Melanoma and Skin Cancer Control: An International Perspective

Howard K. Koh, MD, MPH, FACP, and Alan C. Geller, RN, MPH

Departments of Dermatology and Medicine and the Cancer Prevention and Control Center,
Boston University Medical Center, Boston, Mass.

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Approximately one million Americans are diagnosed with skin cancer each year. Since melanoma and skin cancer are amenable to prevention, education, and early detection, efforts to reduce the incidence of and death from melanoma have developed in many countries. Programs promoting behavioral changes and the incorporation of skin cancer control into national health care agendas have begun in a number of countries. Additional programs for the at-risk and general populations require further development and evaluation.

Introduction

Cutaneous melanoma and skin cancer have become increasingly common public health problems.[1] An estimated 1 million or more Americans are diagnosed annually with skin cancer, comprising half of all incident cancers.[2] Rising incidence and death rates for melanoma in the United States now contribute to a projected 34,100 cases and 7,200 deaths for 1995.[3,4] The rise in melanoma mortality in men was the highest for all cancers.[5] Worldwide, more than 90,000 cases of melanoma are diagnosed annually.[6]

Despite these daunting figures, melanoma and skin cancer are amenable to prevention, education, and early detection. Prevention through reduction of excessive sunlight exposure can potentially decrease melanoma incidence. Education and early detection programs seek to decrease mortality, since melanoma not only is external and recognizable, but also has known risk factors. Furthermore, early melanoma is curable.[7] As a result, melanoma and skin cancer control efforts have begun in the United States,[8-10] United Kingdom,[11] Australia,[7] Canada,[12] Sweden,[13] and other countries.

Prevention

The majority of an individual's lifetime sun exposure occurs during the first two decades of life. Childhood sunburns have been linked with an increased later risk of melanoma.[14] Primary prevention efforts have sought to reach at- risk individuals, including those who tan poorly or burn easily (with a relative risk of 2 to 3), those with a family history of melanoma (with a relative risk of 2 to 8), those with dysplastic nevi or atypical moles (with a relative risk of 7 to 70), and those exposed to excessive sun (with a relative risk of 3 to 5).[15] Special programs must reach children - particularly those who tend to burn rather than tan (type I and type II skin) - as well as their parents and caregivers.[16-18] A broad, "safe sun" strategy includes personal behavior changes, as well as policy, structural, and environmental changes.[18,19]

Personal Behavioral Changes

Recommendations of personal behavioral changes for the general population include (1) minimization of sun exposure during peak ultraviolet B (UVB) radiation during midday hours, (2) use of a sunscreen with a sun protection factor (SPF) of at least 15 (which offers protection from the sun 15 times greater than no sunscreen before skin erythema is induced), (3) use of wide- brimmed hats, sunglasses, and protective clothing (eg, shirts with long sleeves and clothing made of tightly woven fabrics), and (4) avoidance of deliberate tanning, including tanning parlors.

In the United States, programs promoting behavioral change have begun in newborn nurseries,[20] elementary schools,[21] high schools,[22] colleges,[23] at beaches,[24] and at pools.[25] Some programs try to reach children with simple messages.[26] For example, the "Shadow Rule" ("Short shadow! Seek shade!") teaches children that when their shadows are shorter than they are, it is time to seek shade and use sunscreens and hats. Buller et al[21] integrated a sun-safety curriculum into traditional classroom teaching for fourth-, fifth-, and sixth-grade students. Preliminary evaluation indicates positive changes in knowledge and attitudes, with smaller changes in behavior and practice.

Awards have been provided by the Centers for Disease Control and Prevention (CDC) to the Departments of Public Health in five states (Arizona, California, Georgia, Hawaii, and Massachusetts) to provide skin cancer education for children (13 years of age and younger) and their caregivers. Proposed programmatic activity (directed to parents and caregivers) includes education in day care centers and preschools, in camps for children aged 6 through 8 years, and in newborn nurseries.[10] In the United States, the "Healthy People 2000: National Health Promotion and Disease Prevention Objectives" recently called for an increase to at least 60% in the number of people who limit sun exposure, use sunscreens, and wear protective clothing.[10]

Policy, Structural, and Environmental Changes

In an effort to promote awareness of ultraviolet (UV) ray hazards, the United States National Weather Service and the Environmental Protection Agency (EPA) publicized the UV index in television and newspaper weather reports in 58 major cities. This index, ranked on a scale of 1 to 10+, projects intensity for UV exposure and suggests appropriate protection measures. In Australia, policy and structural changes in the community are important components of skin cancer control programs.[7] Such changes include providing shade where possible, rescheduling sporting events away from midday hours to avoid peak exposures, and reducing taxes on sunscreens.

Stratospheric ozone depletion, which is linked to an increase in the UVB radiation that reaches the earth, may exacerbate the skin cancer problem.[27-29] Global policy strategies for ozone preservation began in 1978 by banning of the use of chlorofluorocarbons in aerosol products. The Montreal Protocol of 1987, updated in 1990, calls for the elimination of all aerosol products by the year 2000.[27]

Evaluation

Long-term objectives should include reducing the incidence of melanoma and other skin cancers. Short-term evaluation of sun protection activities should include serial measurements of the rate of intentional sunbathing, frequency of sunburns, attitudes regarding attractiveness of a tan, and use of sun protection measures. Evaluation should assess overall protection measures and then identify those subgroups that are least likely to practice adequate sun protection measures. Studies of various populations in a range of settings (eg, skin cancer screenings, beaches, clinics) note a rate of compliance ranging from 26% to 70% for sunscreen use, with generally higher sun protection practices among women.[30-33] A national overview from a random-digit- dial telephone survey of 2459 white American adults over 16 years of age found that less than 50% of all sunbathers use sunscreen, with compliance lowest in men and persons with lower education levels.[34] Furthermore, less than 50% of sunscreen users reported using the widely recommended SPF 15+, leaving only 25% of sunbathers overall who routinely used the appropriate sunscreen. Special outreach programs may need to target men[35-38] and individuals with lower educational status.

Table 1. Signs and Symptoms of Melanoma ---------------------------------------------------------------------------

ABCD Rule
A = asymmetrical shape B = border irregularity C = color variegation D = diameter greater than 6 mm
Revised Glasgow Seven-Point Checklist*
Major Features:	Change in size of previous lesion or obvious growth of a new lesion Irregular shape Irregular color with a variety of shades of brown and black
Minor Features:	Diameter greater than 7 mm Inflammation Oozing, crusting, or bleeding Change in sensation

* Reprinted with permission from Higgins EM, Hall P, Todd P, et al. The application of the seven-point check-list in the assessment of benign pigmented lesions. Clin Exp Derm. 1992; 17:313-315. ---------------------------------------------------------------------------

Programs in Other Nations

For the last several decades, Australian officials have used public media messages targeting schools, peers, and family for prevention.[16,17] The SunSmart educational programs in Victoria sparked significant increases in use of sunscreens and hats (and concomitant decreases in rates of sunburns) among a cohort of 4428 adult residents (1988 through 1990).[17] Women, particularly adolescents and young adults, experienced positive changes in sun protection knowledge, attitudes, and behavior,[16] and fewer adults now value a suntan.[16] Also, a significant proportion of Australians now recognize the public service announcement of "Slip! Slop! Slap!" (ie, slip on a shirt, slop on a sunscreen, slap on a hat). Australian fashion magazines have featured greater hat use and fewer models with tans since 1982. In the past decade, the sale of sunscreens, especially those of SPF 15 or greater, has increased strongly.[16]

Other nations have developed nationally sponsored recommendations for skin cancer control, with emphasis on a reduction in UV exposure. In the fall of 1994, Health Canada, Environment Canada, the Canadian Cancer Society, and more than 24 organizations met to develop consistent and unified messages on reducing health risks from UV radiation.[12]

Public and Professional Education

Compared with other cancers, early detection of melanoma should be easier since "melanoma writes its message in the skin with its own ink and is there for all to see."[39] Public education campaigns should emphasize the risk factors for melanoma.

A seven-point checklist[40] and the "ABCD" mnemonic, in which "A" represents asymmetry, "B" represents border irregularity, "C" represents varied or dark color, and "D" represents a diameter greater than 6 mm (the size of a pencil eraser) are effective tools in early recognition of melanoma (Table 1). Messages can stress the seriousness of melanoma, as well as its curable nature when found early. More data are needed to ascertain public understanding and awareness of these rules and guidelines.

A number of organizations, particularly the American Academy of Dermatology (AAD), the American Cancer Society, and the Skin Cancer Foundation, have promoted these educational messages. Since 1985, the AAD has publicized skin cancer education and prevention to millions of Americans and free skin screenings for almost three quarters of a million people.[41] The public is informed of the warning signs of skin cancer, the risk factors associated with melanoma, the importance of early detection, and the value of sun protection.[8,41,42] For example, in the United States in May 1992, a total of 238 television stations in more than 150 cities with populations of more than 50,000 people carried skin cancer broadcasts during prime-time news coverage. These messages penetrated all 30 of the top television markets in the United States and reached an estimated 50 million Americans.[8]

In 1995, with support and sponsorship from the CDC, the AAD launched "Melanoma Monday," a public skin cancer self-examination program ("the first day of a lifelong habit of examining your skin"). Preceding this campaign, baseline data documented that only one third of Americans recognized the term "melanoma" as a type of skin cancer, and more than one third did not know any of the early signs of melanoma. Men were less likely than women to closely examine themselves for skin cancer (39% vs 52%, respectively). "Melanoma Monday" media markets reached an estimated 40 to 60 million Americans.[43]

Older persons, particularly men over 50 years of age, experience higher melanoma mortality rates than that of any other American population subgroup.[35] In New Zealand, Australia, and the United Kingdom, melanoma death rates also rank highest in middle-aged and older men.[36-38] While these higher mortality rates may be attributable to biologic factors, middle-aged and older men may require special educational outreach.

Information on the knowledge, attitudes, and practices in older Americans is sparse. In a nationally representative sample of 502 white Americans (50 years of age and older), awareness of skin cancer was relatively high (74% had heard of melanoma), and the major risk factors were widely known, but only 38% believed melanoma was both serious and curable. In addition, skin cancer knowledge and prevention practices were significantly worse among men and individuals with no education beyond high school.[44]

Public education surveys in Canada and Australia show other deficits. In Alberta, Canada (n=3843), only 45% of adult respondents believed that sun exposure affected their cancer risk. Fewer than half of respondents were likely to practice any of the four safe sun habits - wearing hats, using sunscreen, avoiding the sun, and wearing protective clothing.[45] In Australia, where public education efforts are into their second decade, more than 90% of the population have heard of melanoma and believe that it is a serious disease.[16] However, a household survey of 590 Victorian residents found some remaining misconceptions (eg, recognition of moles) about early detection of melanoma. Seborrheic keratoses and squamous cell carcinomas were more likely than early melanoma to be identified as requiring a doctor's attention.[46]

Professional education of medical providers also should be a fundamental component of a melanoma control strategy, as visual screening by a qualified health provider can likely improve early detection.[8] Cockerell et al[47] encourage all physicians' offices to become detection stations for melanoma. However, few data are available regarding skin cancer examinations or instructions regarding detection or sun protection during a routine medical or pediatric visit. In the only study investigating pediatricians' efforts in sun protection counseling to children, Brodkin et al[48] found poor knowledge about risk factors for melanoma and only sporadic counseling on sunlight protection. In addition, minimal skin cancer education currently is provided in American medical schools.

Professional education could augment melanoma case-finding (". . . testing of patients who have sought health care for disorders that may be unrelated to their chief complaints. The encounter is initiated by the patient and the purpose here is a comprehensive assessment of health.").[49] Only an estimated 14% to 25% of melanoma is discovered by a physician at a time when the patient had not noticed anything wrong.[50-52] This percentage can be improved since people at risk for melanoma appear to be integrated into the health care system. An analysis of 216 newly diagnosed melanoma patients in Massachusetts documented extensive contact with physicians in the year prior to diagnosis - 87% had regular physicians and 63% were examined in the year prior to diagnosis. However, only 24% of cases had examined their own skin prior to diagnosis, and only 20% reported physician skin examinations.[53]

Some skin cancer teaching materials provide specific instruction for health professionals. Guidelines teach that melanoma should be considered in the differential diagnosis for a patient who reports a new pigmented lesion or a change in color, size, shape, or surface of an existing mole, especially a rapid enlargement, the development of a raised area on a previously flat lesion, or scaling, ulceration, crusting, or bleeding.[9] In Scotland, documentation of thick melanomas presumably linked to prolonged delay in presentation led to educational programs for general practitioners and the public.[54] The Revised Glasgow Seven-Point Checklist for general practitioners can complement the ABCD rule.[40,55] Early detection programs in western Scotland featured "An Illustrated Guide to Early Malignant Melanoma," a pamphlet that was distributed broadly to internists and general practitioners.[54] From 1985 through 1990, the incidence rate of thick melanomas (more than 1.5 mm) decreased, and mortality appeared to decrease for women but not for men.[56] Similar teaching guides have been developed for physicians in the United States.[57] Physicians have been advised to routinely examine the backs of at- risk individuals, a common site for men (at least one third of all lesions[58]) often associated with poorer survival.[59]

Nurses also can facilitate skin cancer prevention and detection. However, in a survey of 178 nurse practitioners, oncology nurses, and dermatology nurses, Maguire-Eisen et al[60] found that time constraints and inadequate knowledge limited the frequency and accuracy of skin assessment. Bolognia et al[61] compared dermatology nurses and dermatologists for screening accuracy of skin cancer and found that nurses missed few lesions but "overdiagnosed" many. More research is needed to identify the strengths and limitations of nurse participation in screening programs. Early detection by other allied health professionals should be beneficial, but further studies are needed to test their ability to detect early melanoma.

Early Detection

Definition of success of a program for early detection of melanoma ideally should be based on a randomized trial that demonstrates a sustained reduction in the melanoma mortality rates in a defined population compared with a control population.[8,62] However, developing, implementing, and evaluating such trials, especially for screening, pose logistic challenges that involve randomizing and following hundred of thousands of subjects for years at a cost of millions of dollars.[8,62] In addition, a definitive case control study is not feasible until the screening exposure becomes more prevalent.[63]

In the meantime, tracking intermediate- or short-term outcome measures could serve as an indicator of future progress.[8,62] In the absence of randomized screening trials or case-control studies, the AAD programs for screening and early detection offer the only data for evaluation. These programs, which have provided free skin examinations by dermatologists to almost 750,000 Americans from 1985 through 1994,[41] qualify as "mass screening," ie, screening activities of a large segment of the public.[8,63]

AAD activities join screening with education to create a coordinated early detection effort. As Morrison[63] notes, "publicity efforts for cancer control have now given large numbers of well people advice as to when and how they should be examined for various diseases during their early, asymptomatic phases." Education and screening are especially entwined in a cancer that is as uniquely visible as skin cancer. Experts debating the nuances of the definitions of skin cancer screening generally agree that the unique external and visible nature of skin cancer blurred the distinction between screening and education and in fact made them inseparable.[62] More importance was given to whether the program resulted in earlier detection and decreased mortality.[62]

Table 2. International Skin Cancer Screening Recomentations ---------------------------------------------------------------------------

Organization	Recommends General Population Screening	Recommends Screening for High-Risk Persons Only	Does Not Recommend Screening of General Population
American Cancer Society*	X
National Cancer Institute	X
American Academy of Dermatology	X
National Institutes of Health Consensus Development Panel on Early Development Melanoma (1992)	X
United States Preventive Services Task Force		X
Canadian Task Force on the Periodic Health Examination		X
Australian Cancer Society			X
International Union Against Cancer			X
* guidelines

---------------------------------------------------------------------------

Preliminary studies in Massachusetts found that of the at-risk populations attending the AAD screening programs, more than 86% had at least one risk factor, and 78% had at least two risk factors.[64] Screening programs in Rhode Island demonstrated similar results.[65] People who attended screenings in New Zealand had greater risks for skin cancer than the general population, with more than half of participants reporting at least one changing mole over the last 12 months.[66] Screening programs must continue to target high-risk individuals who have the greatest risk of death from melanoma and to identify which educational messages stimulate appropriate concern.

AAD programs for early detection and skin cancer screening appear to detect early melanoma (almost 99% of all screen-detected melanomas are stage I and stage II), with stage and thickness comparing favorably with those of the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry. Of 195,660 people screened in 1992 through 1993 AAD national programs, a minimum of 261 melanomas were confirmed in 257 individuals; only 8.6% of AAD cases were advanced melanoma (metastatic disease, regional disease, or lesions equal to or greater than 1.51 mm in depth) compared with 16.3% of cases in the population-based SEER registry.[8] Screening yield was highest for men 50 years of age and older (a rate of 247 per 100,000). Thirty- six percent of those with confirmed cases would not have seen a physician without the screen.[67] However, self-selection bias and other screening biases exist,[8] and no projections about reduced mortality from screening are possible from these analyses.

Few studies of screening programs have been conducted within defined populations. In western Australia in 1987, 4176 persons aged 40 to 64 years of age (76% of all similarly aged adults in the electoral district) received total body dermatologic examination. Of the 39 suspected melanomas, 12 were pathologically confirmed. An additional six melanomas were detected in persons with a clinical finding of basal-cell carcinoma.[68]

Analyses of the benefits and costs (including increased workload) of skin cancer screenings have just begun and require further investigation. Brandberg et al[69] in Sweden found no extra psychological distress incurred as a result of screening attendance. In the United States, Freedberg et al[70] used AAD data to estimate that screening high-risk patients was likely to be associated with an increase in quality-adjusted life expectancy. The cost effectiveness of skin cancer screening also compared favorably with other major cancer screening activities.[70]

International Skin Cancer Screening Recommendations

With no data from controlled trials, public health recommendations for skin cancer screening remain diverse (Table 2).[8,55,62] In the United States, Healthy People 2000 recommendations call for skin examinations for at least 40% of people aged 50 years and older who visited a primary care provider in the preceding year.[71]

The American Cancer Society and the AAD have endorsed and published methods for self-screening, although no published evidence to demonstrate its efficacy is available to date. A population-based case control study in Connecticut currently is evaluating whether self-examination reduces mortality from cutaneous melanoma.[72]

Targeted screening also may need to concentrate on individuals with atypical moles and dysplastic nevi. Surveillance of these high-risk patients, together with patient education, has resulted in early discovery of melanoma. MacKie et al[73] followed 116 patients, each of whom had three or more clinically atypical nevi, for a minimum of five years. Of 85 patients with atypical nevi but no personal or family history of melanoma, five cases of melanomas were diagnosed. Compared with the expected number of melanomas (0.054), they found a relative risk of 92 (95% CI 30-215). Masri et al[74] and Vasen et al[75] also found thinner melanomas in the surveillance of family members of melanoma patients in Philadelphia and The Netherlands, respectively.

Future Directions

In the United States, the CDC Division of Cancer Prevention and Control has launched an initiative to coordinate skin cancer control nationally, similar to efforts for breast cancer and cervical cancer.[8] A recent national consensus conference attempted to define a national skin cancer control agenda.[10] Panel workshops comprised of experts on skin cancer and public health developed recommendations to the public regarding UV exposure, risk factors, self- screening, and professional recommendations to practicing physicians, nurses, and allied health professionals.

The United Kingdom White Paper, The Health of the Nation (1992), raised as an objective a reduction of the ill health and death caused by skin cancer.[11] Melia et al[11] called for a nationally coordinated, multidisciplinary approach to stem the increasing incidence and mortality rates of melanoma by educating the public, modifying sun exposure, and promoting early detection of cancers.[11] In Sweden, the Stockholm Cancer Prevention Program has developed strategies to establish sun protection curricula within traditional networks of child health and preschool services, schools, colleges of nursing science, and the Federation of Swedish Pharmacists.[13]

Conclusions

During the past few decades, scientists from the fields of dermatology, public health, behavioral science, epidemiology, medicine, oncology, immunology, and nursing, among others, have worked together to promote skin cancer prevention and control. Recent analyses in the United States and Sweden suggest the potential of a future downward trend in melanoma death rates.[76-78] Future multidisciplinary efforts and multiple strategies will be necessary to combat the increasing incidence and mortality of melanoma. Ongoing collaborative work and the inclusion of skin cancer agendas in national health care programs and planning hold promise as strategies to improve early detection and save lives.

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