Melanoma screening

From National Cancer Control Policy
Principles of screening > Melanoma screening


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Melanoma screening


Potentially, melanoma is almost totally preventable. Exposure to excess ultraviolet (UV) radiation is the major environmental factor in its development and one which is amenable to behavioural intervention. While melanoma can in the majority of cases be prevented through appropriate sun protection, discussion continues on the feasibility of population screening for melanoma.

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Screening tests for melanoma

The screening tests proposed for the early detection of melanoma include total body skin examination by a health care professional or skin self-examination. The use of dermoscopy by experienced health professionals has been found to provide increased diagnostic accuracy. Detection of a suspicious lesion constitutes a positive screening test for which further investigation is required. Melanoma is confirmed by biopsy[1].


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Accuracy of skin examination by a general practitioner or specialist

Due to a lack of research, particularly in the Australian setting, it is difficult to assess differences in levels of accuracy for detecting melanoma between general practitioners (GPs) and specialists. A systematic review published in 2001 concluded there was insufficient data to detect any differences in levels of accuracy in detecting melanoma between dermatologists and GPs[2].

Accuracy of diagnosing melanoma has been reported in a number of studies, primarily within screening programs. In the majority of screening programs, clinical skin examination has been conducted by specialists with only one study to date assessing outcomes of whole-body skin examinations conducted by GPs[3]. In that study 2.5% of all suspicious skin lesions detected by the GPs that were excised or biopsied were confirmed to be melanoma with a specificity of 86%. Of lesions suspected of being melanoma, 20.5% were confirmed as melanoma on histology. Most other studies have reported positive predictive values (the probability an individual has melanoma given they test positive on the screening exam) values between 0-12.5%, with levels of accuracy increasing when analyses were restricted to those over the age of 50 years[4][5][6][7][8]. The majority of studies examining clinical accuracy in diagnosing melanoma are not able to report on the sensitivity of the screening program as individuals with negative screens are not followed-up. Fritschi et al. have conducted one of the few studies to follow-up screening participants and reported a sensitivity of 69.7% in the first year after the screening examination[9].


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Aids to clinical diagnosis of melanoma

The use of aids to improve diagnostic accuracy of melanoma is increasing in both specialist and general practice settings. Dermoscopy (surface microscopy, dermatoscopy) uses a hand-held magnifying device to improve visualisation of pigmented skin lesions[10]. Meta-analyses of studies have consistently shown that the use of dermoscopy improves the accuracy of melanoma diagnosis[11][12]. Other studies within the specialist setting have shown a reduction in rates of excisions of benign lesions[13][14]. In the general practice setting, studies have shown improvements in sensitivity for melanoma diagnosis for clinicians who have experience in the use of dermoscopy. In a recent study in Western Australia involving 63 GPs who were trained in the use of dermoscopy and short-term sequential digital dermoscopy, significant improvements in the benign to malignant ratio and a 63% reduction in the number of lesions requiring referral or excision was observed[15]. It is recommended that clinicians who routinely examine pigmented skin lesions be trained in the use of dermoscopy[1].

Total body photography is an additional aid used particularly for individuals at high risk of melanoma such as those with dysplastic naevi. While no randomised-controlled trials have been undertaken, a number of studies have concluded that the use of total body photography has assisted in the detection of early stage melanoma[16][17][18].


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Skin self-examination

Skin self-examination has been suggested as one method to detect melanoma early. More commonly the patient is the first person to detect melanoma[19][20][21][22]. Patients tend to find melanomas when they occur on exposed or visible sites but only a small proportion are found when the patient conducts a deliberate skin examination[22][23]. The efficacy of skin self-examination in detecting melanoma is not well understood due in part to the variety of definitions of skin self-examination used in studies, and in the difficulty in accurately detailing skin examination practices. Further research into the value of skin self-examination is needed.

Death from melanoma is strongly inversely related to thickness at diagnosis, thus earlier diagnosis might be expected to provide the patient with the best possible chance of long-term survival[24]. There is some evidence to suggest melanomas that are detected during a screening examination are thinner than when detected incidentally. In a large Queensland study melanoma detected during a deliberate skin examination by a doctor was more likely to be thinner than if detected incidentally[22]. Similarly in the American Academy of Dermatology Screening Program, a significantly higher proportion of melanomas detected during screening were thinner compared to that seen in the population-based cancer registries[4][8]. Recent results from a Queensland case-control study of melanoma provide the strongest evidence to date for the effectiveness of clinical skin examination. In that study involving over 3,700 patients with melanoma, whole-body skin examination by a doctor in the three years prior to melanoma diagnosis was significantly associated with a lower risk of being diagnosed with thicker melanoma[25].

Skin examination whether by self or by a doctor appears to be increasing in the community. While trends in melanoma in recent years have shown an increase in the incidence of thin melanoma, there has been no corresponding decrease in incidence of thicker lesions[26]. As there are a number of histological types of melanoma, and their growth patterns vary significantly[27], melanomas that grow more aggressively may not be detected until they are quite advanced. Research is necessary to further our understanding of the impact skin screening has on melanoma incidence and survival.

As there is currently no conclusive evidence that routine skin examination results in a reduction in mortality from melanoma, the NHMRC Clinical Practice Guidelines for Melanoma and the U.S Preventive Services Task Force clinical guidelines currently do not recommend routine screening for the general population[1][28].


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References

  1. 1.0 1.1 1.2 Cancer Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines Group. Clinical Practice Guidelines of the Management of Melanoma in Australian and New Zealand. Wellington: Australian Cancer Network Melanoma Guidelines Revision Working Party; 2008 Available from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp111.pdf.
  2. Chen SC, Bravata DM, Weil E, Olkin I. A comparison of dermatologists' and primary care physicians' accuracy in diagnosing melanoma: a systematic review. Arch Dermatol 2001 Dec;137(12):1627-34 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11735713.
  3. Aitken JF, Janda M, Elwood M, Youl PH, Ring IT, Lowe JB. Clinical outcomes from skin screening clinics within a community-based melanoma screening program. J Am Acad Dermatol 2006 Jan;54(1):105-14 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16384764.
  4. 4.0 4.1 Koh HK, Norton LA, Geller AC, Sun T, Rigel DS, Miller DR, et al. Evaluation of the American Academy of Dermatology's National Skin Cancer Early Detection and Screening Program. J Am Acad Dermatol 1996 Jun;34(6):971-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8647990.
  5. Burton RC, Howe C, Adamson L, Reid AL, Hersey P, Watson A, et al. General practitioner screening for melanoma: sensitivity, specificity, and effect of training. J Med Screen 1998;5(3):156-61 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9795877.
  6. Engelberg D, Gallagher RP, Rivers JK. Follow-up and evaluation of skin cancer screening in British Columbia. J Am Acad Dermatol 1999 Jul;41(1):37-42 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10411408.
  7. Geller AC, Sober AJ, Zhang Z, Brooks DR, Miller DR, Halpern A, et al. Strategies for improving melanoma education and screening for men age >or= 50 years: findings from the American Academy of Dermatological National Skin Cancer Sreening Program. Cancer 2002 Oct 1;95(7):1554-61 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12237925.
  8. 8.0 8.1 Geller AC, Zhang Z, Sober AJ, Halpern AC, Weinstock MA, Daniels S, et al. The first 15 years of the American Academy of Dermatology skin cancer screening programs: 1985-1999. J Am Acad Dermatol 2003 Jan;48(1):34-41 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12522368.
  9. Fritschi L, Dye SA, Katris P. Validity of melanoma diagnosis in a community-based screening program. Am J Epidemiol 2006 Aug 15;164(4):385-90 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16760225.
  10. Menzies S, Crotty KA, Ingvar C, McCarthy WH. An Atlas of Surface Microscopy of Pigmented Skin Lesions: Dermoscopy. Sydney: McGaw-Hill; 2003.
  11. Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accuracy of dermoscopy. Lancet Oncol 2002 Mar;3(3):159-65 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11902502.
  12. Bafounta ML, Beauchet A, Aegerter P, Saiag P. Is dermoscopy (epiluminescence microscopy) useful for the diagnosis of melanoma? Results of a meta-analysis using techniques adapted to the evaluation of diagnostic tests. Arch Dermatol 2001 Oct;137(10):1343-50 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11594860.
  13. Carli P, de Giorgi V, Chiarugi A, Nardini P, Weinstock MA, Crocetti E, et al. Addition of dermoscopy to conventional naked-eye examination in melanoma screening: a randomized study. J Am Acad Dermatol 2004 May;50(5):683-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15097950.
  14. Carli P, De Giorgi V, Crocetti E, Mannone F, Massi D, Chiarugi A, et al. Improvement of malignant/benign ratio in excised melanocytic lesions in the 'dermoscopy era': a retrospective study 1997-2001. Br J Dermatol 2004 Apr;150(4):687-92 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15099364.
  15. Menzies SW, Emery J, Staples M, Davies S, McAvoy B, Fletcher J, et al. Impact of dermoscopy and short-term sequential digital dermoscopy imaging for the management of pigmented lesions in primary care: a sequential intervention trial. Br J Dermatol 2009 Dec;161(6):1270-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19747359.
  16. Kelly JW, Yeatman JM, Regalia C, Mason G, Henham AP. A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance. Med J Aust 1997 Aug 18;167(4):191-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9293264.
  17. MacKie RM, McHenry P, Hole D. Accelerated detection with prospective surveillance for cutaneous malignant melanoma in high-risk groups. Lancet 1993 Jun 26;341(8861):1618-20 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8099990.
  18. Feit NE, Dusza SW, Marghoob AA. Melanomas detected with the aid of total cutaneous photography. Br J Dermatol 2004 Apr;150(4):706-14 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15099367.
  19. Koh HK, Miller DR, Geller AC, Clapp RW, Mercer MB, Lew RA. Who discovers melanoma? Patterns from a population-based survey. J Am Acad Dermatol 1992 Jun;26(6):914-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1607408.
  20. Elwood JM, Gallagher RP. The first signs and symptoms of melanoma: a population-based study. In: Elwood JM ed.. Naevi and melanoma: Incidence, interrelationships and implications. Pigment Cell No. 9. Basel: Karger; 1988. p. 140-52.
  21. Brady MS, Oliveria SA, Christos PJ, Berwick M, Coit DG, Katz J, et al. Patterns of detection in patients with cutaneous melanoma. Cancer 2000 Jul 15;89(2):342-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10918164.
  22. 22.0 22.1 22.2 McPherson M, Elwood M, English DR, Baade PD, Youl PH, Aitken JF. Presentation and detection of invasive melanoma in a high-risk population. J Am Acad Dermatol 2006 May;54(5):783-92 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16635658.
  23. Tyler I, Rivers JK, Shoveller JA, Blum A. Melanoma detection in British Columbia, Canada. J Am Acad Dermatol 2005 Jan;52(1):48-54 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15627080.
  24. Balch CM, Soong SJ, Atkins MB, Buzaid AC, Cascinelli N, Coit DG, et al. An evidence-based staging system for cutaneous melanoma. CA Cancer J Clin 2004 May;54(3):131-49; quiz 182-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15195788.
  25. Aitken JF, Elwood M, Baade PD, Youl P, English D. Clinical whole-body skin examination reduces the incidence of thick melanomas. Int J Cancer 2010 Jan 15;126(2):450-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19609948.
  26. Coory M, Baade P, Aitken J, Smithers M, McLeod GR, Ring I. Trends for in situ and invasive melanoma in Queensland, Australia, 1982-2002. Cancer Causes Control 2006 Feb;17(1):21-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16411049.
  27. Liu W, Dowling JP, Murray WK, McArthur GA, Thompson JF, Wolfe R, et al. Rate of growth in melanomas: characteristics and associations of rapidly growing melanomas. Arch Dermatol 2006 Dec;142(12):1551-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17178980.
  28. Wolff T, Tai E, Miller T. Screening for skin cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2009 Feb 3;150(3):194-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19189909.

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