report on early detection of skin cancer 2010

7/30/2019 Report on Early Detection of Skin Cancer 2010

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REPORT TO THE NEW ZEALAND SKIN CANCER STEERING COMMITTEE ON THE

EARLY DETECTION OF SKIN CANCER IN NEW ZEALAND

OVERVIEW

The purpose of this report is to inform the development of the early detection section of the

New Zealand Skin Cancer Control Strategic Framework 2011 to 2014. As recommended at

the meeting of the New Zealand Skin Cancer Steering Committee (SCSC), this report is based

upon a review of the Executive Summary of the 2006 Report on the Early Detection of Skin

Cancer in New Zealand developed by the Early Detection Advisory Group (EDAG).1

Undertaken by a sub-committee of the SCSC (membership appended), the review and

revision process has involved the updating of data and the inclusion of relevant evidence

and recommendations from the Clinical Practice Guidelines for the Management of

Melanoma in Australia and New Zealand2

and the Clinical Practice Guidelines for the

Management of Melanoma in Australia and New Zealand Implementation Plan.3

THE BURDEN OF SKIN CANCER IN NEW ZEALAND

Skin cancer, particularly melanoma, is an important health problem in New Zealand.

Melanoma incidence and death rates are among the highest in the world. In 2007,

melanoma was the fourth most commonly registered cancer (accounting for 11.1 percent of

all registrations) for both males and females.4

In 2007 there were 292 deaths from

melanoma. Rates of melanoma mortality appear to have increased slightly between 1997

and 2007, with the rate of death consistently higher for males than females.4

Mori, Pacific and Asian peoples in New Zealand develop skin cancer, including melanoma,

less frequently than New Zealand Europeans. Mori have about 1/10 the melanomaincidence rate of New Zealand Europeans.5 The incidence rate of melanoma is higher for

Mori than for Pacific peoples. Although Mori have a very low registration rate compared

to the New Zealand population as a whole, they have a greater than expected number of

cases with thicker lesions and more extensive disease at diagnosis.5

In contrast to melanoma, basal cell and squamous cell skin cancers (non-melanoma skin

cancers, or NMSC) are very common, especially in the elderly, with an estimated 67,000 new

cases every year in New Zealand.6 However, mortality from NMSC is lower compared to

mortality from melanoma, with 122 deaths from NMSC as compared with 292 deaths from

melanoma in 2007.7 Nevertheless, NMSC can cause disfigurement and morbidity and,

because of the large numbers involved, its treatment is costly to the health system. It isestimated that for the year 2006, the health-care costs of skin cancer (including NMSC and

melanoma) to New Zealand were NZ$57 million, with the amount for melanoma amounting

to$5.7M per annum.6

MELANOMA PROGNOSTIC FACTORS

For melanoma, the thickness of the lesion is the strongest predictor of prognosis; in general,

the thinner the lesion, the better the outcome. According to an analysis of New Zealand

data, advanced age, non-European ethnicity and nodular and acral lentiginous types of

melanoma are associated with thick melanomas.8


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The most common types of melanoma registered in New Zealand are superficial spreading

melanoma (with the highest incidence), nodular melanoma and lentigo maligna.9 The most

common sites for melanoma are different for men and women, with the leg being the most

common site for women, while the trunk is the most common site in men.9

Different types of melanoma differ in their natural history and tend to behave differently.While some thick melanomas arise from thin melanomas, others may arise de novo.

Therefore, it cannot always be concluded that thick melanomas develop from thin

melanomas or that thick melanomas are due to a delay in recognition, presentation and/or

diagnosis. For some melanomas, progression may be too rapid to permit early detection.

Some thin melanomas may never become thick; some may even regress.10

One type of melanoma, nodular melanoma, may arise de novo and usually is characterised

by rapid growth over a period of weeks or months (i.e., it becomes thick fast). Some other

types, e.g., superficial spreading and lentigo maligna melanomas, tend to develop more

slowly (months, sometimes years). For the slow-growing types, early recognition,

presentation and treatment while still thin are likely to result in a good outcome. As it is notyet possible to determine which will progress and which will not, best practice is to

completely remove lesions with clinical features consistent with melanoma.

Increasing the practice of skin examination either by doctors or laypersons and activities to

raise awareness of skin cancer/melanoma are likely to result in an increased detection and

recorded incidence of melanomas. It might be expected that this would result in the

detection of thin melanomas, thereby preventing their progression to thick melanomas.

However, it has not been shown that an increased detection of thin melanomas corresponds

to a reduction in the incidence of thick melanomas and an improvement in survival .11

EARLY DETECTION STRATEGIES

In order to better target early detection strategies to reduce mortality from skin cancer,

particularly melanoma in New Zealand, EDAG identified the need for additional, more

specific information (which is presently lacking) as to:

who is most likely to develop which type of melanoma (e.g., nodular) who is most likely to develop thick melanoma who is most likely to die of melanoma the extent to which delay in recognition/presentation/diagnosis occurs in New

Zealand and reasons for this.

Therefore, more research is needed on the above factors. Until this information becomesavailable it is difficult to identify strategies that will target those at greatest risk of

developing and dying from melanoma.

New Zealand research undertaken in 2003 showed a high level of awareness that melanoma

is a serious disease (and also that death from melanoma is thought to be more common

relative to other cancers than it actually is).12 While acknowledging the need for further

research to identify targeted strategies to reduce mortality, EDAG highlighted the

importance of ensuring that health professionals and the public have an adequate level of

knowledge.

Although there is consistent evidence that public education campaigns lead to a greaternumber and proportion of melanomas that are thin being detected, EDAG noted that it has


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not been shown that these result in a corresponding reduction in thick melanomas.

Furthermore, such campaigns can result in increased anxiety and unnecessary action, e.g.,

an increase in the proportion of inappropriate doctor visits and skin excision rates.13

Therefore, until we know whom we should target to reduce the incidence of thick

melanomas (knowing also that targeted campaigns should improve specificity and cost

effectiveness), EDAG identified the need for a general approach to a broad populationgroup.

This approach should enable the public to have an adequate level of understanding that

melanoma is a serious cancer by providing good quality information, while at the same time

acknowledging that knowledge doesnt necessarily translate into action.

EDAG also concluded that because there remains uncertainty about the natural history of

melanoma, the most at risk groups and the different outcomes for different types, the early

detection of skin cancer, particularly melanoma, does not lend itself to a mass media

campaign. EDAG therefore recommended strategies that will provide high-quality

information on skin cancer, particularly melanoma, such as the information programmesdeveloped by the Cancer Society for prostate and breast cancers.

Knowing what we know (and dont know), thickness is the best predictor of risk of death

from melanoma. According to an analysis of data from 1994-2004, of those diagnosed with

melanoma, the proportion with thick melanoma (>3.0 mm) was greater for older than

younger people (with the proportion of thick melanomas increasing with age), for males

compared with females, for Mori compared with non-Mori (despite the lower incidence in

Mori), and for those diagnosed with nodular melanoma compared with other types of

melanoma.8

Having considered these factors, EDAG recommended that an information programmeaimed at reducing melanoma deaths should focus on all adults, particularly those 50 years of

age and over. EDAG also recommended that these programmes should:

include information for Mori and Pacific peoples address nodular melanoma ensure older men are targeted.

EDAG recommended that the information programme should begin with information for

health professionals to ensure they have a good understanding of risks, diagnosis and the

management of skin cancer, particularly melanoma. EDAG emphasised that It would be

unethical to promote public education without first ensuring that primary care providers

(including GPs) are well equipped to manage skin cancer, particularly melanoma.

The overall objectives of the programme would be to:

provide information to assist health professionals in their understanding of risks,diagnosis and the management of skin cancer, particularly melanoma

increase knowledge about skin cancer, particularly melanoma, among otherrelevant health workers (e.g., physiotherapists, beauty therapists, etc)

ensure an adequate level of knowledge about skin cancer, particularlymelanoma, in all adults, particularly those aged 50 years and over

improve the quality of information currently available to all adults, particularlythose 50 years and over, including what to look for and specific information on

nodular melanoma, as nearly half (46.7%) of thick (>3 mm) melanomas arenodular14,15


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encourage people to consult a doctor about suspicious lesions.Target audiences would be:

intervention groups- health professionals and health workers

- professional and public media population segment

- all adults, particularly those 50 years and older.

The Clinical Practice Guidelines for the Management of Melanoma in Australia and New

Zealand Implementation Plan3

also identifies the need for both consumer awareness of

melanoma as well as increased general practitioner recognition of suspicious lesions. With

regard to consumers, the Plan cites the New Zealand Guidelines Group publication

Melanoma: Information for you, your family, whnau and friends16

as an example of

guideline-based information. With regard to general practitioners, the Plan recommends

specific initiatives to increase GP awareness and knowledge of guideline best practice

relating to early detection, diagnosis and management of primary melanoma. These includethe delivery of four regional melanoma forums/workshops and the development of

resources to support self-funded continuing medical education (CME).

OTHER RECOMMENDATIONS RELATING TO EARLY DETECTION

In addition to strategies to maintain a high level of awareness among both the public and

health professionals, EDAG considered other early detection policies and strategies. With

regard to these, and for the reasons outlined in its report, EDAG made a number of

additional recommendations.

EDAG did not recommend the practice of skin check (sometimes referred to as spot check)programmes/clinics outside of established medical practice. In EDAGs view, this is because

they have not been evaluated and because of concerns about the possibility of:

inadequate follow up and referral inadequate lighting (which could result in a lesion being missed) lack of privacy examination of single lesions without a full body examination the risk of creating a false sense of security among consumers.

EDAG also recommended monitoring and evaluation of existing skin check

programmes/clinics, which would provide useful information about their effectiveness.

EDAG also recognised that skin screening, defined as a visual inspection of the whole body,

could be one method of achieving early detection. EDAG concluded, however, that

screening did not meet the 2005 Cancer Society criteria for endorsement.17 Of particular

significance to EDAG was:

the absence of high quality evidence from a randomised controlled trial thatscreening is effective in reducing mortality, therefore its value is unknown

the inability to conclude whether or not screening for skin cancer does moregood than harm (possible harms including unnecessary biopsies and treatment).

As a result EDAG recommended that:

population screening for melanoma, basal cell cancer or squamous cell skincancer should not be endorsed or promoted in New Zealand


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opportunistic screening by health professionals should not be encouraged asroutine practice. In situations where screening is undertaken, it should be done

on the basis of informed choice. Individuals should be informed about the

potential benefits and risks of screening and the likely implications of a positive

or negative result.

EDAG highlighted the need for clinicians to remain alert for skin lesions with malignant

features in the context of physical examinations performed for other reasons.

EDAG also recommended that all adults, particularly those 50 years of age and over, should

regularly examine their skin (including skin not normally exposed to the sun) so that they will

be aware of any changes; they should ask for help from someone else to check difficult to

see areas, such as their back. Those who are concerned about skin changes should seek

advice from a doctor.

More recently, the Clinical Practice Guidelines for the Management of Melanoma in

Australia and New Zealand have addressed the issue of screening by whole-body visualinspection. According to the evidence summary in the screening chapter, no adequate

randomised controlled intervention study has been conducted to see if whole-body skin

examination is effective in reducing mortality from melanoma. The Guidelines conclude

that in the absence of substantive evidence as to its effectiveness in reducing mortality

from melanoma population-based skin screening cannot be recommended.2

EDAG also acknowledged broad agreement that those at high risk of developing melanoma

represented a small but important population group that should be identified and offered

surveillance. However, the report states that most surveillance recommendations had not

been evaluated regarding their effect on incidence or mortality.

EDAG therefore recommended that:

an evidence-based approach to the development of guidelines for surveillanceof melanoma be adopted in New Zealand

comparative New Zealand studies are undertaken to measure sensitivity andspecificity of diagnostic technologies in comparison with visual skin inspection.

EDAG also recommended that:

self-administered risk assessment tools for New Zealand be developed andtested

a prognostic index or risk chart for melanoma in New Zealand conditions isdeveloped.

The Clinical Practice Guidelines for the Management of Melanoma in Australia and New

Zealandalso identify the need for identification and management of high-risk individuals.

The Guidelines provide an evidence summary of the major risk factors for melanoma,

recommending that clinicians take these into account in assessing risk. However, as noted in

the Clinical Practice Guidelines for the Management of Melanoma in Australia and New

Zealand Implementation Plan, many of the best-known risk factors (e.g., skin and hair

pigmentation, sunburn family history of melanoma) confer a relatively small increase in risk

(two-fold or less) on their own. Furthermore, as both the Guidelines and the Plan note,

currently there are no accepted algorithms for clinical estimation of melanoma risk at an

individual level. The Plan highlights that this is of particular importance for the majority ofthe New Zealand population who have multiple correlated risk factors.


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With regard to the evidence base for the surveillance of those at high risk, the Guidelines

conclude that although these individuals may benefit from regular clinical surveillance and

education to self screening, there is no evidence to compare the relative effectiveness of

specific surveillance techniques in high-risk patients, as opposed to those at average risk.2

Nevertheless, the Guidelines recommend that:

Individuals at high risk of melanoma and their partner or carer be educated to

recognise and document lesions suspicious of melanoma, and to be regularly

checked by a clinician with six-monthly full body examination supported by total

body photography and dermoscopy as required.

It should be noted that this recommendation has a C grading, indicating that it is based

upon a body of evidence that provides some support but for which care should be taken in

its application.2

Both the EDAG report and the Guidelines Implementation Plan are consistent in theirrecommendation for the development of a high risk assessment tool specific to New Zealand

for clinicians to identify individuals at high risk, with a view to assisting them in the provision

of individualised prevention, early detection and surveillance advice.

RECOMMENDED PRIORITIES FOR SKIN CANCER CONTROL STRATEGIC FRAMEWORK

Having reviewed the recommendations of the Report on the Early Detection of Skin Cancer,

of the Clinical Practice Guidelines for the Management of Melanoma in Australia and New

Zealand and of the Clinical Practice Guidelines for the Management of Melanoma in

Australia and New Zealand Implementation Plan, the sub-committee of the Skin Cancer

Steering Committee recommends the following priorities for the New Zealand Skin CancerControl Strategic Framework 2011 to 2014.

With regard to the early detection pathway, the priorities should be:

Increase awareness and knowledge of Guideline best practice relating to earlydetection of melanoma among health professionals involved in primary care (as

recommended at the meeting of the SCSC)

Increase awareness and knowledge about skin cancer, particularly melanoma,among other relevant health workers

Ensure an adequate level of knowledge about skin cancer, particularly melanoma,among all adults, particularly those 50 years and over.

With regard to the research and surveillance pathway, the priorities should be:

Undertake research to better target early detection strategies to reduce mortalityfrom skin cancer, particularly melanoma, in New Zealand

Undertake research to inform the development of a melanoma high risk assessmenttool specific to New Zealand.

10 November 2010


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Members of the Early Detection Sub-Committee of the Skin Cancer Steering Committee

Associate Professor Brian Cox

Director

Hugh Adam Cancer Epidemiology UnitDepartment of Preventive and Social Medicine

School of Medicine

University of Otago

Dr Judith Galtry

Advisor Skin Cancer Control

Cancer Society of New Zealand

Betsy Marshall

MelNet Coordinator

Dr Tony Reeder

Director and Principal Investigator

Cancer Society Social and Behavioural Research Unit

Department of Preventive and Social Medicine

University of Otago

Dr Mary Jane Sneyd

Hugh Adam Cancer Epidemiology Unit

Department of Preventive and Social Medicine

School of Medicine

University of Otago


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References

1 Early Detection Advisory Group. Report on the Early Detection of Skin Cancer in New

Zealand. Unpublished report. Wellington: HSC and the Cancer Society of New Zealand,

2006.

2 Australian Cancer Network Melanoma Guidelines Revision Working Party. Clinical Practice

Guidelines for the Management of Melanoma in Australia and New Zealand. The Cancer

Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines

Group, Wellington, 2008.

3New Zealand Guidelines Group. Clinical Practice Guidelines for the Management of

Melanoma in Australia and New Zealand: Implementation Plan. Unpublished report for the

Ministry of Health. Wellington: New Zealand Guidelines Group, 2010.

4 Ministry of Health. Cancer: New Registrations and Deaths 2007. Wellington: Ministry of

Health, 2010.

5 Syeyd MJ and Cox B. Melanoma in Mori, Asian and Pacific peoples in New Zealand.

Cancer Epidemiol Biomarker Prev2009;18(6): 1706-13.

6 ODea, D. The Costs of Skin Cancer to New Zealand. Wellington: Cancer Society of New

Zealand, 2009.

7 Ministry of Health. Data tables. Cancer: New Registrations and Deaths 2007. Wellington:

Ministry of Health. http://www.moh.govt.nz/moh.nsf/pagesmh/10173/$File/cancer-reg-

deaths-2007.pdf

8Richardson A, Fletcher L, Sneyd M, Cox B, Reeder AI . The incidence and thickness of

cutaneous malignant melanoma in New Zealand 1994-2004. NZ Med J 2008; 121(1279):18-

26.

9 Richardson A, Fletcher L. Melanoma 1994-2004: Report for the Early Detection of Skin

Cancer Advisory Group. 2006. (Unpublished report)

10 Burton RC, Armstrong BK. Non-metastasizing melanoma? Journal of Surgical Oncology

1998;67:73076.

11

McPherson M, Elwood M, English D, Baade PD, Youl PH, Aitken JF. Presentation anddetection of invasive melanoma in a high-risk population. Journal of the American Academy

of Dermatology2006;54(5): 783-792.

12 Reeder A, Trevena J. Adults perceptions of the causes and primary prevention of

common fatal cancers in New Zealand. NZ Med J 2003;116 (1182): 1-10.

13Del Mar CB, Green AC, Battistutta D. Do public media campaigns designed to increase skin

cancer awareness result in increased skin excision rates? Australian and New Zealand

Journal of Public Health 1997;21(7):751-754.


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14 Chamberlain AJ, Fritschi L, Giles GC, Dowling JP, Kelly JW. Nodular type and older age as

the most significant associations of thick melanoma in Victoria, Australia. Archives of

Dermatology 2002;138: 609-614.

15

Demierre MF, Chung C, Miller DR, Geller AC. Early detection of thick melanomas in theUnited States: beware of the nodular subtype. Archives of Dermatology2005;141(6): 745-

750.

16 New Zealand Guidelines Group. Melanoma: Information for you, your family, whnau and

friends. Wellington: New Zealand Guidelines Group, 2008.

17Cancer Society of New Zealand. Criteria for Cancer Society of New Zealand Assessment,

Endorsement and Identification of Action Relating to Cancer Screening. Wellington: Cancer

Society of New Zealand, 2005.

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