Early detection messages failing to halt deaths from UK’s most common cancer
Two studies due to be presented at the World Congress on Cancers of the Skin in Edinburgh, Scotland, this week, show an increase in advanced-stage skin cancers, highlighting an urgent need to publicise self-check and early detection messages.
Skin cancer is the UK’s most common cancer. Melanoma is the most dangerous form of the disease, and is relatively unique in that it is a highly visible cancer, allowing people to monitor their skin for changes themselves. As with most cancers, early detection improves the chances of survival.Melanoma tumours grow in ‘thickness’ (depth of invasion into the skin) the longer they are left untreated. The ‘Breslow thickness’ of a melanoma lesion, measured in millimetres, is used to assess how advanced it is and has five stages, ranging from the cancer cells only being in the outermost layer of the skin, to the tumour being more than 4mm thick.*
The first study looked at 1,769 melanoma patients seen at the St. John’s Institute of Dermatology at Guy’s and St. Thomas’ Hospitals in London between 1999 and 2012. They found that the incidence of melanoma increased by 76 per cent during the 13-year period. The Breslow thickness of the melanomas increased across all demographic groups, from a mean of 2.25mm to 2.43 mm.
As the data for thin, early stage tumours was excluded from this study, the results suggest that the overall increase in melanomas being diagnosed is, at least in part, due to more advanced cancers which have a much poorer survival, rather than a surge of early-stage tumours in response to greater awareness of the disease.
Study author Dr Wisam Alwan said: “Our data shows an increase in the number of cases of melanoma seen across all stages of disease, including more advanced tumours, with no improvement in survival seen during the study period.
“The number of people dying from melanoma is increasing year on year and this emphasises the necessity of early detection of tumours, given the poor outcomes associated with advanced disease. Strategies that tackle both the prevention of the disease, and that encourage people to seek help earlier, are crucial.”
The second study, from Barts Health NHS Trust in London, reviewed 92 cases of melanoma seen in the region over one year. 16 per cent (15 cases) of ‘thick malignant melanoma’, in which the tumour was greater than 3.5mm and therefore more advanced and harder to treat, were identified. The mean Breslow thickness in this group was 6.4mm, the thickest of the five stages on the Breslow scale (more than 4mm).
Despite the tumour size, 40 per cent of these patients had noticed a changing lesion for at least four months before seeking advice. Interestingly, most (73%) were a type of melanoma called ‘nodular melanoma’ and the authors speculate that current early detection messaging, using the ABCD acronym** (which stands for Asymmetry, Border, Colour and Diameter – the key areas of change to look out for), may not be as applicable to this type of the disease as to other subtypes.
Dr Andrew Lock, one of the study’s authors, said: “It has been suggested that nodular melanomas behave biologically differently from other subtypes, and the ABCD criteria to aid diagnosis may indeed lead to late presentation. Perhaps the latter is applicable mainly to the superficial spreading subtype, which is the more common type of melanoma.
“Our study reinforces the observation that the incidence of thick melanomas is not decreasing. New strategies and education programmes are therefore required for the earlier detection of such tumours.”
Nina Goad of the British Association of Dermatologists said: “The majority of public education campaigns around skin cancer have focussed on preventing the disease, by staying safe in the sun. What these studies show is that we now also need to target our efforts on early detection, by encouraging people to check their skin and report anything suspicious to their GP sooner rather than later.
“We’ve been doing this for some years with our Be Sun Aware Roadshow, where we take mole-checking to high profile venues, and we are now trying to target the people we know tend to present late with skin cancer, which tends to be older men.
“However, the studies raise an interesting point about the different melanoma subtypes. Nodular melanomas, which accounted for the majority of melanomas in the review by Barts Health NHS Trust, are less common than the ‘superficial spreading’ type of melanoma, to which the ABCD rules apply. Their rate of growth is usually faster and unfortunately they are also harder to diagnose clinically. They become life threatening quickly and can mimic other, less harmful skin cancers and benign skin lesions. This makes public messaging for these cancers tricky, and something we are going to need to think about if we want to reduce our melanoma mortality.”
Notes to editors:
*More information on melanoma staging and the Breslow thickness scale can be found at:/library-media/documents/Melanoma%20-%20Diagnosis%20and%20Staging.pdf
** There are three types of skin cancer, and all look different. The following ABCD-Easy rules show you a few changes that might indicate a 'melanoma', which is the deadliest form of skin cancer.As skin cancers vary, you should tell your doctor about any changes to your skin, even if they are not similar to those mentioned here.Remember - if in doubt, check it out! If your GP is concerned about your skin, make sure you see a Consultant Dermatologist, the most expert person to diagnose a skin cancer. Your GP can refer you via the NHS.
Asymmetry - the two halves of the area may differ in shape
Border - the edges of the area may be irregular or blurred, and sometimes show notches
Colour - this may be uneven. Different shades of black, brown and pink may be seen
Diameter - most melanomas are at least 6mm in diameter. Report any change in size, shape or diameter to your doctor
Expert - if in doubt, check it out! If your GP is concerned about your skin, make sure you see a Consultant Dermatologist, the most expert person to diagnose a skin cancer. Your GP can refer you via the NHS
For more information please contact: Matt Gass, Communications Officer, on 020 7391 6084 or firstname.lastname@example.org
If using this study, please ensure you mention that the study was released at the World Congress on Cancers of the Skin.
The conference will be held in Edinburgh from September 3rd to 6th 2014, and is attended by approximately 1,000 UK and worldwide health professionals.
The World Congress on Cancers of the Skin 2014 was founded by The Skin Cancer Foundation, the international organization devoted solely to education, prevention, early detection, and prompt treatment of the world’s most common cancer. It is organised by the British Association of Dermatologists.
042, Epidemiological trends in Malignant Melanoma in a large urban population in England from 1999-2012; Wisam Alwan1, Panos Karagiannis2, George Poulos2, Katie Lacy2
1University Hospital Lewisham, Lewisham and Greenwich NHS Trust, London, UK, 2St. John's Institute of Dermatology, Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK
Analysis of trends in stage, site, 5-year survival and mortality from malignant melanoma in a patient population referred to a tertiary referral centre based in a centralized urban location.
Retrospective study of 1769 cases (913 male, 856 female) referred to our unit from 1999-2012 through analysis of our local melanoma database, electronic patient records and case note review. Cases of cutaneous malignant melanoma of histopathological stage IB and above according to the American Joint Committee on Cancer (AJCC) criteria were included, with a smaller local cohort of 235 patients for which all stages of melanoma were recorded. Data on incidence, mortality, Breslow Thickness, body site and disease stage were analysed.
Mean age of diagnosis was 58 years for all patients during the study interval (mean age for males 60, females 56). Incidence of melanoma (Stage IB and above) increased 1.7-fold from 3.28 to 5.77 per 105 of the population from 1999 to 2012 in line with national trends.
Breslow Thickness increased over the study period for the entire database population from a mean of 2.25mm in 1999-2000 to 2.43 mm in 2011-2012. The trunk was the commonest body site affected in males (36%) and lower limbs in females (36%). No significant differences were observed in stage of disease at presentation for different body sites.
Mortality rate (melanoma-specific deaths) also increased, with a rate of 1.96 per 105 in 2011-2012, compared to 0.10 per 105 at the outset of the study, with men having the poorest outcomes (2.24 per 105 in contrast to 1.70 per 105for females).
5-year melanoma-specific survival figures were 96%, 85%, 78% and 32% for stage I-IV disease respectively; consistent with published data.
Malignant Melanoma continues to rise in incidence and is associated with significant mortality. Primary prevention strategies to reduce disease incidence and delayed presentation are crucial. The rising mortality rate highlights the necessity of early detection of tumours given the poor outcomes associated with advanced disease. No improvement in survival was seen during our study however we hope that the new targeted and immunomodulatory therapies will result in improved future survival rates in our patient population.
 Balch CM, Gershenwald JE, Soong SJ, et al. Final version of 2009 AJCC melanoma staging and classification. (J Clin Onc. 2009.20;27(36):6199-206)
043, Thick melanomas: A persistent problem; Andrew Lock, Nilukshi Wijesuriya, Rino Cerio
Barts Health NHS Trust, London, UK
Cutaneous melanoma remains on the increase in Europe, but recently has stabilised. Many recent studies have shown an increase in detection of melanomas <1mm probably due to earlier diagnosis. However, the incidence of thick malignant melanomas (TMM) seems to have remained at least constant (Tejera-Vaquerizo A, Mendiola-Fernández M, Fernández-Orland A, et al. Thick melanoma: the problem continues. J Eur Acad Dermatol Venereol 2008; 22:575-9; Murray CS, Stockton DL and Doherty VR. Thick melanoma: the challenge persists. Br J Dermatol 2005; 152:104-9).
Our skin cancer multidisciplinary team (SMDT) meeting serves a region with a population of approximately 1.7 million. We manage over 200 new cutaneous melanomas per year. We reviewed our primary cutaneous melanomas over a 12 month period, specifically those with a breslow thickness ≥ 3.5mm, aiming to identify important associations or demographic factors associated with TMM.
15 cases of TMM were identified. Of these, 9 were females and 6 males. 13 of the 15 (87%) were aged over 60 years and most patients were of white ethnicity. 11 of the 15 (73%) melanomas were of nodular subtype and breslow thickness ranged from 3.5mm to 15mm (mean 6.4mm). Of the cases, 7 were ulcerated (47%) with a mean dermal mitotic count of 9 per mm2 (range 1-27 per mm2). Pre-existing naevus was seen in none and lymphovascular spread was present in 2/15 (13%). Despite the size, 6/15 (40%) patients had noticed a changing lesion for at least 4 months before seeking advice. Most (67%) cases of TMM identified were in caucasian patients ≥ 60, and were of nodular subtype. Body site was variable and included most sites, including the ankle.
It may be that nodular melanomas behave biologically differently from other subtypes, and the ABCD criteria to aid diagnosis may indeed lead to late presentation. Perhaps the latter is applicable mainly to the superficial spreading subtype.
Our study reinforces the observation that the incidence of TMM is not decreasing. In this group sex difference was minimal. The reason for our findings remains unclear and is multifactorial. However, new strategies and education programmes are, therefore, required for the earlier detection of such tumours to reduce its incidence in these patients.
About the BAD
The British Association of Dermatologists (BAD) is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease. The BAD provides free patient information on skin diseases and runs a number of high profile campaigns, including Sun Awareness, which runs from May to September annually and includes national Sun Awareness Week in May. Website: www.bad.org.uk/sunawareness