Follow-up program helps detect melanoma earlier in high-risk patients

A follow-up program for patients at high risk of developing skin cancer appears to be associated with the detection of melanomas at early stages and with good prognosis, according to a report posted online today that will appear in the May print issue of Archives of Dermatology, one of the JAMA/Archives journals.

Efforts to improve melanoma prognosis have focused on identifying and closely monitoring individuals at high risk, according to background information in the article. 'Fair-skinned persons, persons who tan with difficulty, blond or red-haired persons and persons with blue eyes have more risk of developing melanoma than the general population,' the authors write. 'The presence of many pigmented lesions, including freckles and clinically typical or atypical nevi; intermittent sun exposure and severe sunburns, especially during childhood; and exposure to artificial UV-A radiation have all been associated with an increased risk of melanoma.' Individuals with a personal or family history of melanoma are also at high risk.

Dermoscopy - a noninvasive diagnostic technique in which a clinician performs a microscopic evaluation of a skin lesion - improves the accuracy of melanoma diagnoses, the authors note. Gabriel Salerni, M.D., of Hospital Clinic of Barcelona, Institut d'Investigacions Biomediques August Pi I Sunyer, Barcelona, and colleagues analysed data from 201 patients diagnosed with melanoma in one specialised unit, including 40 who were in a follow-up program for high-risk individuals and 161 who were referred for evaluation by another clinician. All melanomas diagnosed among these patients were evaluated by dermoscopy.

Most of the melanomas diagnosed in the follow-up program did not match clinical or dermoscopic features characteristic of melanoma. For example, only 12 percent fulfilled all four ABCD criteria outlined for melanoma detection - asymmetry (A), uneven borders (B), colours (C) and differential dermoscopic structures (D). This compares with 63.6 percent of the melanomas detected among individuals referred to the institution but not in the follow-up program.

In addition, 70 percent of melanomas diagnosed in the follow-up group were in situ (had not spread beyond the initial site), compared with 27.9 percent of those in the referred group. The Breslow index - a measure of tumour thickness - was also lower among the melanomas diagnosed through the follow-up program. The follow-up cancers also tended to be diagnosed at earlier stages: 70 percent were diagnosed at stage zero and 30 percent at stage IA. Among the referral group, 27.9 percent were diagnosed at stage zero, 37.6 percent at stage IA, 12.7 percent at stage IB, 10.9 percent at stage II, 8.5 percent at stage III and 2.4 percent at stage IV.

'The inclusion of patients who are high risk for melanoma in follow-up programs allows the detection of melanoma in early stages, with good prognosis, even in the absence of clinical and dermoscopic features of melanoma,' the authors conclude. 'In the general population without specific surveillance, melanoma continues to be diagnosed at more advanced stages. Our findings suggest that current efforts in public and medical education might have no substantial effect in this group. Further strategies and educational programs may be needed to improve the early detection of these lesions. We believe that high-risk individuals, whenever proper resources are available, should be referred to melanoma centres or qualified institutions for regular follow-up.'