"The significant increase in melanoma incidence in the U.S., particularly thin melanoma, without a concomitant decrease in melanoma mortality, raises the concern that early detection efforts, such as visual skin screening, may result in... the detection of indolent lesions that would not have progressed to fatal melanoma prior to being detected by routine care," the authors of a new study wrote in JAMA Dermatology.
The University of Pittsburgh Medical Center (UPMC) began a primary care screening initiative in 2014; participating clinicians received training in melanoma identification by skin examination and were encouraged to offer annual screening to patients 35 years and older.
The current study reports outcomes from the first five years of the program. The main outcome was the thickness of melanomas diagnosed in screened and unscreened patients.
Among close to 600,000 screen-eligible patients, 24.3% were screened at least once. Screened patients were older (median age, 59 vs. 55), and more likely to be female (56.8% vs. 55.6%) and non-Hispanic White (86.1% vs. 83.4%) than unscreened patients.
After adjustment for age, sex, and race, screened patients were more likely than unscreened to be diagnosed with in situ melanoma (incidence, 30.4 vs, 14.4; hazard ratio, 2.6) or thin invasive (1 mm or less) melanoma (incidence, 24.5 vs. 16.1; HR, 1.8).
Screened patients also were more likely to be diagnosed with in situ interval melanomas (incidence, 26.7 vs. 12.9; HR, 2.1) or thin invasive interval melanomas (incidence, 18.5 vs. 14.4; HR, 1.3). Interval melanomas are those diagnosed at least 60 days after an initial screening examination.
The incidence of melanoma thicker than 4 mm in unscreened and screened patients, respectively, was 3.3 and 2.7 (HR, 0.8) for all melanomas and 2.7 and 1.5 (HR, 0.6) for interval melanomas.
"Our study is unique in that we looked at the relationship between screening and the later development of thick melanoma," Dr. Laura Ferris of UPMC told Reuters Health by email.
There was a downward trend in thick melanomas in screened patients, she noted, "but this was not statistically significant, so it is hard to draw firm conclusions about the meaning of these findings. These very deadly melanomas are also relatively rare, so larger studies may be needed to determine if screening does reduce the incidence."
Dr. Ferris said, "Ultimately, we screen in the hope of preventing melanoma deaths while causing the least harm to the patient. If we can reduce the number of people who will be treated with effective but expensive drugs that carry risk, such as checkpoint inhibitors, then that is a benefit of screening, too."
Two editorials accompanied the study, and authors of both commented in emails to Reuters Health.
Dr. Robert Swerlick of Emory University, sole author of one editorial, said, "The most important message that I want to convey to clinicians is that despite the broad acceptance that untargeted skin cancer screenings and skin checks prevent melanoma deaths, there is virtually no evidence to support this."
"In the absence of demonstrable clinical benefit to patients, these practices deliver only harm," he said. "We need to re-evaluate what we communicate to the public, what we tell our trainees, and what we define as best clinical practices. I understand this will be incredibly difficult to walk back on what we have been saying and doing for more than 50 years."
Dr. Sancy Leachman of Oregon Health and Science University in Portland, coauthor of the other editorial, said, "It is not sufficient to evaluate the consequences of screening without also evaluating the consequences of NOT screening. The failure to diagnose early is important, probably more important than overdiagnosis in the case of melanoma."
"If I had anything that looked like a melanoma, I would be more than willing to have a scar from the removal even if the chance the lesion would kill me was very low," she said. "The benefit of saving my life is worth the risk of removing a spot that didn't need to go."
"But when you look at whole populations, the picture becomes a little less clear," she acknowledged. "How many unnecessary diagnoses are we willing to accept to save one life? Ten, 500, 100,000? Balancing benefits and harms is key."
"We need to focus on risk stratification," she said. "This will catch the largest number of lethal melanomas possible, while minimizing the harm to people who are unlikely to have a lethal melanoma. But even low-risk individuals can occasionally get a deadly melanoma, and choosing to screen only high-risk individuals will lead to greater death in the low-risk population."
"Teaching all people to look at their own skin is also part of the solution," she added. "If everyone did a self- or partner-skin exam every month or two, and then had anything unusual checked by a provider, most melanomas could be detected earlier, with better outcome."
SOURCE: https://bit.ly/3JuqYcU, https://bit.ly/3LXk7KD and https://bit.ly/3uyTCoN JAMA Dermatology, online April 6, 2022.
By Marilynn Larkin
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