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Screening for melanoma in adults and adolescents

Screening for melanoma in adults and adolescents
Authors:
Alan C Geller, RN, MPH
Susan Swetter, MD
Section Editors:
Joann G Elmore, MD, MPH
Hensin Tsao, MD, PhD
Deputy Editor:
Jane Givens, MD, MSCE
Literature review current through: Sep 2022. | This topic last updated: Oct 04, 2021.

INTRODUCTION — The incidence of melanoma skin cancer, the most fatal form of skin cancer, is increasing faster than any other potentially preventable cancer in the United States [1].

Screening for melanoma refers to the routine examination of asymptomatic individuals to identify suspicious lesions that require evaluation to establish a diagnosis. This topic discusses screening for melanoma with a skin examination, either during a clinical examination by a primary care clinician or by patient self-examination.

Specifics about clinical features and diagnosis of melanoma, risk factors for melanoma, inherited susceptibility to melanoma, primary prevention of melanoma, melanoma in children, and staging of melanoma are discussed separately:

(See "Melanoma: Clinical features and diagnosis".)

(See "Risk factors for the development of melanoma".)

(See "Inherited susceptibility to melanoma".)

(See "Primary prevention of melanoma".)

(See "Melanoma in children".)

(See "Tumor, node, metastasis (TNM) staging system and other prognostic factors in cutaneous melanoma".)

Skin examination can also detect skin cancers that have a more favorable prognosis than melanoma, including basal cell and squamous cell carcinomas that require excision. These are discussed separately. (See "Treatment and prognosis of basal cell carcinoma at low risk of recurrence" and "Treatment and prognosis of low-risk cutaneous squamous cell carcinoma (cSCC)".)

EPIDEMIOLOGY AND CLASSIFICATION — The age-standardized annual incidence of melanoma worldwide is estimated at 22 in 100,000 people and has been increasing in the past decades [2-4]. However, it is not clear to what extent this represents an increase in true disease occurrence, or an increase in thin melanoma diagnosis due to greater screening or change in biopsy rates or histopathologic diagnosis [5].

Most melanomas arise as superficial indolent tumors that are confined to the epidermis, where they remain for several years. During this stage, the horizontal or "radial" growth phase, the melanoma is almost always curable by surgical excision alone. Melanomas that infiltrate deep into the dermis are in a "vertical" growth phase and have metastatic potential. A definitive diagnosis of melanoma is made by pathological analysis of a biopsy of the lesion. (See "Melanoma: Clinical features and diagnosis", section on 'Diagnosis confirmation' and "Pathologic characteristics of melanoma", section on 'Growth phases of melanoma'.)

Melanomas occur in sun-exposed and in non-sun-exposed areas. Non-sun-exposed melanomas are less readily detectable and less responsive to available treatments due to differences in tumor biology between those in non-sun-exposed and sun-exposed areas. Sun exposure is less of a risk factor among darker-skinned persons [6]. (See "Systemic treatment of metastatic melanoma with BRAF and other molecular alterations" and "Systemic treatment of metastatic melanoma with BRAF and other molecular alterations", section on 'KIT mutations (acral and mucosal melanoma)'.)

Melanoma that is confined to the epidermis (eg, melanoma in situ) is generally cured following surgery or other types of treatment. For people with invasive melanoma, five-year survival rates average over 90 percent. Survival rates depend on the stage of the disease at the time of diagnosis, and survival declines steadily as tumor thickness and disease stage increase. (See "Pathologic characteristics of melanoma", section on 'Melanoma in situ' and "Tumor, node, metastasis (TNM) staging system and other prognostic factors in cutaneous melanoma", section on 'Eighth edition AJCC TNM staging' and "Pathologic characteristics of melanoma".)

The four major subtypes of invasive cutaneous melanoma (ie, superficial spreading, lentigo maligna, acral lentiginous, and nodular melanoma) are described elsewhere (table 1). (See "Pathologic characteristics of melanoma".)

RISK FACTORS — Risk factors for melanoma incidence include genetic, phenotypic, and environmental factors (table 2) and are discussed in detail elsewhere (see "Risk factors for the development of melanoma").

In addition, there are also certain characteristics that place patients at higher risk of dying from melanoma:

Skin of color – Although there is a far lower incidence of melanoma among Black patients, the five-year relative survival is lower than for White patients (69 versus 93 percent) [7,8]. The same trends have been observed in the Hispanic American population, who have a low incidence of melanoma but demonstrate a growing burden of disease and greater likelihood of presenting with advanced disease compared with non-Hispanic White individuals [9,10].

Greater mortality in patients with skin of color (eg, skin phototypes IV to VI) (table 3) may be due to delayed diagnosis due to a lower perceived risk of disease or lower rates of skin examinations, locations of melanoma in atypical non-sun-exposed areas (eg, leg, hip, and feet), a higher proportion of acral and nodular subtypes, and a decreased ability to seek care for localized disease [11-14].

White males over age 50 – Nearly 50 percent of melanoma deaths in the United States occur among White men over age 50, and men in this age group have been found to have a higher risk of death due to melanoma than women in the United States, New Zealand, Australia, and the United Kingdom (particularly West Scotland) [3,15]. Poorer melanoma survival for men may be explained both by differences in tumor biology and by differences in skin awareness, self-examination, and other early detection practices [16-21].

APPROACH TO SCREENING

Overview — Not all organizations recommend skin cancer screening. The US Preventive Services Task Force (USPSTF) states that there is inadequate information to make a recommendation for or against population-based screening [22], while other groups such as the Australian Cancer Network and the Canadian Cancer Society suggest screening in high-risk populations [23,24]. Mass skin cancer screening of the entire population is unlikely to be beneficial, feasible, and/or cost-effective.

We suggest targeted screening of higher-risk groups, along with focused patient and provider education on acral/mucosal melanoma risk and warning signs in people of color. Our approach places a high value on melanoma detection among high-risk patients in the primary care setting.

We do not use risk assessment tools to determine which patients need screening as these have limited applicability and may be more complex than asking the patient directly about risk factors [15-20].

If a skin lesion is found, the clinician should make appropriate referrals (to dermatology where possible) for further evaluation of all lesions with prominent features of the ABCDE rule (asymmetry, border irregularity, color variegation, diameter >6 mm, evolution), the “ugly duckling” sign (a pigmented lesion that is visibly different from the others in a given individual), the Glasgow seven-point checklist, or other concerning signs or symptoms (eg, itching, bleeding, a lesion growing under a nail or as a pigmented line in a nail) [25]. These clinical prediction rules are discussed in further detail elsewhere. (See "Melanoma: Clinical features and diagnosis", section on 'Indications for referral' and "Melanoma: Clinical features and diagnosis", section on 'Clinical prediction rules'.)

Surveillance of patients in melanoma-prone kindreds is described separately. (See "Inherited susceptibility to melanoma", section on 'Surveillance in melanoma-prone kindreds'.)

Genetic testing may be useful to detect increased risk for melanoma only in very limited situations, generally for patients with multiple family members with melanoma. This is described separately. (See "Inherited susceptibility to melanoma".)

High-risk patients — For patients at high risk for either developing melanoma, or for mortality due to melanoma, we suggest annual screening with a full-body skin examination by a clinician with skin expertise. The screening examination can take place either during a routine health maintenance visit or another encounter. These patients include those with any of the following characteristics:

White adults age 50 and above.

Total nevus count above 50 and/or presence of large (atypical/dysplastic) nevi. (See "Risk factors for the development of melanoma", section on 'Number of nevi' and "Melanoma: Clinical features and diagnosis", section on 'History and risk factors'.)

Personal history of skin cancer.

Immunosuppression, particularly chronic use of medications that suppress the immune system such as that used by organ transplant recipients. (See "Epidemiology and risk factors for skin cancer in solid organ transplant recipients".)

Very sun-sensitive individuals and those with “red hair phenotype” (eg, light skin pigmentation, red or blond hair color, high-density freckling, and light eye color [green, hazel, blue]).

A family history of melanoma in one or more first-degree relatives or in more than one second-degree relative on the same side of the lineage. Those with at least three affected members (including one or more first-degree relatives) on one side of the family are at very high risk.

Non-high-risk patients — We suggest not providing routine screening with full-body clinical skin examination in non-high-risk patients. This advice is in keeping with other expert groups including the USPSTF, the Australian Cancer Network, and the Cancer Council Australia [22,23,26].

However, we do suggest the clinician carefully observe the skin of all patients undergoing a physical examination in the course of a routine or sick visit (opportunistic case finding), particularly in those areas of the skin that are hard for patients themselves to see. A focused skin examination of the palms, soles, and digits may be of value in people with darker skin, who are more likely to have acral melanoma (rather than ultraviolet radiation-related melanoma).

Advice to patients — We educate all patients about melanoma risk factors and appearance. We advise them to look at and be familiar with their skin and to alert their clinicians if they note changing moles or other suspicious skin lesions. People with darker skin should be educated about examination of the soles/palms/digits.(See 'Patient self-examination' below.)

If a partner, family member, or friend is assisting the patient in examining the skin, it is helpful to have that individual be familiar with the patient’s existing moles so they can identify the ones that change, particularly in hard-to-see areas. Photographs can be helpful for this. (See "Melanoma: Clinical features and diagnosis", section on 'Support techniques for clinical diagnosis'.)

All patients should be educated about the importance of sun protection for melanoma prevention. (See "Primary prevention of melanoma", section on 'Sun protection'.)

PERFORMING SKIN EXAMINATION — Methods to screen for melanoma involve visual examination of the skin. Both clinicians and patients should have a systematic approach and need to know what to look for in order to perform an effective total body skin examination.

Clinician total body skin examination — The clinician performing a total body skin examination should standardize the order in which the examination is performed, both to ensure completeness and because the clinician examination serves as a model for patient skin self-examination. Thus, if a clinician ignores an area, it may convey the unintended message to the patient that this area is unimportant and that they can ignore it as well.

Melanomas can occur anywhere on the skin surface. Screening the total skin surface, including the scalp and soles of the feet, all of which are harder to view with self-examination, could aid early detection. Relative to their incidence, scalp lesions have greater mortality, and this area should be examined carefully by clinicians. Men have more lesions of the back whereas women have more lesions on their lower legs, since these are common areas for sunburn and sun exposure [27]. (See 'Effectiveness of screening' below.)

Clinician examination for skin cancer can be carried out in a few minutes, with the following tools and technique:

Tools

Source of bright light

Magnifying lens

For health providers trained in its use, a dermatoscope (see "Overview of dermoscopy")

Perform the skin examination in a systematic order

Seated examination of:

-Face, head and neck

-Scalp (part the hair or use a blow dryer)

-All surfaces of arms and hands

-Axilla

Seated or standing examination of the posterior aspect of the upper body

Supine examination of the chest, abdomen, anterior thighs and legs, dorsal feet, soles, and toe webs

Prone examination of the calves, posterior thighs, buttocks, and back

Patient self-examination — In self-examination, particular attention must be devoted to screening of the back, particularly for men, because approximately one-half of melanomas occur on the trunk on men [28-30] and approximately one-third on the back [31]. It is difficult to perform self-examination of the back, so partners, friends, or family may need to participate in the examination. If patients cannot examine their back or do not have someone else to do this, they should be requesting such examinations from their clinician.

Having a partner involved in skin self-examination may increase the rates of self-examination performance and melanoma detection. It is helpful to have that individual know the patient’s moles as well so they can identify the ones that change, particularly in hard-to-see areas. Patients and/or partners can also take photographs of suspect moles [32]. Patients who detect a suspect skin lesion should contact their clinicians promptly for further evaluation.

Tools

Full-length mirror

Hand mirror (for closer inspection of the back of the neck, scalp, back, and buttocks)

Perform the skin examination in systematic order

Entire front and back of the body

Sides of the body with arms raised

Palms, forearms, upper arms, and axillae

Back of the legs and feet, toe web spaces, and soles of feet

Recognizing melanoma — Certain tools can help clinicians and patients identify lesions to evaluate further for melanoma. These include the "ugly duckling" sign, the ABCDE rule of melanoma (picture 1), and the Glasgow revised seven-point checklist. However, melanomas in prepubertal and pubertal children often lack the conventional ABCDE criteria and may be clinically amelanotic (nonpigmented). The clinical features of melanoma are discussed in detail elsewhere. (See "Melanoma: Clinical features and diagnosis" and "Melanoma: Clinical features and diagnosis", section on 'Clinical prediction rules'.)

Detecting melanoma in children is discussed separately. (See "Melanoma in children", section on 'Physical examination'.)

Examples of typical melanomas are shown in photographs (picture 2A-I). Further photographs are provided elsewhere. (See "Melanoma: Clinical features and diagnosis".)

RATIONALE FOR SCREENING — The benefits of screening for melanoma may seem straightforward because the prognosis of melanoma is significantly better for early-stage (thinner) melanoma which is curable by simple excision compared with later-stage melanoma. In addition, visual skin examination is safe and well tolerated by patients, and risk factors for melanoma are readily identifiable [33,34].

However the harms of screening for melanoma include the potential that false-positive findings on skin examination will lead to an increased number of dermatology referrals and unnecessary biopsies, and the possibility of overdiagnosis (ie, the diagnosis of melanoma that is either biologically indolent or so slow-growing that it would never become clinically meaningful during the patient’s lifetime). (See 'Harms of screening' below.)

Further, the effectiveness of a screening skin examination depends on several factors including the clinician’s ability to identify early-stage disease, the natural history of melanomas subtypes, the pathologist’s ability to diagnose and histologically stage the disease, and identification of the tumor at a stage where treatment would be more effective.

The effectiveness of screening is also influenced by the fact that not all subtypes of melanoma have biologic and clinical factors that are conducive to recognition by visual examination, particularly the nodular melanoma subtype, which may be clinically amelanotic [35-38]. In addition, some melanomas may be clinically unrecognizable, and the detectable preinvasive phase may be absent, as with some nodular melanomas, or too short in duration to be detected by periodic skin examination.

EFFECTIVENESS OF SCREENING

Overview of available data — Randomized trial data are not available for melanoma screening, and therefore it is not certain that screening will result in decreased mortality due to melanoma [21,22]. A randomized trial of screening is likely not feasible, as it has been estimated that approximately 800,000 participants would be required to detect a difference in mortality because of the relatively low melanoma mortality rate [21].

Data are available from observational studies; however, in general, observational studies are subject to potential study bias (lead time bias, length bias) (see "Evidence-based approach to prevention", section on 'Special biases'). Further, the observational studies about melanoma screening vary as to who performed the screening, which target populations were screened, and which components of care were included as screening. For example, in some studies screening was directed at all individuals (eg, population-based screening), and in others screening was targeted to only those with specific risk factors. Some studies of "screening" for melanoma extended their scope to include forms of early diagnosis (examination of patients with a concern about a skin lesion, termed “lesion directed screening” but not “screening” by a clinician of an asymptomatic individual), and some studies incorporated patient education programs in addition to screening [35].

Clinician screening

Uncertain effect on mortality — The best observational data about the effect of clinician screening on mortality rates include a large year-long population screening effort in Germany, the Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany project (SCREEN), in which clinician skin examination was associated with melanoma mortality reduction five years after the screening program, although the mortality reduction did not persist in longer-term follow-up [39-42].

The SCREEN pilot study began with a program to generate intensive public and professional awareness, followed by offers for screening by general practitioners. Among 1.9 million adults, 360,000 chose to be screened (three-quarters of participants choose screening by a non-dermatologist trained in skin examination). Overall, 620 persons needed to be screened to detect one melanoma. Ninety percent of melanomas detected by screening were less than 1 mm thick. Five years following the screening effort, despite a screening participation rate under 20 percent, mortality from melanoma among adults in the pilot program area was nearly 50 percent lower than in the rest of Germany and contiguous Denmark and was lower than expected based on historical rates. However, the mortality decline seen at the five-year mark was not sustained; two years later, mortality rates returned to the pre-screening level [43]. Further, a subsequent analysis raised questions about the reliability of the ICD-10 codes used to determine cause of mortality in the study; during the time when melanoma deaths decreased, there was an unexplained increase in codes indicating deaths due to malignant neoplasms of ill-defined, secondary, and unspecified sites [43]. The pilot study also had methodological limitations in that it lacked randomization, an internal control group, and individual level data [44].

In contrast to the mortality benefit observed at five years in the SCREEN pilot study, a subsequent nationwide program in Germany to offer adults aged ≥35 years skin cancer screening every two years demonstrated no measurable decline in melanoma mortality through five years of follow-up [42,43,45-47].

Other observational studies have not identified an association between clinician examination and survival from melanoma. A 20-year survival analysis of a large cohort of cases confirmed the lack of association between skin self-examination, clinician examination, or casual skin examination and death from melanoma [48].

Effect on melanoma thickness — Observational studies have consistently shown that melanomas detected by clinicians during a skin examination are thinner than those found by patients or their significant others [31,49-59]. Because melanoma thickness is associated with prognosis (thinner melanomas have a substantially more favorable prognosis), it has been considered a surrogate marker for melanoma mortality. Identification of thinner melanomas thus supports a benefit of screening.

Examples of screening effect on thickness include:

A population-based case-control study in Queensland, Australia showed that, when compared with unscreened patients, primary care clinician screening was associated with thinner melanoma lesions [53]. Melanoma lesion thickness was thinner among patients who reported having a full skin examination by a clinician during the three years preceding a diagnosis of melanoma, compared with those who had not had a skin examination. Screened patients had a 14 percent lower risk for a lesion >0.75 mm thick. The decrease in risk was greatest for the thickest melanomas (risk reduction 40 percent for lesions ≥3 mm).

Similarly, in the Western Pennsylvania primary care physician-based screening intervention, clinician screening was associated with a higher rate of melanoma diagnoses, including increased diagnoses of stage T1 (≤1 mm) melanoma and melanomas in situ, but not thicker melanomas [60].

Uncertain effect of clinician specialty and training — Study results vary as to whether there are differences between the results of skin examination by dermatologists and primary care clinicians.

Some studies show that detection by a dermatologist rather than a non-dermatologist results in thinner and earlier-stage lesion detection [54,61,62]. Other studies found no difference between dermatologist and primary care clinician examination [63]. A systematic review of 32 studies concluded that the available data were inadequate to demonstrate differences between dermatologists and primary care physicians in diagnostic accuracy of lesions suggestive of melanoma [64].

The value of clinician training to detect melanoma has been demonstrated in several studies. Few medical professionals have specific education in early detection of melanoma [65-69]. Dermatologists have been found to be better at detecting melanoma by photographs than primary care physicians [70]. In a population-based screening program in the United States, the rate of melanoma diagnosis rose almost 80 percent among patients screened at practices with the highest proportion of providers trained using INFORMED (INternet curriculum FOR Melanoma Early Detection), an online educational system for primary care clinicians [67,71-73]. Outcomes among patients could not be directly compared due to the absence of individual patient-level data.

Patient self-examination efficacy — A few retrospective and case-control studies have associated patient self-examination of the skin with the detection of thinner tumors, a reduced risk of advanced melanoma, and reduction in mortality [54,58,74-76]. However, the studies have limitations, and overall, data in support of self-examination are limited.

A prospective workplace time series conducted in northern California from 1965 to 1996, involving a pre-awareness, education, and skin screening program, resulted in a reduction in the incidence of thicker melanoma and a lower-than-expected death rate compared with the statewide cancer registry statistics over the time period assessed [77].

Lesion-directed evaluation, in which clinicians examine lesions identified by patients using predetermined criteria, required less time and resulted in similar melanoma detection rates as total skin examination in a study that compared total body examination by experienced dermatologists in two sociodemographically similar regions in Belgium [78]. Lesion-directed evaluation showed a similar detection rate (2.3 versus 3.2 percent) but was 5.6 times less time-consuming. Further investigation of public education leading to lesion-directed evaluation may show a cost-benefit for patients and practitioners.

However, even many individuals at a high risk of melanoma do not do skin self-examination [79,80]. Rates of self-examination may be increased by programs that involve computer-assisted patient education, telecommunication reminders, partner hands-on tutorials, partner involvement in skin self-examination, cues and aids, brief counseling and follow-up telephone call, and tailored feedback letters [81-83]. In a two-year randomized trial including 494 melanoma patients and their partners, the effect of a structured educational intervention on the performance of skin self-examination and early detection of new melanomas was examined [82]. During the two years of follow-up, a total of 66 patients (13.4 percent) developed a new melanoma. In the group receiving the intervention, 43 melanomas (33 in situ) were identified by patients or their partners and 10 by clinicians; by contrast, all 16 melanomas in the control group were identified by clinicians and none by the patient-partner pairs.

A survey tool for patients to assess their awareness of freckling, moles, and atypical nevi may help high-risk patients become aware of their risk status by identifying their own skin findings that place them at increased risk [16]. With this tool, concordance between the patient's report and the clinician’s skin examination, measured on a scale where 1 = perfect agreement, was good for freckles (0.67), moderate to good for moles (0.60), and moderate for atypical nevi (0.43).

Feasibility of community screening — A randomized trial of population screening in Australia, where the rate of melanoma is higher than in most other countries, showed that community-based melanoma screening programs are feasible [84]. The trial included three components: community education to provide information about melanoma and screening, education and support for medical practitioners to improve clinician skills, and free skin-screening services. The study design called for randomizing 44 Queensland communities, but this was not completed due to lack of funding. Rates of performance of the whole-body skin cancer examination were measured by surveys of residents [84,85]. Baseline screening rates were similar in intervention and control towns (11.2 and 11.3 percent, respectively). At two years, screening rates rose to 35 percent in intervention towns compared with 14 percent in control communities [86]. More than 16,000 whole-body examinations were performed by general practitioners and special screening services, with skin cancer detected in 2.4 percent (33 melanomas, 259 basal cell carcinomas, and 97 squamous cell carcinomas) [87]. The specificity of the skin examination for melanoma was 86 percent. As this study was not completed due to lack of funding, the potential benefits versus harms of community screening remain uncertain.

HARMS OF SCREENING — The harms of screening for melanoma include the potential that false-positive findings on skin examination will lead to an increased number of dermatology referrals and unnecessary biopsies, with resulting anxiety, scarring, and expense and the possibility of overdiagnosis (ie, the diagnosis of melanoma that is either non-growing or so slow-growing that it would never become clinically meaningful during the patient’s lifetime). The diagnosis of melanocytic lesions is also challenging, with substantial variability noted among pathologists [88]. Screening also has "opportunity costs,” ie, the recognition that a clinician's time is a finite resource that is best spent on care that provides the greatest opportunities for benefits to the patient and is of known effectiveness.

False-positive screens — As the majority of the population will not be diagnosed with melanoma, the potential for false-positive screens is of concern when considering mass screening programs. However, data are limited on this topic. A few small studies suggested that screening by primary care clinicians trained in skin cancer screening was not associated with an increase in utilization of dermatology services. In a United States population-based melanoma screening program, 1572 patients were screened by primary care clinicians trained using an online educational system. Screening was associated with increased rates of melanoma diagnosis but was not associated with increased rates of dermatology visits, biopsies, or surgeries [67,71-73]. Similarly, in a small Veterans Affairs (VA) health care system pilot study, trained primary care clinicians offered screening to 258 patients; 189 accepted screening, and there were no differences between the number of dermatology referrals or skin biopsies in the pre- and post-training periods [89].

Psychosocial impact of screening — In the VA study, the psychosocial impact of screening for melanoma was evaluated; a sample of screened patients reported positive reactions to clinician screening (though some patients preferred dermatologist examination), lack of psychosocial harms (eg, discomfort undressing, distress over referrals), and appreciation of screening as a valuable addition to their health care [90]. The population-based screening program surveyed a small sample of patients who were biopsied as a result of screening; biopsied patients reported no difference in anxiety or depression compared with patients screened but not biopsied using standardized and validated measures of anxiety and depression [91]. Larger studies are needed to more clearly define the harms of melanoma screening.

Variability of pathologic diagnosis — Skin cancer screening will only be effective if the subsequent diagnosis is accurate, yet the assessment and classification of melanocytic skin lesions is challenging for pathologists. One study found that 23 percent of skin biopsies in the United States are of melanocytic skin lesions [92], highlighting the importance of the pathologists’ diagnosis. The pathologic thresholds to label morphologic changes as cancer have fallen over time [93], and extensive variability among pathologists has been noted [94]. For example, diagnoses of melanoma in situ and early-stage invasive melanoma were neither reproducible nor accurate in a large study of 187 pathologists [88,95]. In addition to acknowledging the uncertainty in pathology reports, other suggestions have included use of standardized classification systems to improve communication [96,97], having skin biopsies interpreted by experienced board certified or fellowship trained pathologists [98], or obtaining second opinions [99,100].

Overdiagnosis — Data quantifying the potential harms of melanoma screening are scant [83]; however, the United States Surveillance Epidemiology and End Results (SEER) Program results indicate an increase in detection of early-stage melanoma without benefit on mortality [101]. This discrepancy suggests overdiagnosis, in which lesions detected only as a result of screening would not have led to clinically significant symptoms. Overdiagnosis can lead to treatment of biologically indolent lesions with increased patient morbidity and health-related costs. (See "Evidence-based approach to prevention", section on 'Risk of overdiagnosis (pseudodisease) in cancer screening'.)

Specifically, analysis of SEER data suggests that, despite efforts to improve screening and detection, melanoma detection practices have not lowered rates of prognostically unfavorable tumors [101-105]. Based on SEER data from 1986 to 2001, there was a 2.5-fold increase in skin biopsy rates among patients aged 65 and older [101]. This was associated with increased detection of in situ and early-stage invasive melanoma but not increased detection of advanced melanoma, and melanoma mortality rates remained stable during the reporting period [101]. Analysis of SEER data from the subsequent eight years similarly found increases in the rates of skin biopsy and an associated increase in melanoma in situ detection [102]. The incidence of invasive melanoma initially increased but then decreased, and the associations between skin biopsy and invasive melanoma incidence were complex and varied in state-level analyses.

INVESTIGATIONAL APPROACHES — In addition to visual screening, research is ongoing to find imaging and molecular technologies to detect melanoma at an early stage when cure is feasible. Studies of patients known to have melanoma have led to identification of a set of autoantibody biomarkers. In a study of 124 melanoma patients and 121 healthy controls, the panel of 10 autoantibodies to tumor-associated antigens had a sensitivity of 79 percent and a specificity of 84 percent for primary melanoma detection [106]. This small, early report of a blood test method has not been validated or studied in a screening population. Additional studies are therefore needed to determine if use of such a biomarker panel would be beneficial or harmful if used in routine population-based screening.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Melanoma screening, prevention, diagnosis, and management".)

INFORMATION FOR PATIENTS — Several websites describing self-examination are available for patient access [107,108]:

The American Academy of Dermatology

The Skin Cancer Foundation

In addition, UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

The Basics topics (see "Patient education: Melanoma skin cancer (The Basics)")

Beyond the Basics topics (see "Patient education: Melanoma treatment; localized melanoma (Beyond the Basics)" and "Patient education: Melanoma treatment; advanced or metastatic melanoma (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

No randomized trials have been conducted to establish the efficacy of screening for melanoma on mortality reduction, but observational studies evaluating the impact on tumor thickness or mortality are encouraging. Although the majority of melanomas are initially detected by patients themselves, melanomas detected by clinicians have consistently been shown to be thinner than those found by patients or their significant others. (See 'Effectiveness of screening' above.)

The harms of screening for melanoma include the potential that false-positive findings on skin examination will lead to an increased number of dermatology referrals and unnecessary biopsies, with resulting anxiety, scarring, and expense, and the possibility of overdiagnosis (ie, the diagnosis of melanoma that is either non-growing or so slow-growing that it would never become clinically meaningful during the patient’s lifetime). (See 'Harms of screening' above.)

Patients with certain risk factors are at high risk of developing or dying from melanoma:

White adults age 50 and above.

Total nevus count above 50 and/or presence of large (atypical/dysplastic) nevi.

Personal history of skin cancer.

immunosuppression, particularly chronic use of immunosuppressive medications such as those used by organ transplant recipients.

Very sun-sensitive individuals and those with “red hair phenotype” (eg, light skin pigmentation, red or blond hair color, high-density freckling, and light eye color [green, hazel, blue]).

Family history of melanoma in one or more first-degree relatives or in more than one second-degree relative on the same side of the lineage. Those with at least three affected members (including one or more first-degree relatives) on one side of the family are at very high risk. (See 'High-risk patients' above.)

For high-risk patients, we suggest screening for melanoma (Grade 2C). Screening involves a full-body skin examination performed yearly by a clinician who has had appropriate training in the identification of melanoma (clinician examination) as well as education for patients about melanoma risk factors and advice to alert their clinician if self-examination detects changing moles or other suspicious skin lesions. (See 'High-risk patients' above and 'Clinician screening' above.)

For the general population outside of these high-risk groups, we do not routinely screen with clinician skin examination. However, for patients without identified increased risk, clinicians should remain vigilant for any suspicious lesions identified in the course of a routine or sick visit (opportunistic case finding). A focused skin examination of the palms, soles, and digits may be of value in people with darker skin, who are more likely to have acral melanoma. All patients should be aware of melanoma clinical warning signs and bring any concerning lesions to the clinician’s attention. (See 'Non-high-risk patients' above.)

Certain tools can help clinicians and patients identify lesions to evaluate further for melanoma. These include the "ugly duckling" sign, the ABCDE rule of melanoma (picture 1), and the Glasgow revised seven-point checklist. Further detail is provided elsewhere (see "Melanoma: Clinical features and diagnosis" and "Melanoma: Clinical features and diagnosis", section on 'Clinical prediction rules'). Detecting melanoma in children is discussed separately. (See "Melanoma in children", section on 'Physical examination'.)

When suspicious lesions are detected, appropriate referrals are warranted (to a dermatologist where possible) for further evaluation of all such lesions. (See "Melanoma: Clinical features and diagnosis", section on 'Management of suspicious lesions'.)

All patients should be educated about the importance of sun protection for melanoma prevention. (See "Primary prevention of melanoma", section on 'Sun protection'.)

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Topic 4845 Version 60.0

References