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1 PDF hosted at the Radboud Repostory of the Radboud Unversty Njmegen The followng full text s a publshers verson For addtonal nformaton about ths publcaton clck ths lnk http//hdlhandlenet/266/248 Please be advsed that ths nformaton was generated on and may be subject to change

2 Skn Cancer Screenng Focusng on Melanoma Yelds More Selectve Attendance Mchette J M de Rooj, MD; Frans H J Rampen, PhD; Leo J Schouten, MD; H A Martno Neumann, PhD ton of screenees wth lesons suggestve of melanoma ncreased from % n 99 to 7% durng the 99 campagn (P=4) The proporton of dysplastc nev rose from 2% to 77% (PC) Nonmelanoma skn cancers were less often encountered (7% n 99 vs 26% n 99; P=9) Actnc keratoses were also less numerous (6% vs 5%; PC) Background Screenng theoretcally reduces death and morbdty from malgnant melanoma The ratonale of screenng for nonmelanoma skn cancer s more debatable, snce mortalty s very low M ethods We organzed a screenng campagn n Southern Lmburg, the Netherlands, n 99 Press releases and publc announcements referred only to melanoma The results were compared wth smlar campagns n Arnhem and Endhoven, the Netherlands, n 99; these, however, addressed skn cancer n general Results There were 446 people attendng the 99 Concluson Screenng concentratng on melanoma ncreases the rates of lesons suggestve of melanoma and dysplastc nev, whereas the proportons of basal and squamous cell carcnomas and actnc keratoses decrease These fndngs may have mportant mplcatons wth regard to the cost-effectveness of skn cancer screenng efforts screenngs, compared wth 246 n 99 The propor (Arch Dermatol 995; ) ROGNOSS OF m algnant melanoma depends strongly on early recognton Screenng as a means of secondary preventon enhances tons of melanomas, dysplastc nev, and other pgmented skn lesons and nonmelanoma skn cancers, after a screenng program wth meda attenton focusng on melanoma only, early detecton and, theoretcally, reduces death and morbdty from mela noma,2 Vsual examnaton of the skn by n Arnhem and Endhoven n 99, a to- tal of 246 partcpants had been regs- dermatologsts s an acceptable, relable, and nexpensve screenng tool Snce From the Unversty Hosptal of Maastrcht (the Netherlands) (Drs de Rooj and Neumann); Snt Anna Hosptal, Oss, the Netherlands (Dr Rampen); and the Comprehensve Cancer Centers KL and KO, Maastrcht and Njmegen, the Netherlands (Dr Schouten) 985, voluntary skn cancer and mela- tered The campagn n Southern Lmnoma screenng clncs have been held n the Unted States 7 Smlar clncs were burg n 99 attracted 446 partcpants There was no marked dfference n the sex rato between the 99 and 99 exer- cses n Arnhem and Endhoven, 47% of the screenees were younger than 5 years, compared wth 66% n Southern Lmburg The shft toward younger partcpants was hghly sgnfcant (PC) T a b le summarzes the demographc profle of the attendees at both earn pagns T a b le 2 shows the most relevant organzed n the Netherlands n 989 (Oss) and n 99 (Arnhem and Endhoven)8 The screenng exercses n the Netherlands were plot studes to nvestgate the practcal mplcatons of such screen- ngs All screenngs n the Unted States and the Netherlands so far have concen- trated on skn cancer n general, ncludng both melanoma and nonmelanoma skn cancer Mortalty from nonmelanoma skn cancer s low n terms of health strategy prortes, these skn lesons are nsgnfcant One may argue that skn cancer screenng should be confned to malgnant melanoma We studed the propor- ; V r ARCH DERMATOL/VOL, APR 995

3 MATERALS AND METHODS n June 99, free melanoma detecton clncs were conducted n Southern Lmburg, the Netherlands, un der the auspces of the Dutch Academy of Dermatol ogy and Venereology and the Comprehensve Can cer Centers KL (Maastrcht, the Netherlands) and KO (Njmegen, the Netherlands) The area encom passes approxmately 65 nhabtants All der matologsts n the regon partcpated n the study The screenees were examned at sx hosptal loca tons on a fst come, frst served bass The program was announced n the regonal newspapers, on the regonal rado and televson statons, and by post ers n watng rooms of general practtoners and n pharmaces and publc lbrares Specal emphass was placed on the rsk factors and symptoms of early ma lgnant melanoma and ts precursor lesons No ref erence was made to the nonmelanoma skn cancers and ther rsk denomnators Because of the large turnout, skn examna tons were confned to specfc lesons the atten dants were worred about Systematc examnaton of the entre skn was performed only on those who ntentonally opted for a complete skn check and on those who showed a specal skn mark that was sug gestve of dysplastc nevus or melanoma These fac tors were the same ones used n the 99 programs When more than one clncal dagnoss was consd ered, only the sngle worst dagnoss was recorded No bopses or therapeutc nterventons were per formed durng the screenngs The partcpant receved a letter of referral wth the proposed lne of management to hs or her fam ly physcan when a cancerous or precancerous le son was suspected Persons wth borderlne lesons or mnmal extent of precursor states were not re ferred so as to avod undue concern and medcal treat ment Four months after the campagn, persons wth a postve screen result were contacted for followup Those who dd not respond were approached agan after months The results of the Southern Lmburg campagn were compared wth those of two earler campagns n Arnhem n June 99 and n Endhoven n Octo ber 99 The screenngs n Arnhem and End hoven had been planned and executed n a smlar way, bt de precampagn publc releases had em phaszed skn cancer n general nstead of mela noma n partcular To test for dfferences between the two populatons, the x 2 statstc was used fndngs related to skn malgnant neoplasms The pro porton of screenees wth lesons clncally suggestve of melanoma was hgher n 99 than durng the cam pagns n Arnhem and Endhoven Together, melanoma and lentgo malgna were suspected n 7% of the screenees n 99, compared wth only n % n 99 (P=Q4) Lesons suggestve of nonmelanoma skn can cer were less numerous n 99 The proporton of per sons wth presumptve nonmelanoma skn cancer (basal Clncs n 99 and 99 99* V --v* lü,\r Sex dstrbuton l WÊMÏËÊÊ F > ;-v j ; * \ v J w v ^A -V - r v >5 ;r 4 > ;< / \ \ V y r A s 588 (4) S t * * * " -r- X- ll! % W V S Vf "V ll ** > 6-69, V - V/- A \ f < r \w-yx- *Arnhem and Endhoven, the Netherlands t Southern Lmburg, the Netherlands *, ^ - v " m -ty v ljmelanorrme«!^ - Av V! j ; ; m üííwaug, v ; l V - V ; ; A,, y- *, * > * * í cancers carcnoma v, * / ; <,- * t 5!v rtr***( *" _ s s * * o í! 72/69 (7) /6 (26) 9 < > V; ; t V v rr ; *f - - v ; - ; > \ r >? V 92/9 (7) ;/ í y V *Amhem and Endhoven, the Netherlands t Southern Lmburg, the Netherlands Numbers of malgnant neoplasms/numbers of attendees; percentages and P values relate to numbers of attendees and squamous cell carcnoma and Bowen s dsease) de creased from 7% n 99 to 26% n 99 (P=9) Data pertanng to precursor lesons and bengn skn condtons are presented n T ab le At two of sx cln cs n the Arnhem regon, no presumed dagnoses had been recorded, apart from skn malgnant neoplasms The total number of attendees wth evaluable data for pre cursor lesons and bengn skn marks n 99 was 87 The proporton of dysplastc nev had ncreased substan tally n 99 as compared wth 99 Also, common and congental nevocytc nev were more frequently encoun tered n 99 However, the proporton of freckles and solar lentgnes had slghtly decreased Actnc kerato ses were dstnctly more numerous n 99 than n 99 clncally bengn lesons derma tofbro mas eczema fectons, were less often seen durng the last screenng, all at a statstcally sgnfcant level ARCH DERMATOL/VOL, APR

4 NW more n Arnhem, tumor mcrostage was documented n Table Presumptve Dagnoses of Precursor Lesons and Bengn Condtons No (%) fve of sx cases; three of these were mm thck or more Ths shft to thnner lesons was statstcally sgnfcant 99* (n=87) (n=446) P (P=4, Mann-Whtney test) The proporton of screenees wth nonmelanoma skn cancer confrmed by pathologc examnaton was larger n Arnhem than n Southern Lmburg (2% and %, respectvely; P=) Nev T ab le 4 gves an overvew of the malgnant neoplasms Nevocellular 724 (99) 2 (56) < Dysplastc 8(2) 9 (77) < Congental 52 (29) 7 (89) < Halo (6) 4 () >5 Blue 9 (5) 24 (6) >5 Lentgnes, freckles 2 (66) 229 (55) >5 Keratoses Actnc 4 (6) 6 (5) < Seborrhec 6 () 8 (27) < Dermatofbromas 4 (74) 94 (47) < Vascular lesons 4(6) 24 () < Fbromas, skn tags 89 (49) 68 (4 ) >5 * * Cysts 62 (4) 27 (7) < Vral warts 4 (24) 9 (9) < confrmed by pathologc examnaton at follow-up The dfference n age dstrbuton of both study populatons prompted us to perform a logstc regresson analyss, ncludng sex and age n the model For all nevocel- lular lesons (common nev, congental nev, dysplastc nev, and melanoma), the odds ratos were statstcally sgnfcantly ncreased n the Southern Lmburg screenng as compared wth the Arnhem screenng The odds rato for melanoma, ncludng lentgo malgna, was 84 (95% confdence nterval, 6 to 292) C O M M E N T Eczema, psorass, fungal nfectons 82 () 5(28) * Arnhem and Endhoven, the Netherlands t Southern Lmburg, the Netherlands Table 4 Numbers of Malgnant Neoplasms Confrmed by Pathologc Examnaton No % < Screenng offers much potental for reducng mortalty from malgnant melanoma However, many questons about proper methods of screenng for skn cancer and melanoma and ts ultm ate value reman unanswered,2 Detecton campagns have defnte unwarranted effects n terms of creatng anxety and ncurrng extra health expendtures Snce 985, the Amercan Academy of Dermatology has been sponsorng open-access screenng clncs 7 Smlar clncs have been organzed * (n (n»446) P S n the Netherlands8" So far, attenton has been pad to both melanoma and nonmelanoma skn cancer Non- Melanomas Lentgo malgna 4 melanoma skn cancer s seldom lethal and does not warrant screenng Screenng confned to melanoma n Melanoma n stu nvasve melanomas < mm st mm Thckness unknown Totalt Nonmelanoma skn cancers Basal cell carcnoma Squamous cell carcnoma Bowen s dsease Total 6/6 () / /4(2) 44/42() 5 stead of screenng for skn cancer n general may consderably ncrease the yeld of postve screens Ths study shows that when specal emphass s placed on the rsk factors and symptoms of malgnant melanoma and ts precursor lesons n the publc announcements and press releases, the percentages of screenees attendng wth skn lesons clncally suggestve of common moles, congental nev, dvsülastc nev melanoma squamous M m M carcnoma * Arnhem, the Netherlands t Southern Lmburg, the Netherlands Numbers of malgnant neoplasms/numbers o f attendees; percentages and P values for nonmelanoma skn cancers relate to numbers of attendees Mann-Whltney U test, consderng leson thckness Follow-up of the persons wth presumed skn malgnant neoplasms seen n 99 was only acheved n the regon of Arnhem, wth 96 partcpants; no follow-up data were avalable for the clnc held n Endhoven, wth 52 screenees n 99, follow-up was accomplshed at all clncs n Southern Lmburg The proporton of melanomas confrmed by pathologc examnaton was smlar n both groups (%) Sx melanomas were dagnosed n Arnhem and n Southern Lmburg Most melanomas dagnosed n Southern Lmburg were early lesons only one patent had a melanoma mm thck or also apples to bengn skn condtons, eg, eczema, psorass, dermatofbromas, and seborrhec keratoses We also compared the bopsy-proved skn malgnant neoplasms between both campagns Sx melanomas were recorded n 99 one lentgo malgna and fve nvasve melanomas n the 99 campagn, melanomas were dagnosed four lentgo malgna lesons, three n stu superfcal spreadng melanomas, fve nvasve melanomas less than mm thck, and only one thck melanoma (2 mm) Although the proporton of confrmed melanomas n both programs was smlar (%), the relatve yeld of early lesons was dstnctly hgher n the 99 program (P=4) The total number of confrmed melanomas mght have been hgher n Southern Lmburg f all suspected melanoma cases had been followed up Follow-up was ncomplete for two possble melanomas and two cases of lentgo malgna n Arnhem all presumptve ARCH DERMATOL/VOL, APR

5 melanoma dagnoses were followed up The total of confrmed melanomas seems rather low There were 72 potental melanomas dagnosed, ncludng 7 lentgo malgnas, n 69 persons Sxty-eght tumors were adequately followed up Ths gves a postve predctve value of only 9% Ths low test performance probably results from the ncluson of many pgmented lesons wth low clncal suspcon among the presumptve melanoma dagnoses The yeld of hstologcally confrmed dysplastc nev was 48 n Arnhem only dysplastc nev were hsto- pathologcally confrmed Despte the ncomplete follow-up of persons wth presumed dysplastc nev n both screenng exercses, and the rather subjectve nterpretaton of dagnostc mnutae of dysplastc nev by ndvdual dermatologsts and hstopathologsts, we are confdent that the true rate of dysplastc nev was substantally hgher n the recent campagn The peak occurrence of cutaneous melanoma s at 4 to 5 years of age Nonmelanoma skn cancer generally afflcts the elderly Our 99 campagns exhbted a relatve excess of elderly persons wth peak attendance rates between 4 ancl 7 years The 99 seres showed a preponderance of aclult screenees, wth peak attendance rates between 2 and 5 years The shft toward a younger cohort s encouragng n ths respect, age s probably not a confounder Nevertheless, we executed a multvarate analyss, whch dsclosed screenng locaton to be an ndependent rsk varable n Southern Lmburg, Accepted for publcaton December, 994 Ths study was supported n part by a grant from the Comprehensve Cancer Centers KL (Maastrcht) and KO (Njmegen) These are nonproft governmentsupported bodes that deal wth the management, educaton, nte nsttutonal treatment strateges, and screenng of cancer on a regonal level Presented as a poster exhbt at the Amercan Academy of Dermatology Meetng, New Orleans, La, February 4-9, 995 The followng dermatologsts partcpated n the Lmburg screenng program P J M f Bessems, PhD, L E G Bossuyt, MD, T Deleu, MD, M J T Go, PhD, R F P J Hulsmans, MD, L C G Kerkhofs, MD, A M J van der Kley, MD, M j Korstanje, PhD, J C C A Lumbers, MD, H C j Lbertan, MD, P A F A van Neer, MD, R L M A Prevoo, MD, C ] G Sanders, MD, P J Velthus, PhD, K J M Vssers-Croughs, MD, and f Wute, PhD Thanks are due to P J M Berretty, PhD, B E W L van Huystee, MD, L A L M Kemeney, PhD, and C H H M Njs, MD, for help n the organzaton of the screenng exercses n Arnhem and Endhoven We would lke to thank Brgtte Gjsen and Rap de Rooj for ther assstance wth the organzaton of the clncs Sandra van Heertum was very helpful wth the data processng Correspondence to Department of Dermatology, Unversty Hosptal St Radboud, PO Box 9, 65 HB Njmegen, the Netherlands (Dr de Rooj) sgnfcantly more melanomas were clncally dagnosed than n Arnhem REFERENCES Attendees of skn cancer and melanoma screenng programs dffer from the general populaton n ther rsk profle4 People attendng n response to the multmeda publcty efforts seem to be at approprately hgh rsk Screenng exercses show a relatvely hgh yeld of confrmed skn cancers, as compared wth the expected harvest of prevalent cases from the general populaton,6,7, On the other hand, the proper value of self-examnaton and self-selecton as a screenng tool has been questoned5 To maxmze the yeld of screenng, t s mperatve to talor programs to attract those persons at hghest rsk Our survey demonstrates that precampagn messages must A most promsng fndng of our project s the decreased proporton of nonmelanoma skn cancers and certan precancerous states of low or neglgble clncal and epdemologc concern basal and squamous cell carcnomas actnc keratoses t s queston screenng procedures can alter the natural course of nonmelanoma skn cancer n a sgnfcant proporton of those screened One of the major drawbacks of the rather ttn- > o n cancer so screenng far n the Unted States and n the Netherlands s the ntaton of nsgnfcant and borderlne cases nto cal crcut Screenng only for melanoma may means of ncreasng the detecton rate of an and potentally lethal dsease Selectve screenng f o n Koh HK, Lew RA, Prout MN Screenng for melanoma/skn cancer theoretc and practcal consderatons J Am Acad Dermatol 989; Koh HK, Mller DR, Geller AG, et al Screenng for melanoma and other skn cancers Cln Dermatol 992;97- Rgel DS, Fredman RJ, Kopf AW, et al mportance of complete cutaneous examnaton for the detecton of malgnant melanoma J Am Acad Dermatol 986; Feld S Melanoma/skn cancer screenng n Mchgan J Am Acad Dermatol 987; Olsen TG, Feeser TA, Conte ET, et al Skn cancer screenng a local experence J Am Acad Dermatol 987; Bologna JL, Berwck M, Fne JA Complete follow-up and evaluaton of a skn cancer screenng n Connectcut J Am Acad Dermatol 99; Koh HK, Caruso A, Gage, et a Evaluaton of melanoma/skn cancer screenng n Massachusetts Cancer 99; Groenendal H, Rampen FHJ, Broekman JM Bevolkngsonderzoek naar hudkanker; ervarngen n Oss Ned Tìjdschr Geneeskd 99; Rampen FHJ, van Huystee BEWL, Kemeney LALM Molanoma/skn cancer screenng clncs experences n the Netherlands J Am Acad Dermatol 99; Rampen FHJ, van Huystee BEWL, Kemeney LALM Practcal consderatons of melanoma/skn cancer screenng clncs Dermatology 992;849-9 Rampen FHJ, Neumann HAM, Kemeney LALM Fundamentals of skn cancer/ melanoma screenng campagns Cln Exp Dermatol 992; McDonald CJ Status of screenng for skn cancer Cancer Elwood JM Screenng for melanoma and optons for ts evaluaton J Med Screenng 994; Koh HK, Geller AC, Mller DR, et al Who s beng screened for melanoma/skn may de- r of pernoma may mprove cost-e crease over sons wth mnor or c cancer? J Am Acad Dermatol 99; Rampen FHJ, Berretty PJM, van Huystee BEWL, et al Lack of selectve attendance of partcpants at skn cancer/melanoma screenng clncs J Am Acad Dermatol 99;