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Summary

  1. Top of page
  2. Summary
  3. Literature search
  4. Cutaneous malignant melanoma incidence, survival and mortality in association with socioeconomic status
  5. Association of socioeconomic status with intermittent ultraviolet radiation exposure
  6. Association of socioeconomic status with understanding and knowledge of cutaneous malignant melanoma
  7. Discussion
  8. Remaining questions to be answered
  9. References

Socioeconomic status (SES) is associated with cutaneous malignant melanoma (CMM) in Northern Europe, despite equal access to health care. SES per se is not responsible for this association, which must be ascribed to important risk factors for CMM such as intermittent ultraviolet radiation (UVR) exposure, and screening for CMM possibly owing to a greater knowledge and understanding of CMM. Our review of the literature showed that high SES is associated with increased risk of CMM, thinner tumours, increased survival and decreased mortality from CMM – the latter shown among women, and in recent studies also among men. There is evidence that high SES is associated with sun holidays, whereas low SES is associated with the use of sunbeds. Findings suggest that high SES is associated with the use of physicians and dermatologists for marks and moles, possibly owing to more knowledge and better understanding of CMM. We conclude that there has been a true increase in CMM incidence among high SES individuals in Northern Europe probably due to past intense intermittent UVR exposure, especially in connection with sun holidays. However, the increased risk of CMM and a better outcome of CMM in high SES individuals may also be conditioned by frequent recourse to physicians, which may be ascribed to more knowledge and better understanding of CMM, although more studies on this subject are warranted. Thicker CMM tumours and increased CMM mortality among low SES individuals in recent decades may reflect exposure to intermittent UVR, such as the use of sunbeds, as well as delayed diagnosis.

A positive association of socioeconomic status (SES) with risk of cutaneous malignant melanoma (CMM) has been well known for many years. However, SES per se is not responsible for this association, but must be ascribed to certain risk factors for CMM that are closely associated with SES.

Intermittent ultraviolet radiation (UVR) exposure is considered a major risk factor for CMM.[1-4] The risk of CMM increases significantly with the number of sunburns,[5-8] sun holidays[8-12] and use of sunbeds.[8, 13, 14] In Northern Europe, where incidence rates are high, the largest increase in the incidence has been on the intermittently exposed body parts (limbs and trunk).[3, 15-19] Moreover, a few studies have shown that the association of risk of CMM with SES applies to CMM on the intermittently exposed limbs and trunk.[20-24] Hence, intermittent exposure to UVR, assessed in terms of sun holidays, sunburns and use of sunbeds, could be important causal factors of the association of SES with CMM.

There are disparities in CMM tumour characteristics across SES groups in Northern Europe. The following studies reported data from the late 1970s through the 2000s. In Holland, individuals from the lowest SES group were more often diagnosed with a CMM above 2 mm in thickness (both in percentage of all CMMs within this group and in absolute numbers) when compared with the highest SES group (SES measured by income and education).[25] Likewise, in the west of Scotland, individuals from the lowest SES group were more often diagnosed with a CMM above 1·5 mm in thickness (in percentage of all CMMs within the group but not in absolute numbers) when compared with the highest SES group (SES measured by car ownership, population density, affiliation to the labour market and social class).[26] In Sweden, individuals with shorter schooling had thicker tumours (1·2 mm) than individuals with higher education (0·8 mm).[27] The disparity in tumour thickness across SES groups probably reflects that screening for CMM (organized or not) affects time of diagnosis and hence survival and mortality from CMM.[16]

Therefore, there is a need to investigate whether knowledge and understanding of CMM are causal factors of the association of SES with CMM, as these factors will inevitably affect an individual's use of physicians or dermatologists for marks and moles.

We reviewed the existing literature on the association of SES with CMM incidence, survival and mortality in Northern Europe to obtain an overview of the disparities in CMM across SES groups in a part of the world where equal access to the health care system is pursued. Additionally, we aimed to assess if the association of SES with CMM can be ascribed to important determinants of intermittent UVR exposure (i.e. sun holidays, sunburns and use of sunbeds) and determinants of screening for CMM in an individual (i.e. knowledge and understanding of CMM).

Literature search

  1. Top of page
  2. Summary
  3. Literature search
  4. Cutaneous malignant melanoma incidence, survival and mortality in association with socioeconomic status
  5. Association of socioeconomic status with intermittent ultraviolet radiation exposure
  6. Association of socioeconomic status with understanding and knowledge of cutaneous malignant melanoma
  7. Discussion
  8. Remaining questions to be answered
  9. References

The literature was searched from March 2013 to October 2013 using PubMed/Medline. The following keywords or corresponding Medical Subject Headings terms were used: melanoma, socioeconomic status, income, tumour thickness, breslow, mortality, risk, ultraviolet light, sunlight, behaviour, sun exposure, holidays, sunburn, leisure activities, sunbed, tanning, solarium, delayed diagnosis, health care, awareness, primary prevention, screening, attitudes. Studies from Denmark, Norway, Sweden, Holland, England and Wales, Scotland and Finland (hereafter referred to as Northern Europe) including these keywords in the title, in the abstract and in the reporting data were reviewed systematically. These countries were chosen owing to 100% coverage of the national population by cancer registries,[28] and high scores in the Euro Health Consumer Index, which provide a comparative index for national healthcare systems.[29] Furthermore, a manual search was performed for references cited in certain articles.

Cutaneous malignant melanoma incidence, survival and mortality in association with socioeconomic status

  1. Top of page
  2. Summary
  3. Literature search
  4. Cutaneous malignant melanoma incidence, survival and mortality in association with socioeconomic status
  5. Association of socioeconomic status with intermittent ultraviolet radiation exposure
  6. Association of socioeconomic status with understanding and knowledge of cutaneous malignant melanoma
  7. Discussion
  8. Remaining questions to be answered
  9. References

High incidence and improved survival from CMM were associated with higher SES (Table 1).

Table 1. The association of socioeconomic status (SES) with cutaneous malignant melanoma (CMM) incidence, mortality and survival in Northern Europe. [UPWARDS ARROW] (increase), [DOWNWARDS ARROW] (decrease), [RIGHTWARDS ARROW] (no association), + (men and women analysed together)
Study (first author)Country of originMeasure of SESStudy periodCMM incidence in association with higher SESCMM mortality in association with higher SESSurvival from CMM in association with higher SES
  1. NA, not available. M, male. F, female. aExcess mortality. b5-year survival. cCMM of trunk, arms and legs. dHazard ratio. eCMM-specific survival. fWomen classified by the occupation of their husband. gStandardized mortality ratio. hCMM of trunk, upper arm, legs.

Birch-Johansen34DenmarkEducation, Income1994–2003 M [UPWARDS ARROW]; F [UPWARDS ARROW]M [DOWNWARDS ARROW]a; F [DOWNWARDS ARROW]aM [UPWARDS ARROW]b; F [UPWARDS ARROW]b
Vågerö63SwedenOccupation1961–1973 M [UPWARDS ARROW]; F [UPWARDS ARROW]NAM [UPWARDS ARROW]b; F [UPWARDS ARROW]b
Vågerö24SwedenOccupation1961–1979M [UPWARDS ARROW]c; F [UPWARDS ARROW]cNANA
Linet22SwedenOccupation1961–1979M [UPWARDS ARROW]c; F (NA)NANA
Hemminki64 SwedenEducation1971–1998M [UPWARDS ARROW]; F [UPWARDS ARROW]NANA
Hemminki15SwedenOccupation1970–1998M [UPWARDS ARROW]; F [UPWARDS ARROW]NANA
Erikson33SwedenOccupation1991–2003NAM [RIGHTWARDS ARROW]d; F[RIGHTWARDS ARROW]dNA
Eriksson27SwedenEducation1990–2010NAM [DOWNWARDS ARROW]d; F [DOWNWARDS ARROW]dM + F [UPWARDS ARROW]e
Pérez-Goméz23SwedenOccupation1971–1989M [UPWARDS ARROW]; F [UPWARDS ARROW]NANA
Elstad30NorwayEducation1971–2002NAM [UPWARDS ARROW]d; F[RIGHTWARDS ARROW]dNA
Rimpela65FinlandOccupation, Education1971–1975M [UPWARDS ARROW]; F[RIGHTWARDS ARROW]NANA
Lee31 England and WalesOccupation1949–1972M [UPWARDS ARROW]; F [UPWARDS ARROW]fM [UPWARDS ARROW]g; F [UPWARDS ARROW]f,gNA
Streetly32England and WalesOccupation1979–1983NAM [UPWARDS ARROW]g; F[RIGHTWARDS ARROW]f,gNA
Beral20England and WalesOccupation1970–1975M [UPWARDS ARROW]c; F (NA)M [UPWARDS ARROW]g; F (NA)NA
Elwood21EnglandOccupation1984–1986M + F [UPWARDS ARROW]hNANA
Shack36EnglandIncome1998–2003M [UPWARDS ARROW]; F [UPWARDS ARROW]NANA
MacKie26ScotlandCar ownership, Population density, Affiliation to the labour market, Social class1979–1993M [UPWARDS ARROW]; F [UPWARDS ARROW]M + F [DOWNWARDS ARROW]dM [UPWARDS ARROW]b; F [UPWARDS ARROW]b
Doherty66ScotlandCar ownership, Population density, Affiliation to the labour market, Social class1978–2004M [UPWARDS ARROW]; F [UPWARDS ARROW]NANA
MacKie67ScotlandOccupation1978–1980M [UPWARDS ARROW]; F[RIGHTWARDS ARROW]NANA
Aarts35HollandIncome, Economic value of house/apartment1996–2008M [UPWARDS ARROW]; F [UPWARDS ARROW]NANA
Van der Aa25HollandIncome, Education1994–2005M + F [UPWARDS ARROW]NANA

Studies found increased risk of CMM mortality among men in association with high SES in the periods 1971–2002 in Norway,[30] and in the periods 1949–1972,[31] 1970–1975[20] and 1979–1983[32] in England and Wales. Only one of these studies reported an increased risk of CMM mortality among women in association with high SES when classified by the occupation of their husband.[31] In Sweden there was no significant difference in risk of CMM mortality across SES groups in the period 1991–2003.[33] In contrast, studies from Scotland, Sweden and Denmark reporting data from the periods 1979–1993, 1990–2010 and 1994–2003, respectively, showed a decreased risk of CMM mortality among high SES individuals in both men and women.[26, 27, 34] In summary, most early studies from the 1970s and 1980s reported increased mortality with increasing SES in men, but not in women. In contrast, more recent studies from the 1990s and 2000s showed a decreased mortality with increasing SES in both men and women (Table 1).

Increased CMM incidence among high SES individuals may be due to exposure to risk factors such as intermittent UVR, but also to screening, as seen for breast and prostate cancer.[28, 35, 36] The increased survival from CMM among high SES individuals may be owing to a better prognosis because the tumour is found at a less advanced stage,[16] or may simply reflect that screening will advance the time of diagnosis and hence ‘artificially’ increase survival time.[37] Hence, we should look at mortality from CMM to assess if screening and exposure to risk factors may account for the increased incidence of CMM found among high SES individuals. The findings of a higher mortality in association with high SES in the early studies from the 1970s and 1980s suggest a true increase in the disease among high SES individuals, which must be the result of exposure to risk factors such as intermittent UVR. The lower mortality among high SES individuals in more recent studies from the 1990s and 2000s suggests that more CMMs may be found earlier, leading to thinner tumours,[25, 27] which will eventually decrease mortality. Hence, we reviewed the literature with the aim of assessing if the association of SES with CMM in Northern Europe can be ascribed to important determinants of intermittent UVR exposure, that is sun holidays, sunburns, and use of sunbeds and/or determinants of screening for CMM, that is knowledge and understanding of CMM.

Association of socioeconomic status with intermittent ultraviolet radiation exposure

  1. Top of page
  2. Summary
  3. Literature search
  4. Cutaneous malignant melanoma incidence, survival and mortality in association with socioeconomic status
  5. Association of socioeconomic status with intermittent ultraviolet radiation exposure
  6. Association of socioeconomic status with understanding and knowledge of cutaneous malignant melanoma
  7. Discussion
  8. Remaining questions to be answered
  9. References

Sun holidays

Our review of the literature showed that only three studies from Northern Europe have previously assessed the association of SES with taking sun holidays. A questionnaire study from England conducted in 1995 showed a stronger tendency for the highest socioeconomic group (measured by education and occupation) to holiday abroad in sunny countries.[38] Likewise, a Swedish questionnaire study conducted in 1982 showed that the number of trips south and educational level were highly correlated,[12] which is in agreement with the findings that in the 1960s, 1970s and 1980s the highest social classes in Sweden more often took holidays in sunny countries than the rest of the population (Table 2).[24] However, low-cost travel may have changed this tendency today, but to our knowledge no recent studies have assessed how SES affects holidays taken abroad by Northern Europeans.

Table 2. The association of socioeconomic status (SES) with intermittent ultraviolet radiation (UVR) exposure in Northern Europe
Study (first author)Country of originStudy methodsMeasure of SESStudy periodMeasure of intermittent UVR exposureIntermittent UVR exposure in association with higher SES
Jackson[38]EnglandQuestionnaireEducation, occupation1995Sun holidayIncreased
Westerdahl[12]SwedenQuestionnaireEducation1982Sun holidayIncreased
Vågerö[24]SwedenInterviewSocial class1968, 1974, 1981Sun holidayIncreased
Stott[42]U.K.InterviewType of housing, education1996SunburnNo association
Jackson[38]EnglandQuestionnaireEducation, occupation1995Use of sunbedDecreased
Koster[44]DenmarkQuestionnaireEducation2007Use of sunbedDecreased
Bentzen[45]DenmarkQuestionnaireOccupation2011Use of sunbedDecreased

In an observational case–control study based on personal UVR dosimetry and sun exposure diaries, Danish patients with CMM increased their UVR dose on days abroad and on holidays during the first three summers after diagnosis to a level above that of matched controls. Moreover, patients spent more than twice the number of days abroad outside Northern Europe in a sunny country compared with controls.[39] Interestingly, further analyses of this data set showed that 64% of the patients with CMM belonged to the higher SES groups 1 or 2 (measured by education and occupation; this information was obtained through interviews),[40] as opposed to only 36% of the controls (= 0·048, analysed by the χ2 test, unpublished data). This suggests that Northern Europeans of higher SES, with a diagnosis of CMM, may travel abroad more often than individuals of lower SES without CMM.

Sunburn

A study based on interviews from the U.K. in 2004 found that there was significantly less awareness of sunburn as a risk factor for cancer among lower SES groups (measured by occupation),[41] although this study did not provide a direct measure of sunburns in relation to SES. However, another interview study from the U.K. from 1996 found no clear association between the number of sunburns within the last 12 months and SES (measured by type of housing and occupation) (Table 2).[42] Interestingly, although not a direct measure of the association between SES and sunburns, a prospective cohort study of 93 638 Norwegian women conducted between 1991 and 2001 showed that the association of CMM with SES (measured by education) was partly attributable to the number of sunburns.[43]

Use of sunbeds

Questionnaire studies have shown that there was an overall stronger tendency for persons with less education in Denmark (conducted in 2007) and those of lower SES (measured by occupation) in England (conducted in 1995) to use sunbeds.[38, 44] In accordance with these findings a Danish study conducted in 2011 showed that high SES of mothers (measured by occupation) was associated with less use of sunbeds among their daughters (Table 2).[45]

Our review of the literature from Northern Europe suggests that travelling abroad to sunny countries is associated with high SES, and hence may contribute to the association of SES with CMM. However, we must acknowledge that the studies reported data from nearly 20 years ago,[12, 24, 38] or were based on a small sample size.[39] There was not enough evidence to conclude that sunburn was associated with high SES, although, interestingly, holidays abroad in sunny countries are associated with a high risk of sunburn.[46] Our review also showed sunbed use in recent decades to be associated with low SES, which is peculiar given the lower incidence of CMM among low SES individuals, although it may contribute to the higher mortality from CMM among low SES individuals. Another important issue to consider is that some individuals will use sunbeds frequently, which will lead to continuous UVR exposure, not necessarily resulting in sunburn, whereas other individuals will use sunbeds sporadically, which will lead to intermittent UVR exposure.

Lastly, another interesting measure of intermittent UVR exposure was assessed in a recent study from Denmark where it was found that having a home garden – an indicator of high SES measured by income – was associated with increased intermittent UVR exposure of the trunk and limbs, and with increased risk of CMM of the trunk and extremities.[4]

Association of socioeconomic status with understanding and knowledge of cutaneous malignant melanoma

  1. Top of page
  2. Summary
  3. Literature search
  4. Cutaneous malignant melanoma incidence, survival and mortality in association with socioeconomic status
  5. Association of socioeconomic status with intermittent ultraviolet radiation exposure
  6. Association of socioeconomic status with understanding and knowledge of cutaneous malignant melanoma
  7. Discussion
  8. Remaining questions to be answered
  9. References

A literature search showed that few studies have been conducted on this subject in Northern Europe (Table 3). In a questionnaire study from England conducted in 1995, there was a trend showing that the highest SES group (measured by occupation and education) were the least likely to seek medical advice about moles that changed and check for mole changes.[38] In contrast, two questionnaire studies from England conducted in 1997 showed that individuals of higher SES (SES measured by car ownership, population density, affiliation to the labour market and social class) were more likely to seek medical advice for skin abnormalities such as marks and moles (Table 3).[47, 48] Other studies have shown that the use of specialists was highest in the most affluent municipalities in Denmark in 1988–1993 and among individuals with higher education in Holland in 1991,[49, 50] although not reporting on use of dermatologists specifically and, overall, neither of the studies showed a direct association between SES and knowledge and understanding of CMM. Only two studies conducted in 1987 and 1997 in England and Scotland addressed this question and found that high SES individuals (measured by education and occupation) were more knowledgeable about moles and skin cancer than low SES individuals (Table 3).[48, 51] Likewise, an interesting finding was made in Sweden that male physicians and male physicians with a PhD degree had the highest risk of CMM in situ, indicating that knowledge and understanding of CMM may contribute significantly to early detection, although the study did not directly provide data assessing knowledge and understanding of CMM in association with SES.[52]

Table 3. The association of socioeconomic status (SES) with use of a physician or dermatologist for moles, and understanding and knowledge of cutaneous malignant melanoma (CMM)
Study (first author)Country of originStudy methodsMeasure of SESStudy periodUse of a physician or dermatologist in association with higher SESKnowledge and understanding of CMM in association with higher SES
  1. NA, not available.

  2. aPhysician; bwomen; cdermatologist; dSES assessed by car ownership, population density, affiliation to the labour market and social class; eSES assessed by education.

Jackson[38]EnglandQuestionnaireEducation, occupation1995DecreasedaNo association
Eiser[47]EnglandQuestionnaireCar ownership, population density, affiliation to the labour market, social class1997IncreasedaNA
Newman[51]England and ScotlandQuestionnaireEducation, occupation1987NAIncreasedb
Melia[48]EnglandQuestionnaireEducation, car ownership, population density, affiliation to the labour market, social class1997Increasedc,dIncreasede

These findings suggest that high SES is associated with the use of specialists and thereby possibly earlier diagnosis, although, to our knowledge, only two older studies have found a positive association between SES and knowledge and understanding of CMM, moles and skin cancer in Northern Europe.[48, 51]

Discussion

  1. Top of page
  2. Summary
  3. Literature search
  4. Cutaneous malignant melanoma incidence, survival and mortality in association with socioeconomic status
  5. Association of socioeconomic status with intermittent ultraviolet radiation exposure
  6. Association of socioeconomic status with understanding and knowledge of cutaneous malignant melanoma
  7. Discussion
  8. Remaining questions to be answered
  9. References

SES per se is not responsible for the association of SES with CMM, which must be ascribed to certain risk factors directly associated with CMM. In this article we have reviewed the literature on the association of SES with CMM incidence, survival and mortality to provide an overview of the disparities of the disease across SES groups in Northern Europe. Additionally, we aimed to assess if the association of SES with CMM can be ascribed to important determinants of intermittent UVR exposure (i.e. sun holidays, sunburn and use of sunbed) and determinants of screening for CMM (i.e. knowledge and understanding of CMM in Northern Europe, where equal access to health care for all SES groups is pursued).

This study was limited by differences in measures of SES across countries and decades (Tables 1-3), which will inevitably lead to shortcomings in our assessment of a general association of SES with CMM, as well as with intermittent UVR exposure and knowledge and understanding of CMM.

Overall, the observations for the association of SES with CMM incidence, tumour thickness, survival and mortality from CMM in Northern Europe from the 1950s through the 2000s, together with the association of SES with intermittent UVR exposure and knowledge and understanding of CMM in Northern Europe may be explained by the following:

  1. An association between high SES and risk factors (intermittent UVR exposure especially during holidays abroad) from the 1950s through the 1980s approximately, leading to a higher CMM incidence, as well as higher CMM mortality in high SES individuals compared with low SES individuals.
  2. With the onset of growing public awareness and screening (organized or not) of CMM, earlier diagnosis among high SES individuals, most prone to consult a physician for marks and moles, has led to continuing higher CMM incidence, thinner tumours, increased survival from CMM and eventually the lower CMM mortality seen in recent decades than in lower SES individuals.
  3. Possibly, an association between low SES and increasing exposure to risk factors (e.g. use of sunbeds and perhaps the effect of low-cost travel) has started to cause a true increase in the occurrence of the disease among low SES individuals and, together with delayed diagnosis, eventually has led to thicker tumours and increased mortality from CMM than among high SES individuals.

Our findings suggest that there is a variation by sex in the association of SES with CMM mortality. Most studies, especially more recent studies, reported that women overall had a benefit from higher SES in terms of lower mortality, whereas both higher and lower mortality from CMM in association with SES were observed among men, although the most recent studies showed a lower mortality among high SES men (Table 1). Recent studies have shown decreased male survival from CMM even after controlling for tumour thickness, health insurance and SES,[53] and it has been suggested that sex differences, rather than tumour characteristics such as thickness, are responsible for the survival differences between men and women.[54] Hence, when conducting studies on the association of SES with CMM it will be relevant to separate the analyses for men and women.

Serum vitamin D has been shown to be associated with improved survival from CMM,[55] which could be explained by a direct protective role of vitamin D in CMM. However, it may simply reflect that high levels of UVR exposure induce high levels of vitamin D,[56, 57] which coincide with the thinner CMMs most often diagnosed among high SES individuals. Still, it is reasonable to investigate if high SES is partly associated with increased survival from CMM due to high levels of vitamin D caused by the sun and diet. In that respect, it is also suggested that certain dietary components (which may be associated with SES) protect against UVR-induced skin cancer, such as CMM, by affecting epigenetic mechanisms, for example blocking UVR-induced DNA hypermethylation in the skin, which is known to silence tumour suppressor genes.[58]

In conclusion, in this review we found that high SES is associated with high risk of CMM, thinner tumours, increased survival and decreased risk of mortality from CMM in Northern Europe – the latter shown especially among women and likewise among men in more recent studies. We suggest that the higher risk of CMM among high SES individuals partly reflects more holidays abroad in sunny countries resulting in high intermittent UVR exposure. Studies suggest that the increased risk of CMM together with a better outcome, that is lower tumour thickness and lower mortality from CMM, in high SES individuals may equally well be due to more frequent use of physicians and dermatologists for marks and moles, and hence earlier diagnosis, which can possibly be ascribed to more knowledge and better understanding of CMM, although more studies on this subject are warranted. Recent studies show that lower SES groups also engage in intermittent sun exposure by using sunbeds. We speculate if the association of low SES with increased mortality from CMM registered in recent decades may partly be ascribed to increasing exposure to intermittent UVR from low-cost travel and use of sunbeds together with delayed diagnosis owing to less use of physicians and dermatologists, resulting in poorer prognosis than for high SES individuals.

Remaining questions to be answered

  1. Top of page
  2. Summary
  3. Literature search
  4. Cutaneous malignant melanoma incidence, survival and mortality in association with socioeconomic status
  5. Association of socioeconomic status with intermittent ultraviolet radiation exposure
  6. Association of socioeconomic status with understanding and knowledge of cutaneous malignant melanoma
  7. Discussion
  8. Remaining questions to be answered
  9. References

There is a need for studies that assess how CMM incidence and tumour thickness, and survival and mortality from CMM have evolved across various SES groups in Northern Europe over several decades. Such information will allow us to differentiate between SES groups when analysing the current trends in CMM epidemiology, which will be very valuable in order to assess how CMM epidemiology has changed over time across SES groups. For a better understanding of the factors responsible for the association of SES with CMM, ongoing studies on UVR exposure behaviour, including travel to sunny countries, sunburn, use of sun protective measures and sunbeds across various SES groups, will be valuable either through questionnaire studies or through objective measurements such as sun exposure diaries and UVR dosimetry.[59, 60] Optimally, such studies should also assess diet and serum vitamin D in association with SES, knowing that these factors may affect CMM incidence, survival and mortality. Moreover, there is a need for comprehensive questionnaire studies investigating the general public's understanding and knowledge of CMM, as well as SES-related barriers to consulting a physician or dermatologist in connection with skin disorders.

References

  1. Top of page
  2. Summary
  3. Literature search
  4. Cutaneous malignant melanoma incidence, survival and mortality in association with socioeconomic status
  5. Association of socioeconomic status with intermittent ultraviolet radiation exposure
  6. Association of socioeconomic status with understanding and knowledge of cutaneous malignant melanoma
  7. Discussion
  8. Remaining questions to be answered
  9. References