Archive for May, 2012
This was reported by Reuters this week from Archives of Dermatology:
Screening finds skin cancer, but does it save lives?
Thursday, May 24, 2012
By Andrew M. Seaman
NEW YORK (Reuters Health) – 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.
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.
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.
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 (see Reuters Health story of May 7, 2012.)
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.
SOURCE: http://bit.ly/Ju1EQV Archives of Dermatology, online May 21, 2012.
This was in the news today (nineMSN):
Some Australians are still ignoring warnings to have their skin regularly checked by professionals, a survey has found.
The national survey of about 1500 Australians who bought sunscreen found about half – 48 per cent – had not had their skin checked by a medical practitioner in the past five years.
Generation Y were the worst offenders with 64 per cent failing to get their skin checked for abnormalities in the past five years, the survey by consumer researchers Canstar Blue found.
However, about 40 per cent had been to a doctor in the past year for a skin checkup.
Fifty-eight per cent of survey respondents performed their own skin checks once a month and baby boomers were the most vigilant, with about 66 per cent of people in this age group regularly checking their own skin.
Meanwhile, about one in five respondents ignored the slip, slop, slap message and had been sunburnt severely in the past year.
Cancer Council Australia’s Skin Cancer Committee chair, Terry Slevin, said that how often people should visit their doctor for skin checks depended on their skin type, skin cancer risk and history, and sun exposure in childhood.
He said some people would need to be checked more than once a year.
According to the Cancer Council, men are the least likely to be vigilant about their skin.
“All our data tells us that the main culprits who aren’t doing the right thing when it comes to early detection of skin cancer is blokes,” Mr Slevin told AAP.
He said people should have a discussion with their GP about how regularly they should get checked.
About 1800 people die from skin cancer in Australia every year, he said.
The survey results were drawn from 1443 people who had bought sunscreen in the past six months.
The survey was based on market research commissioned by Canstar Blue, which tracks consumer satisfaction.
Aspirin May Cut Melanoma Risk
I have previously touched on this before
Thanks to Dr Dowling for bringing this to my attention.
Society for Investigative Dermatology
Source reference: Gamba C, et al “Aspirin is associated with lower melanoma risk in a cohort of postmenopausal women in the Women’s Health Initiative (WHI)” SID 2012; Abstract 236.
By Charles Bankhead, Staff Writer, MedPage Today
Published: May 14, 2012
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and Dorothy Caputo, MA, BSN, RN, Nurse Planner
This study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
An observational study from the Women’s Health Initiative found that postmenopausal women reporting that they take aspirin had a significantly reduced risk of melanoma over 11 years of follow-up compared to non-aspirin users.
Note that taking other nonsteroidal anti-inflammatory drugs (NSAIDs) was not associated with risk of developing melanoma.
RALEIGH, N.C. — The risk of malignant melanoma declined by more than 20% in women who reported using aspirin, a new analysis of the Women’s Health Initiative (WHI) showed.
In addition to the overall benefit, increasing duration of aspirin use was associated with even larger risk reductions, such that women who reported using aspirin for 5 years or more had a 30% lower risk of melanoma compared with nonusers.
Use of non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) did not significantly influence the risk of melanoma, Carol Gamba, BS, reported here at the Society for Investigative Dermatology meeting.
“We found that any use of aspirin was associated with a lower risk of melanoma overall, but also offered greater protection with greater duration of use,” said Gamba, of Stanford University in Stanford, Calif.
“Women who reported any aspirin use had a 21% reduction in the risk of melanoma,” she added.
Observational studies have shown significant associations between use of NSAIDs and lower risks of gastric, colorectal, and breast cancer. Trials of aspirin intervention, as well as meta-analyses of the trials, have demonstrated significant reductions in cancer incidence, metastasis, and cancer mortality in patients taking aspirin, said Gamba.
Epidemiologic studies and clinical trials have yielded inconsistent data regarding associations between NSAID use and melanoma.
NSAIDs, including aspirin, are thought to exert anticancer effects by disrupting signaling in the cyclooxygenase (COX) pathway, and more specifically pro-inflammatory COX-2. Moreover, laboratory studies have shown COX-2 levels correlate with melanoma progression and survival, said Gamba.
The WHI provided a large database for continuing the investigation of potential associations between NSAIDs and melanoma. At study entry, WHI participants provided a large amount of information relevant to their medical history, including medication use.
WHI participants were asked to identify all medications they had taken at least twice a week during the 2 weeks before enrollment, including nonprescription medications. From this information, Gamba and colleagues extracted data about the type, name, frequency, and dosage of NSAIDs the women used, as well as duration of use.
The NSAID analysis included 59,806 WHI participants, all of whom were postmenopausal at entry to the study. Baseline responses showed that 25% of the women used aspirin, 15% used other NSAIDs, and 59% used neither.
Follow-up in the three NSAID-use categories averaged 11 to 12 years. During follow-up, the study participants had 548 new melanoma diagnoses, consisting of 289 in situ lesions and 259 lesions that were invasive at diagnosis.
Separation of all melanoma cases by NSAID category showed that aspirin users accounted for 115 of the cases, other NSAID users for 89, and women who reported no NSAID use accounted for 344 new cases. After adjustment for a variety of demographic and clinical variables, the aspirin group had a 21% lower risk of melanoma compared with nonusers (P=0.01).
The analysis also showed a significant effect of duration of aspirin use on melanoma risk. After stratifying aspirin users into tertiles (<1 year, 1 to 4 years, ≥5 years), the investigators found that each progression to the next highest category was associated with an 11% reduction in melanoma risk, topping out at 30% for the highest-use category.
Gamba pointed out that a negative clinical trial of aspirin to prevent melanoma used low-dose (100 mg) aspirin, whereas 75% of the aspirin users in the WHI analysis used full-strength aspirin.
A different picture emerged from the analysis for users of other NSAIDs. WHI participants who reported any NSAID use had a melanoma risk similar to that of study participants who did not use aspirin or NSAIDs. In contrast to the data for aspirin, increasing duration of other NSAID use did not affect the relative risk, said Gamba.
A separate analysis of women who reported using acetaminophen — a pain reliever that does not inhibit COX-2 — showed no effect on melanoma risk.
Gamba acknowledged the inherent limitations of retrospective and observational studies and of relying on self-reported information from patients. She also pointed out that the findings apply to a population of white, postmenopausal women.
This article is in press in JAAD. I believe it highlights two points, firstly that concordance between biopsies and excisions in only 62% and, secondly, that subtype was best predictor of depth.
Pretreatment risk stratification of basal cell carcinoma (BCC) is largely based on histologic subtype reported from biopsy specimens.
We sought to determine the degree of concordance between characteristics identified on biopsy specimen and excision and to determine if histologic characteristics other than subtype correlated with depth of invasion.
Histologic specimens of 100 BCC biopsy specimens and corresponding excisions were reviewed. Anatomic site, histologic subtype, maximum depth of extension, contour of the lobules at the leading edge, elastosis characteristics, presence of necrosis, calcification, and ulceration were recorded. Concordance between biopsy specimens and their excisions with relation to depth of tumor lobules was analyzed.
The concordance between the subtype of biopsy specimen and excision was 62%. Micronodular tumors had the greatest mean depth, followed by infiltrative, nodular, and superficial subtypes. Subtype reported from biopsy specimen (P = .0002) and excision (P < .0001) correlated to depth and was superior to age, contours of excision specimens, the presence of necrosis, and the extent of excisional solar elastosis. Gender, anatomic site, contours of biopsy specimens, elastosis color, elastosis type, the presence of ulceration, and calcification did not correlate with depth.
Selection bias is present as only standard excisions were included; BCCs treated by other methods were not examined.
BCC subtype identified on biopsy specimen may not correlate with subtype identified on excision. Morphologic subtype has the highest correlation with depth and reporting should reflect the highest risk growth pattern if a biopsy specimen contains more than one pattern. Consideration should be given to reporting necrosis and degree of solar elastosis.
Women diagnosed with melanoma are more likely to survive the skin cancer than men and less likely to have it recur, according to a European study.
The findings, published in the Journal of Clinical Oncology, support research showing that women are less likely to die from melanoma, the deadliest of the skin cancers.
Researchers suggested that biological differences between the sexes might influence how the body deals with the cancer, although a definitive explanation on the better outcome for women remains uncertain. Lead author Arjen Joosse and his team looked at four clinical trials that melanoma patients had joined.
The more than 2 600 study participants were followed for two to 12 years. Over time, 366 of the men and 267 of the women died.
This meant women were 30 percent less likely to die from any cause during the time studied, and nearly 30 percent less likely to die from the melanoma than men.
They were also 30 percent less likely to have a relapse.
Earlier studies had hinted that behaviours explained the differences between men and women – such as women being perhaps more likely to visit their doctor after noticing changes on their skin, and being diagnosed with cancer earlier as well as having thinner tumours.
But even when the researchers took into account the thickness of the tumours, they found that women had a 30 percent advantage over men in the progression of the disease. “Once somebody has melanoma, we believe that men and women deal with it differently,” said Vernon Sondak, chair of the department of Cutaneous Oncology at Moffitt Cancer Center.
The obvious potential explanation was oestrogen, Joosse said – but if oestrogen was responsible, then post-menopausal women, who have low oestrogen levels, should have a smaller advantage over men in their age group than younger women have over younger men. – Reuter