Screening finds skin cancer, but does it save lives?
Gerald Hurowitz, M.D.·Published 25 May 2012·9 min read
Key points
Doctors find a high number of malignant tumors when a state-wide skin cancer screening program is introduced, says a new study.
For the study, the researchers examined data from the Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany (SCREEN) program, which was conducted in the German state of Schleswig-Holstein between 2003 and 2004.
Some people decided to see a dermatologist while others went to a general practitioner who referred them to a dermatologist if they suspected skin cancer.
- One person dies of melanoma every hour (every 62 minutes).
Doctors find a high number of malignant tumors when a state-wide skin cancer screening program is introduced, says a new study.
Based on results from a program in Germany, researchers say 116 people need to be screened for skin cancer and five people need to have a biopsy to find one malignant tumor.
They, however, cannot say whether the screenings actually saved lives.
Still, the numbers reported in the new study are "quite good," said Dr. Alexander Katalinic, one of the study's coauthors, in an email to Reuters Health.
In the United States, the last time the government-backed U.S. Preventive Services Task Force (USPSTF) looked at the screenings in 2009, the group said there was not enough evidence to recommend full-body exams to check for signs of skin cancer in adults. The USPSTF, however, did not recommend against it either.
Dr. Virginia Moyer, the chair of the USPSTF, said the group reviews its guidelines every few years, and as for now its 2009 recommendation stands.
SOME FALSE POSITIVES
For the study, the researchers examined data from the Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany (SCREEN) program, which was conducted in the German state of Schleswig-Holstein between 2003 and 2004. (Germany has had a national skin cancer screening program in place since July 2008.)
More than 360,000 people older than 20 years old and living in the state chose to be screened by doctors who went through a special training to identify suspicious skin lesions or moles.
Skin cancer is the most common form of cancer in the United States. In the United States in 2008, 59,695 people were diagnosed with melanomas of the skin, and 8,623 people died from it.† CDC leads national efforts to reduce skin cancer through education. When in the sun, seek shade, cover up, get a hat, wear sunglasses, and use sunscreen.
More than 45,000 cases of melanoma occurred in 45 states and the District of Columbia each year between 2004 and 2006, according to the report. Melanoma is the deadliest type of skin cancer, causing about 8,000 deaths in the U.S. each year.
Significant Findings
- Deaths caused by melanoma accounted for $3.5 billion in lost productivity each year. - A person who died of melanoma between 2000 and 2006 died 20 years prematurely, compared to 17 years from other cancers. - Melanoma rates were higher among white, Hispanic females aged 50 and younger, and Asian/Pacific Islander females aged 40 and younger, compared to their male counterparts. This study also found that Hispanics, American Indians/Alaska Natives, and Asians were diagnosed with melanoma at younger ages than whites and blacks.
Written and revised by
Gerald Hurowitz, M.D.
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- Melanoma incidence was higher among females than males, increased with age, and was higher in non-Hispanic whites than Hispanic whites, blacks, American Indians/Alaska Natives, and Asians/Pacific Islanders.
- In 2005, 34% of adults had been sunburned in the past year, and in 2004, 69% of adolescents were sunburned during the previous summer.
- Doctors are required by law to report melanomas to central cancer registries, but many dermatologists reported being unaware of reporting requirements.
Some people decided to see a dermatologist while others went to a general practitioner who referred them to a dermatologist if they suspected skin cancer.
Overall, about 16,000 people had a biopsy - about one for every 23 people who were screened. Doctors identified about 3,100 malignant tumors from those biopsies.
The cost for each screening is about $27. A biopsy can run over $100, and the removal of a malignant skin lesion can cost about $800.
The researchers cannot say how many screenings led to an unnecessary biopsy or treatment, because of the program's design. But, Katalinic said "of course there are false positives."
Overall, there were 3,103 malignant skin tumors, and 585 of those were malignant melanomas, the most deadly type.
More than 50 people between the ages of 20 and 49 years old had to have a biopsy to identify one melanoma. That's more than double the 20 biopsies needed to find one in people over 65 years old.
MELANOMA
- One person dies of melanoma every hour (every 62 minutes).
- One in 55 people will be diagnosed with melanoma during their lifetime.
- Melanoma is the most common form of cancer for young adults 25-29 years old and the second most common form of cancer for young people 15-29 years old.
- The survival rate for patients whose melanoma is detected early, before the tumor has penetrated the skin, is about 99 percent. The survival rate falls to 15 percent for those with advanced disease.
- The vast majority of mutations found in melanoma are caused by ultraviolet radiation.
- The incidence of many common cancers is falling, but the incidence of melanoma continues to rise at a rate faster than that of any of the seven most common cancers. Between 1992 and 2004, melanoma incidence increased 45 percent, or 3.1 percent annually.
- An estimated 123,590 new cases of melanoma were diagnosed in the US in 2011 — 53,360 noninvasive (in situ) and 70,230 invasive, with nearly 8,790 resulting in death.
- Melanoma accounts for less than five percent of skin cancer cases,20 but it causes more than 75 percent of skin cancer deaths.
- Survival with melanoma increased from 49 percent (1950 - 1954) to 92 percent (1996 - 2003).
- Melanoma is the fifth most common cancer for males and sixth most common for females.
- Women aged 39 and under have a higher probability of developing melanoma than any other cancer except breast cancer.
- About 65 percent of melanoma cases can be attributed to ultraviolet (UV) radiation from the sun.
- One or more blistering sunburns in childhood or adolescence more than double a person's chances of developing melanoma later in life.
- A person's risk for melanoma doubles if he or she has had more than five sunburns at any age.
- Survivors of melanoma are about nine times as likely as the general population to develop a new melanoma.
Katalinic said, as an epidemiologist, he thinks the number needed to screen or biopsied should be improved, especially among younger people. There were also 1961 basal cell carcinomas, 392 squamous cell carcinomas and 165 were other types of malignant tumors.
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DID THE SCREENING HELP?
The United States' National Cancer Institute says about two million people in the U.S. are treated for basal cell or squamous cell cancers every year. As for melanomas, the American Cancer Society says more than 76,000 people will be diagnosed with one in 2012 and about 9,000 will die from it.
"The main question is do we find the right skin cancers to prevent deaths and morbidity (or costs)," said Katalinic.
Another study Katalinic coauthored reported that there was a significant drop in deaths from skin cancer following the program.
Deaths from skin cancer fell by about 50 percent - to one melanoma death or fewer per every 100,000 people each year. The number of deaths from skin cancer in neighboring regions that didn't do screening remained the same over time.
Skin cancer and ETHNICITY
- Asian American and African American melanoma patients have a greater tendency than Caucasians to present with advanced disease at time of diagnosis.
- Skin cancer comprises one to two percent of all cancers in African Americans and Asian Indians.
- While melanoma is uncommon in African Americans, Latinos, and Asians, it is frequently fatal for these populations.
- As few as 48 percent of melanomas in African Americans are diagnosed at an early stage, compared to 74 percent in Hispanics and 84 percent in Caucasians.
- The overall melanoma survival rate for African Americans is only 77 percent, versus 91 percent for Caucasians.
- Melanomas in African Americans, Asians, Filipinos, Indonesians, and native Hawaiians most often occur on non-exposed skin with less pigment, with up to 60-75 percent of tumors arising on the palms, soles, mucous membranes and nail regions.
- Basal cell carcinoma (BCC) is the most common cancer in Caucasians, Hispanics, Chinese, Japanese, and other Asian populations.
- Squamous cell carcinoma (SCC) is the most common skin cancer among African Americans and Asian Indians.
- Squamous cell carcinomas in African Americans tend to be more aggressive and are associated with a 20-40 percent risk of metastasis (spreading).
- Skin cancer represents approximately 2-4 percent of all cancers in Asians.
- Among non-Caucasians, melanoma is a higher risk for children than adults: 6.5 percent of pediatric melanomas occur in non-Caucasians.
Even that drop, however, could be due to an increased awareness of skin cancer and not the screening itself. The study also didn't look at whether there was a decrease in overall deaths.
"This is terrific information and certainly will be useful," said Moyer of the new study. But, she added, it does not answer the question of whether the screening led to better health outcomes. Also, she said the study could have benefited from a comparison group, who did not get screened.
Moyer said the approach of the SCREEN program may also be a way for the U.S. to solve the problem of there not being enough dermatologists to screen everyone for skin cancer.
Basically, specially trained doctors who are not dermatologists act as gatekeepers and refer patients who have suspicious lesions or moles to dermatologist.
"In terms of feasibility, if it were the case that screening were shown to result in better health outcomes, this would be one possible way to manage that," said Moyer.
Frequency of Excisions and Yields of Malignant Skin Tumors in a Population-Based Screening Intervention of 360 288 Whole-Body Examinations
Results Overall, 15 983 excisions were performed (1 of 23 screenees). A total of 3103 malignant skin tumors were diagnosed in 2911 persons: 585 MMs, 1961 BCCs, 392 SCCs, and 165 other malignant skin tumors. Overall, 116 persons (3103 of 360 288) had to be screened to find 1 malignant tumor, with 1 of 620 for MM, 1 of 184 for BCC, and 1 of 920 for SCC. Twenty excisions were performed to find 1 melanoma in men 65 years and older, but more than 50 excisions were required to find 1 melanoma in men aged between 20 and 49 years.
Conclusions The results of SCREEN suggest a high yield of malignant skin tumors in a large-scale population-based screening project. We found that a high number of excisions was performed in the youngest screenees with an associated low yield, suggesting a need in screener training to emphasize a more conservative attitude toward excisions in young screenees.
To our knowledge, SCREEN is the largest skin cancer screening project implemented worldwide. Although this sample size is substantially larger than those of other studies, we achieved comparable yields, especially for melanoma findings, suggesting that large-scale screening interventions detect a high rate of malignant skin lesions. Herein, we report a high number of excisions for few confirmed skin cancers in young screenees. Future screening activities may, therefore, benefit from improved training of the physicians regarding selection of lesions requiring excision. Specifically, we suggest (1) adapting the training curriculum toward a more conservative attitude toward excisions in young screenees and (2) implementing a formal and tailored feedback system in which quality indicators, such as Yield-S and Yield-E, stratified by age and sex are reported to the nondermatologist physicians and dermatologists. We conclude that these results not only inform current policy makers and the wider research community but can also be used as a comparison for the upcoming evaluation of the national Skin Cancer Early Detection Program that was implemented in Germany in July 2008.
Correspondence: Annika Waldmann, PhD, Institute of Clinical Epidemiology, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160 (Haus 50), 23562 Luebeck, Germany (Annika.Waldmann@uksh.de).
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