Primary prevention efforts for melanoma

Journal of Drugs in Dermatology, Sept-Oct, 2004 by Varee N. Poochareon, Daniel G. Federman, Robert S. Kirsner

Introduction

The incidence and mortality of malignant melanoma is increasing at alarming rate. Over 58,000 Americans will be diagnosed with melanoma in 2003 and nearly 10,000 lives will be lost (1). Melanoma often affects young adults, therefore in terms of years of life lost and lost productivity, is considered to be one of the most costly cancers (2), posing an alarming threat to members of all generations. Skin cancers are exceedingly common; it is estimated that over 1,500,000 Americans will be diagnosed with skin cancer this year, and the lifetime risk of developing a skin cancer is one in five (3). Although the incidence of melanoma (accounting for only 5% of skin cancers) is significantly lower than that of nonmelanoma skin cancers, including basal cell carcinoma and squamous cell carcinoma, melanoma's higher mortality rate has led to special emphasis on its prevention, early detection and treatment (4,5).

A potentially curable disease when detected early (6), melanoma is also a preventable one. In terms of prevention, melanoma is likely to be second only to lung cancer in terms of potential for primary prevention. Much of the current research focuses on early detection and screening programs (secondary prevention). However, a growing number of studies have investigated the primary prevention of melanoma, that is, the reduction of exposure to known risk factors in an effort to prevent development of the disease. The aim of this article is to review recent data from such primary prevention studies.

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Prevention of Disease

Disease prevention has been categorized into primary prevention, secondary prevention, and tertiary prevention. Primary prevention is aimed at decreasing the incidence of a disease through the removal or reduction of precipitating (risk) factors prior to the development of disease (6). Secondary prevention involves early detection of the pre-malignant condition or cancer, leading to earlier intervention, which has the potential to reduce morbidity and mortality. Cancer screening is a form of secondary prevention. Tertiary prevention targets complications and further deterioration of an already-established disease, often focusing on palliation and measures to decrease the morbidity and mortality of a late-stage disease process.

With respect to melanoma, primary prevention strategies have mainly targeted excessive exposure to the suns ultraviolet light, with the aim of increasing knowledge and awareness of the harmful effects of sun exposure, changing attitudes about tanning and the necessity of sun protection, and most importantly, changing behavior to increase effective protective measures. Most prevention programs share the goal of eventually altering long-term medical outcomes, such as decreasing the incidence of melanoma, the stage at diagnosis, morbidity, and most importantly, mortality from the disease. However, given the long latency of melanoma from ultraviolet exposure to the development of disease, shorter-term outcome measures have been used as surrogates for incidence and mortality rates. In addition to improvements in knowledge, attitudes, and behavior, biologic surrogates such as the incidence of sunburn, the amount of pigmentation and the number and type of melanocytic nevi have been used as outcomes of intervention programs.

As stated previously, screening for melanoma is considered a form of secondary prevention. Determining whom to screen, when to screen, and how often screening should occur is an area of active investigation. Screening the entire population may provide valuable information regarding the prevalence, natural history, and effect of early treatment of malignant melanoma (6). Performing full body skin examinations during the course of a routine office visit may prove to be both life-saving and cost-effective in the long term, whether screening is performed by a dermatologist or non-dermatologist. In selectively targeting known high-risk populations (for example, patients with a personal or family history of melanoma or dysplastic nevi), the yield may be higher than for those without such risk factors and screening may augment other general prevention strategies. Additionally, patient self-examination may also be a useful adjunct to screening performed by healthcare professionals. With respect to melanoma, tertiary prevention focuses on reducing the damaging effects of metastatic melanoma, which unfortunately, has no established cure (6).

The remainder of this paper will focus on strategies and programs aimed at primary prevention of melanoma. It should be underscored that education is critical in all primary prevention strategies. By the dissemination of information about the genesis and progression of melanoma, community knowledge will hopefully improve, resulting in subsequent changes in attitude and behavior. It is also hoped that such changes will lead to increased availability of shade, sunscreen, and protective clothing at venues where people receive ample sun exposure (beaches or school playgrounds), as well as changes in the scheduling of outdoor activities to hours where exposure to ultraviolet light is less intense (7). Public education about melanoma also aims for changes at an individual level: positive personal changes in knowledge, awareness, attitude, and behavior with regard to sun exposure have been the goal of many recent primary prevention interventions. It is assumed that significant changes at an individual level will eventually lead to structural changes in the community, and identifying persons at high risk for melanoma improves the efficiency with which current public health programs bring about change.