited JD, Grichnik JM. Does this patient have a mole or a melanoma? JAMA 1998;279:696-701.

41. Burton RC, Howe C, Adamson L, et al. General practitioner screening for melanoma: sensitivity, specificity, and effect of training. J Med Screen 1998;5:156-161.

42. Engelberg D, Gallagher RP, Rivers JK. Follow-up and evaluation of skin cancer screening in British Columbia. J Am Acad Dermatol 1999;41:37-42.

43. Jonna BP, Delfino RJ, Newman WG, Tope WD. Positive predictive value for presumptive diagnoses of skin cancer and compliance with follow-up among patients attending a community screening program. Prev Med 1998;27:611-616.

44. McGee R, Elwood M, Williams S, Lowry F. Who comes to skin checks? NZ Med J 1994;107:58-60.

45. De Rooij MJ, Rampen FH, Schouten LJ, Neumann HA. Skin cancer screening focusing on melanoma yields more selective attendance. Arch Dermatol 1995;131:422-425.

46. De Rooij MJ, Rampen FH, Schouten LJ, Neumann HA. Volunteer melanoma screenings: follow-up, compliance, and outcome. Dermatol Surg 1997;23:197-201.

47. Hourani LL, LaFleur B. Predictors of gender differences in sunscreen use and screening outcome among skin cancer screening participants. J Behav Med 1995;18:461-477.

48. Katris P, Crock JG, Gray BN. Research note: the Lions Cancer Institute and the Western Australian Society of Plastic Surgeons skin cancer screening programme. Aust NZ J Surg 1996;66:101-104.

49. Katris P, Donovan RJ, Gray BN. Nurses screening for skin cancer: an observation study. Aust NZ J Pub Health 1998, 22:381-383.

50. Rivers JK, Gallagher RP. Public education projects in skin cancer: experience of the Canadian Dermatology Association. Cancer 1995;75:661-666.

51. Dozier S, Wagner RF Jr, Black SA, Terracina J. Beachfront screening for skin cancer in Texas Gulf coast surfers. South Med J 1997;90:55-58.

52. Harvey I, Frankel S, Marks R, Shalom D, Nolan-Farrell M. Non-melanoma skin cancer and solar keratoses. I. Methods and descriptive results of the South Wales Skin Cancer Study. Br J Cancer 1996;74:1302-1307.

53. Harvey I, Frankel S, Marks R, Shalom D, Nolan-Farrell M. Non-melanoma skin cancer and solar keratoses. II. Analytical results of the South Wales Skin Cancer Study. Br J Cancer 1996;74:1308-1312.

54. Ichihashi M, Naruse K, Harada S, et al. Trends in nonmelanoma skin cancer in Japan. Recent Results Cancer Res 1995;139:263-273.

55. Tornberg S, Mansson-Brahme E, Linden D, et al. Screening for cutaneous malignant melanoma: a feasibility study. J Med Screen 1996, 3:211-215.

56. Bergenmar M, Tornberg S, Brandberg Y. Factors related to non-attendance in a population-based melanoma screening program. Psycho-Oncology 1997;6:218-226.

57. Ruskiewicz J. Skin cancer and actinic keratoses. J Am Optom Assoc 1998;69:229-235.

58. Whited JD, Hall RP, Simel DL, Horner RD. Primary care clinicians' performance for detecting actinic keratoses and skin cancer. Arch Int Med 1997;157:985-990.

59. Friedman LC, Webb JA, Bruce S, Weinberg AD, Cooper H.P. Skin cancer prevention and early detection intentions and behavior. Am J Prev Med 1995;11:59-65.

60. Herd RM, Cooper EJ and Hunter JA, et al. Cutaneous malignant melanoma. Publicity, screening clinics and survival—the Edinburgh experience 1982-90. Br J Dermatol 1995;132:563-570.

61. Marghoob AA, Slade J, Salopek TG, Kopf AW, Bart RS, Rigel DS. Basal cell and squamous cell carcinomas are important risk factors for cutaneous malignant melanoma: screening implications. Cancer 1995;75:707-714.

62. van der Spek-Keijser LM, van der Rhee HJ, Toth G, Van Westering R, Bruijn JA, Coebergh JW. Site, histological type, and thickness of primary cutaneous malignant melanoma in western Netherlands since 1980. Br J Dermatol 1997;136:565-571.

63. Veierod MB, Thelle DS, Laake P. Diet and risk of cutaneous malignant melanoma: a prospective study of 50,757 Norwegian men and women. Int J Cancer 1997;71:600-604.

64. De Rooij MJ, Rampen FH, Schouten LJ, Neumann HA. Total skin examination during screening for malignant melanoma does not increase the detection rate. Br J Dermatol 1996;135:42-45.

65. Elwood JM. Screening for melanoma and options for its evaluation. J Med Screen 1994;1:22-38.

66. Hanrahan P.F., Hersey P. and D'Este C.A. Factors involved in presentation of older people with thick melanoma. Med J Aust 1998;169:410-414.

67. MacKie RM, Hole D. Audit of public education campaign to encourage earlier detection of malignant melanoma. BMJ 1992;304:1012-1015.

68. Koh HK, Geller AC. Public health interventions for melanoma: prevention, early detection, and education. Hematol Oncol Clin North Am 1998;12:903-928.

69. Giles GG, Armstrong BK, Burton RC, Staples MP, Thursfield VJ. Has mortality from melanoma stopped rising in Australia? Analysis of trends between 1931 and 1994. BMJ 1996;312:1121-1125.

70. Melia J, Cooper EJ, Frost T, et al. Cancer Research Campaign health education programme to promote the early detection of cutaneous malignant melanoma. II. Characteristics and incidence of melanoma. Br J Dermatol 1995;132:414-421.

71. Melia J. Early detection of cutaneous malignant melanoma in Britain. Int J Epidemiol 1995;24:S39-44.

72. Hersey P, Sillar RW, Howe CG, et al. Factors related to the presentation of patients with thick primary melanomas. Med J Aust 1991;154:583-587.

73. Metzger S, Ellwanger U, Stroebel W, Schiebel U, Rassner G, Fierlbeck G. Extent and consequences of physician delay in the diagnosis of acral melanoma. Melanoma Res 1998;8:181-186.

74. Warso M, Gray T, Gonzalez M. Melanoma of the hand. J Hand Surg 1997;22:354-360.

75. Larsson K, Shaw H, Thompson J, Harman R, McCarthy W. Primary mucosal and glans penis melanomas: the Sydney Melanoma Unit experience. Aust NZ J Surg 1999;69:121-126.

76. Holden R, Damato B. Preventable delays in the treatment of intraocular melanoma in the UK. Eye 1996;10:127-129.

77. Bennett DR, Wasson D, MacArthur JD, McMillen MA. The effect of misdiagnosis and delay in diagnosis on clinical outcome in melanomas of the foot. J Am Coll Surg 1994;179:279-284.

78. Baccard M, Chevret S, Chemaly P, Morel P. Delay in diagnosing melanoma: a prospective study in 102 patients. Ann Dermatol Venereol 1997;124:601-606.

79. Epstein DS, Lange JR, Gruber SB, Mofid M, Koch SE. Is physician detection associated with thinner melanomas? JAMA 1999;281:640-643.

80. Richard MA, Grob JJ, Avril MF, et al. Melanoma and tumor thickness: challenges of early diagnosis. Arch Dermatol 1999;135:269-274.

81. Geller AC, Halpern AC, Sun T, et al. Participant satisfaction and value in American Academy of Dermatology and American Cancer Society skin cancer screening programs in Massachusetts. J Am Acad Dermatol 1999;40:563-566.

82. Stern RS, Boudreaux C, Arndt KA. Diagnostic accuracy and appropriateness of care for seborrheic keratoses: a pilot study of an approach to quality assurance for cutaneous surgery. JAMA 1991;265:74-77.

83. Freedberg K. Screening for melanoma: a cost-effectiveness analysis. J Am Acad Dermatol 1999;41:738-745.

Author Affiliations

[a]Helfand, Mahon, Eden: Division of Medical Informatics and Outcomes Research, Evidence-based Practice Center, Oregon Health Sciences University, Portland, OR.
[b]Helfand: Division of General Internal Medicine, Portland Veterans Affairs Medical Center, Portland, OR.
[c]Frame: Tri-County Family Medicine, Cohocton, NY.
[d]Orleans: The Robert Wood Johnson Foundation, Princeton, NJ.

Copyright and Source Information

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Source: Helfand M, Mahon SM, Eden KB, Frame PS, Orleans CT. Screening for skin cancer. Am J Prev Med 2001;20(3S):47-58 (http://www.elsevier.com/locate/ajpmonline).

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