Secondary Prevention of Melanoma

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Secondary Prevention of Melanoma
Allan C. Halpern, MD Memorial Sloan Kettering
Cancer Center
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Outline

• Prevention- general concepts
• Melanoma prevention- growing complexity
• Specific strategies for melanoma prevention
• Aids to melanoma detection / diagnosis

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ENVIRONMENTAL EXPOSURE
Attributable mortality
PRIMARY- CURABLE
PRIMARY- INCURABLE
PRECURSOR
GENETIC SUSCEPTIBILITY
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Attributable mortality
PRIMARY- CURABLE
PRIMARY- INCURABLE
PRECURSOR
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Secondary Prevention
Attributable mortality
PRIMARY- CURABLE
PRIMARY- INCURABLE
PRECURSOR
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Outline

• Prevention- general concepts
• Melanoma prevention- growing complexity
• Specific strategies for melanoma prevention
• Aids to melanoma detection / diagnosis

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Nodular
Lentigo Maligna Melanoma
Acral Lentiginous Melanoma
Superficial Spreading Melanoma
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Melanoma
ENVIRONMENTAL EXPOSURE
?
Attributable mortality
PRIMARY- INCURABLE
PRIMARY- CURABLE
PRECURSOR
GENETIC SUSCEPTIBILITY
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Outline

• Prevention- general concepts
• Melanoma prevention- growing complexity
• Specific strategies for melanoma prevention
• Aids to melanoma detection / diagnosis

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Sun Protection as Melanoma Prevention

• VERY important, but
• Sunlight (UV) is not easily avoided
• Significant potential tradeoffs
• Vitamin D, Obesity, SAD
• Sun induced melanoma may be innately less
  aggressive
• Long latency- delayed effects

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Secondary Prevention (Early Detection)

• Self detection
• Physician detection

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Self Detection

• Accounts for the majority of melanoma diagnosis
• Offers the most bang for the buck
• Especially important in the absence of formal
  screening programs

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Keys to Early Self Detection

• Awareness
• Knowledge of warning signs
• Timely pursuit of evaluation / biopsy

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Self Examination

• Case control study 650 cases 549 controls
• Adjusted Odds Ratios
• melanoma 0.66
• advanced disease (MM patients) 0.58
• SSE may reduce melanoma mortality by 63

Berwick et al. JNCI 88(1)17-23, 1996
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Going beyond the ABCDs of Melanoma

• Asymmetry
• Border Irregularity
• Color variegation
• Diameter 5mm
• EMPHASIS ON CHANGE!!!

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Physician Detection

• Opportunistic screening
• Low priority
• Formal screening
• USPSTF, Canadian Task Force, American Cancer
  Society
• No RCT Insufficient data

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Australian Pilot Study of Skin Cancer Screening

• 9 towns
• Primary care screening

Aitken et al, J Am Acad Dermatol, 2006
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Barriers to Physician Detection

• Workforce issues
• Specialty specific expertise
• Relative priority among health promotional
  activities
• Shifting focus of cosmetic dermatology

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Outline

• Prevention- general concepts
• Melanoma prevention- growing complexity
• Specific strategies for melanoma prevention
• Aids to melanoma detection / diagnosis

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Imaging Aids for Early Detection and Improved
Diagnosis

• Dermoscopy
• Whole body photography (digital imaging)

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Dermoscopic evaluation of individual concerning
lesions
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Clinical
Dermoscopy
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Diagnostic accuracy
ROC Receiver Operating Characteristic
Dermoscopy experts
Dermoscopy non-experts
Clinical without dermoscopy
Kittler et al. Lancet Oncology 2002 3159-65
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Photographically assisted follow up of high risk
individuals
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Standardized poses
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B
A
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Summary

• Prevention- general concepts
• Melanoma prevention- growing complexity
• Specific strategies for melanoma prevention
• Aids to melanoma detection / diagnosis

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Action Points

• Raise public awareness / knowledge
• Lobby for physician education in skin cancer
  detection
• Grass roots demand for opportunistic screening
• Advocacy for secondary prevention research