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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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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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[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.
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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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