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Prevention



Cutaneous melanoma represents a significant public health problem, as it commonly affects young productive people and there is virtually no cure for advanced cases: accordingly, any effort should be made to promote both primary (risk reduction) and secondary (early detection) prevention [1-20].


Primary prevention

Public education campaigns are major tools in achieving primary prevention of melanoma [1, 2]. Public education should especially target individuals at increased risk (see Risk factors section). These high risk individuals should be strongly encouraged to reduce their exposure to (intermittent) UV radiation, including artificial UV exposure for tanning purposes. For the role of sunscreens in melanoma prevention, see Risk factors section (Sun exposure paragraph). However it is important to note that so far reducing sun exposure has not led to any significant reduction in melanoma incidence. Whilst it is understood that any changes may take many years to be apparent, in Australia because of a parallel increase in screening the incidence of melanoma is rising rapidly albeit with very thin tumours which have no significant impact on mortality. There has also been some concerns recently about the danger of recommending sun avoidance as this may have significant impact on Vitamin D metabolism with a high prevalence of Vitamin D deficiency in many Caucasian populations.


Secondary prevention

In the light of its resistance to current medical treatment (see Conventional therapy section), the early detection of melanoma is critical to improve the clinical outcome of this disease. Although mass screening is an attractive form of secondary prevention, randomized clinical trials (screening vs no screening) are lacking. A population-based case-controlled study has shown that skin self-examination was associated with a reduced incidence of melanoma [3], and reports of mass screening of the general population have demonstrated that most melanomas detected were thin (< 1 mm) [4, 5]. Accordingly, some advocate educational campaigns aimed at teaching the general population to perform self-examination in order to recognize the warning signs of melanoma [6], usually according to the ABCDE rule of thumb (Figure 1) [7]. Besides physical examination, clinicians almost routinely use dermoscopy in order to detect suspicious patterns of early melanoma (see Dermoscopy section). However, other investigators have reported that self-examination is not associated with early diagnosis [8, 9], and the evidence of an advantage for surveillance and screening programs is stronger in high-risk persons, who should therefore be followed up regularly [10, 11]. It is anticipated that secondary prevention is much more likely to save lives compared to primary prevention which so far has not proven to be very effective.


Chemoprevention

There is some evidence that melanoma development might be prevented or delayed by drugs of sufficiently low toxicity to make clinical trials of chemoprevention feasible and potentially successful in high-risk individuals [12]. However, this research field is still in its infancy and available findings are controversial [13].



References

[1] Thompson JF et al, Cutaneous melanoma. Lancet 2005, 365:687-701

[2] Poochareon VN et al, Primary prevention efforts for melanoma. J Drugs Dermatol 2004, 3:506-19

[3] Berwick M et al, Screening for cutaneous melanoma by skin self-examination. J Natl Cancer Inst 1996, 88:17-23

[4] Rossi CR et al, Early detection of melanoma: an educational campaign in Padova, Italy. Melanoma Res 2000, 10:181-7

[5] Koh HK et al, Evaluation of the American Academy of Dermatology's National Skin Cancer Early Detection and Screening Program. J Am Acad Dermatol 1996, 34:971-8

[6] Weinstock MA, Progress and prospects on melanoma: the way forward for early detection and reduced mortality. Clin Cancer Res 2006, 12:2297s-2300s

[7] Abbasi NR et al, Early diagnosis of cutaneous melanoma: revisiting the ABCD criteria. JAMA 2004, 292:2771-6

[8] Carli P et al, Dermatologist detection and skin self-examination are associated with thinner melanomas: results from a survey of the Italian Multidisciplinary Group on Melanoma. Arch Dermatol 2003, 139:607-12

[9] Melia J et al, The relation between mortality from malignant melanoma and early detection in the Cancer Research Campaign Mole Watcher Study. Br J Cancer 2001, 85:803-7

[10] Lange JR et al, Screening for cutaneous melanoma. Surg Oncol Clin N Am 2005, 14(4): 799-811

[11] Helfand M et al, Screening for skin cancer. Am J Prev Med 2001, 20(3 Suppl):47-58

[12] Demierre MF et al, Chemoprevention of melanoma: an unexplored strategy. J Clin Oncol 2003, 21:158-65

[13] Freeman SR et al, Statins, fibrates, and melanoma risk: a systematic review and meta-analysis. JNCI 2006, 98:1538-46

[14] Hamidi R et al, Prevalence and predictors of skin self-examination: prospects for melanoma prevention and early detection. Int J Dermatol 2008, 47:993-1003

[15] Bordeaux JS et al, Melanoma: prevention and early detection. Semin Oncol 2007, 34:460-6

[16] Bishop JN et al, The prevention, diagnosis, referral and management of melanoma of the skin: concise guidelines. Clin Med 2007, 7:283-90

[17] Markovic SN et al, Malignant melanoma in the 21st century, part 1: epidemiology, risk factors, screening, prevention, and diagnosis. Mayo Clin Proc 2007, 82:364-80

[18] Lao CD et al, Targeting events in melanoma carcinogenesis for the prevention of melanoma. Expert Rev Anticancer Ther 2006, 6:1559-68

[19] Demierre MF, Epidemiology and prevention of cutaneous melanoma. Curr Treat Options Oncol 2006, 7:181-6

[20] Bataille V et al, Melanoma--Part 1: epidemiology, risk factors, and prevention. BMJ 2008, 337:a2249




AUTHOR(s)

Veronique Bataille (West Hertfordshire Hospitals NHS Trust, Hemel Hempstead HP2 4AD, bataille@doctors.org.uk)


UPDATED

May 2009



Figure 1: The "ABCDE" rule for the early diagnosis of cutaneous melanoma.

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