Editor's note: This is the first installment of a 2-part series.
Does screening people for skin cancer save lives? Results of pilot study conducted in Germany and published in Cancer last fall seem to indicate that it does—by as much as a 47% reduction in mortality. Yet, will widespread screening ever occur in the United States?
Alan Geller, MPH, RN, senior lecturer in the department of social and behavioral sciences at Harvard School of Public Health in Boston, Massachusetts, certainly hopes so. As coauthor of the study and cochair of the International Task Force on Skin Cancer Screening and Prevention, Geller, along with fellow cochair and study coauthor Martin Weinstock, MD, PhD, professor of dermatology at Brown University in Providence, Rhode Island, has been closely involved with developing the study, as well as a larger screening trial currently ongoing in Germany. While other common cancers such as breast, prostate, and cervical have all experienced substantial declines in mortality, melanoma has not, and Geller and his colleagues are hoping to reverse that trend.
The initial study, conducted in the German state of Schleswig-Holstein, from July 1, 2003, to June 30, 2004, screened 360,288 people aged 20 years and older by whole-body examination. The authors of the study, known as Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany (SCREEN), compared trends in melanoma mortality in Schleswig-Holstein with those in adjacent regions and other areas in Germany that did not have skin cancer screening. Melanoma mortality in Schleswig-Holstein declined by 47% to 1.0 per 100,000 men and by 49% to 0.7 per 100,000 women by 2008 to 2009, most likely because the lesions that were found were thinner and therefore easier to treat. In each of the adjacent regions and in the rest of Germany, mortality rates were stable.
Although Geller calls those results “very promising,” he and others are eagerly awaiting the results of a nationwide skin cancer screening trial in Germany that began in January 2008 and has already screened more than 20 million people. That trial is offering full-body screenings to people aged 35 years and older, but Geller anticipates results will not be available for a few more years. “Even if that trial showed half the mortality reduction of the Schleswig-Holstein trial, that amount would still be considered substantial,” says Geller.
Because melanoma needs to be found early to have the best rates of treatment, skin cancer screening should have a strong recommendation from the US Preventive Services Task Force (USPSTF) before it can be recommended in the United States on a large-scale basis, Geller says. Currently, the USPSTF rates the evidence as “insufficient to assess the balance of benefits and harms of using a whole-body skin examination by a primary care clinician or patient skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population,” according to its summary of recommendations. These recommendations would need to be changed to a grade A or B recommendation in order to see much broader scale screening, says Geller.
In addition to showing a significant decline in mortality, researchers also would need to show that the costs and potential harms from screening do not outweigh the benefits, he says. Among the questions that need to be answered are how many people need to be screened and number of biopsies performed to save 1 life, how much anxiety is created by screening results, and how much morbidity occurs, Geller says.
“This is the first real evidence to suggest what we all feel to be true,” says Sancy Leachman, MD, PhD, chair of dermatology at the Oregon Health and Science University in Portland. “But the data needs to be replicated in the United States because we have a very different medical system.”
In Germany, for example, which has a more socialized medicine system, screenings can be mandated. The United States has a much more independent system in which providers like to tailor treatment to the individual, says Dr. Leachman.
Meanwhile, John Kirkwood, MD, vice chairman for clinical research at the University of Pittsburgh School of Medicine in Pennsylvania, is working on a program that he and others hope will help validate the Schleswig- Holstein study results. Although that study is promising, it was not a randomized, controlled trial, he says. “There has not been a prospective study in a relatively closed system that has shown you can reduce melanoma mortality,” he says. Although details of this study have yet to be completely finalized, Dr. Kirkwood says he has strong support from both the University of Pittsburgh and its health plan. “We will be able to identify who did and did not receive screenings, and which physicians received the education on how to do the screenings,” he says. “We hope it will help fuel mandated screening in our country.”
If the USPSTF were to change its recommendation to an A or B grade, under the current strong prevention focus of President Obama's health care program, insurers would be instructed to begin reimbursing for full-body skin examinations, Geller says.
In anticipation of that possibility, Dr. Weinstock has developed the INFORMED (INternet curriculum FOR Melanoma Early Detection) Web-based training program that is teaching primary care physicians across the country how to conduct full-body skin examinations. Dr. Kirkwood's study in Pittsburgh would incorporate this training method.
In addition, Geller and his colleagues are conducting a study at 8 medical schools across the country, called the Integrated Skin Exam study, which is testing whether medical students receiving an educational video and a series of boosters learn how to perform more effective skin cancer examinations than students who receive only a video, or those who receive neither. “We'd like to be in a position where we have a fully trained physician workforce to do skilled skin exams if and when screening becomes reimbursable,” says Geller.
Dr. Leachman, meanwhile, hopes that the potential promise of widespread skin cancer screening is “just the tip of the iceberg.”
Part 2 of this article, which will appear in the July 15 issue, will look at the use of sentinel lymph node biopsies in diagnosing melanoma.
Melanoma Organization Continues to Pursue Tanning Salon Bans
The effort to ban indoor tanning by minors has a champion in Valerie Guild. And, for her, the fight is personal. Guild, president of the nonprofit organization AIM at Melanoma, lost her daughter Charlie to melanoma in 2003, 9 months after she was diagnosed with stage IV disease at the age of 25. Although Charlie was not an indoor tanner, she still was cut down in the prime of her life—something Valerie hopes to see others avoid. “Pediatric melanoma is rising at the rate of 2% per year, and the rate of the disease among young women is twice that of young men,” Guild says. “It's not just a disease of old, white men anymore.”
According to AIM at Melanoma, nearly 30 million people in the United States tan indoors annually, including 2.3 million teens. At the same time, melanoma rates among young women have soared 50% since the 1980s, corresponding to the growth of the indoor tanning industry.
The World Health Organization, which has classified tanning beds as a level 1 carcinogen, recommends that their use be restricted for anyone under the age of 18 years, whereas the American Cancer Society recommends everyone avoid tanning beds altogether. Several countries, including England and Wales in the United Kingdom, have banned teen indoor tanning, and Brazil banned tanning beds for cosmetic purposes for the entire population. Currently, California and Vermont ban the use of tanning beds for individuals under the age of 18, and at least 33 states regulate the use of tanning facilities by minors, such as requiring parental permission. Some counties and cities also regulate the use of tanning salons.
AIM at Melanoma has helped spearhead the effort to get legislation to restrict tanning salon usage by teens introduced and passed in various states. Utah, for example, passed legislation that went into effect last year requiring parental permission for those under 18 years to use an indoor tanning salon.
Sancy Leachman, MD, PhD, chair of dermatology at the Oregon Health and Science University in Portland, was involved in the effort to pass the legislation when she served as director of the melanoma and cutaneous oncology program at the University of Utah's Huntsman Cancer Institute in Salt Lake City. “The jury's still out on how successful this will be, but if nothing else, it increases awareness,” says Dr. Leachman.