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Malignant Melanoma Update 1993

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Malignant Melanoma Update 1993 JOURNAL OF INSURANCE MEDICINE VOLUME 26, No. 2 SUMMER 1994 MALIGNANT MELANOMA UPDATE 1993 CHARLES W. LYNDE, MD, FRCP(C) Acting Head of Dermatology Toronto Western Hospital Assistant Professor of Medidne University of Toron to President Lynde Center for Dermatology Introduction: Statistics of incidence among women. Malignant melanoma is the number one cancer in white women age 25-29, second There has been a dramatic increase in the incidence of most prevalent in women age 30-35, second only to melanoma throughout the world. breast cancer. This rate of increase in the incidence of this disease is not just a specific flare or matter of more In the United States the incidence of melanoma has cases suddenly being reported. almost tripled in the past four decades growing faster than that of any other cancer. It now ranks number eight Melanoma counts for only 5% of the cases of skin can- to all types. No major change in diagnostic criteria can cers but counts for the majority of skin cancer deaths. explain this rapid increase. Approximately 32,000 Americans developed melanoma in 1991 and 6,500 died While the numbers of people getting melanoma has yet of it. In terms of the life time risk, in 1935 it was one in to show much positive change, there are changes in the 1,500 and it is now felt that by the year 2,000, 1 to 75 to 5-year survival rate for those who have the illness. In 90 Americans will develop melanoma of which I in 300 British Columbia, between 1970-74 for example, the will die. 5-year survival rate for men was 65%, by 1984 it in- creased to 82%. The survival rate for women during the In terms of Canadian statistics, they are comparable, our same period increased to 88% from 80%. Similarly, in population being approximately a tenth of the U.S. the U.S., while the death rate has continued to increase population. Approximately 3,100 new cases of malig- with increased incidence 5 years, survival has more nant melanoma will be diagnosed in 1993 in Canada than doubled from 40% in the 1940’s to over 80% in the with 540 deaths resulting from this condition. 1980’s.1’2 The increase in survival is felt to be attribut- able to early diagnosis on the part of physicians and the Overall the incidence of malignant melanoma (Canada) public. is now 9 per 100,000 population although incidence varies from a high of 14 per 100,000 in British Columbia Unlike many other forms of cancer which affect primar- to I per 100,000 in Newfoundland. (By comparison, the ily older people, melanoma frequently affects young incidence of lung cancer is now 73 per 100,000.) While people. The median age for patients with melanoma is the mortality rate for melanoma is increasing, it is hold- in the low 40’s. Thus, diagnosis and cure of cutaneous ing steady and even appears to be decreasing among melanoma in young individuals can lead to dramati- women. In the U.S., of the 6,800 deaths in 1993, 4,200cally increased life extension unachievable in cancers (62%) will be in men and 2,600 (38%) will be in women.that primarily affect older individuals. This is felt to be partly as result of women being more health conscious and taking better overall care of them- Epidemiology selves. The precise causation of melanomas is unknown, al- This tells us that men are still one of the main groups though epidemiologic and case control studies suggest we have to address to let them know that they are the sunlight is the most important environmental factor in ones who are dying disproportionately from this dis- the pathogenesis of melanoma with radiation in the ease. ultraviolet B range proposed to be the critical compo- nent. Malignant melanoma has the fastest growing incidence rate of all cancers among men, the third fastest increase 247 VOLUME 26, NO. 2 SUMMER 1994 MALIGNANT MELANOMA UPDATE 1993 The incidence of melanoma in whites generally corre- compounded by the phenotype of the population. Rates lates inversely with latitude; i.e., rates are higher closer of melanoma are relatively low in persons with outdoor to the equator and progressively lower in areas near the occupations, but much higher in middle class people poles. In the Eastern Australia Mole Stud~ Jason Rivers, with high recreational exposure. Except for lentigo ma- et al,3 recruited a total of 1,123 caucasian children be-ligna; melanoma does not regularly occur on skin most tween the ages of 6-15 years old in three cities along a exposed to the sun, such as the face. One would also latitude gradient Melbourne 38 S, Sydney 34 S, Towns- have to explain mucosal melanoma. Equally aside from ville 19 S. For each child the age, sex, eye and hair color, one single report, studies using ultraviolet light alone skin reflectance, response to sun exposure, ability to tan, have failed to induce melanoma regularly in animals. and place of residence were determined. Each student The body of evidence supports the risk of melanoma was examined by one of three trained medical ob- depends more on the intermittent exposure to the sun, servers, and the total number of moles greater than 2 especially earl in life than on simple cumulative expo- mm were recorded for all body sites excluding the sure. One has to think about the increased recreational genitalia and scalp. The average number of moles for exposure to the sun, the depletion of the earth’s ozone the entire cohort was 44. Older children and those with layer increasing ultraviolet penetration to the earth and blue eyes, light hair, fair skin, many freckles, and a the increased use of sunbeds and tanning parlors. tendency to painful burns with peeling, and an inability to tan had significantly more moles than children with- Loraine Marrett, et al4 in 583 case controls in southern out these features. As well, the number of moles in- Ontario have further identified that people with a large creased as one lived closer to the equator. This latter number of nevi, who have red or blond hair, having a factor remained a significant independent risk factor history of freckling in response to sun exposure and after controlling for age and phenotypic characteristics. burn with no tan after repeated sun exposure are par- These results indicate that in the Australian population ticularly at high risk. Interestingl)~ in their study it was at very high risk for melanoma, school children have also suggested that exposure to fluorescent lighting very large numbers of melanocytic nevi. The geo- may also be a risk factor. Other studies have found this, graphic variation in mole counts would support a solar but dismissed it as a confounding factor. ultraviolet radiation role in the causation of these le- sions. The phenotypic characteristics that predispose In the past, melanoma was notorious for its poor prog- one to the development of moles in childhood are simi- nosis. The current 5-year survival rate of 80% is a great lar to those that increase one’s risk for melanoma in later improvement over the 50% rate in 1950. Nevertheless, life. the overall mortality rate has increased by 150%, driven up by the rising incidence rate. Other investigators have linked blistering sunburns in childhood or adolescence with increased rates of mela- We Wish to Win the War on Melanoma noma in later life. Whites, especially those with a ten- dency to bum rather than tan when exposed to sunlight, Several advances have dramatically improved our abil- have higher rates of melanoma than nonwhites. Migra- ity to diagnose and treat melanoma. tion studies by other investigators suggest that child- hood or adolescence represents a critical period for 1) Recognition of Melanoma ultraviolet burn. Australian children less than age 15 who migrated to Britain maintained high rates of ma- The first was to recognize that melanoma has distinct lignant melanoma, whereas children from England who clinical features: The great physician Hippocrates rec- came to Australia after age 15 had low rates of malig- ognized and described melanoma, and since then vari- nant melanoma. ous names, including melano sarcoma, melano carcinoma, Kaposis melano sarcoma, have been used to Xeroderma pigmentosa, a rare autosomal recessive dis- describe this tumor. order characterized by deficient repair of ultraviolet B damaged DNA shows a greater than 100-fold higher It really wasn’t until the 1960"s or 70"s that we began to rate of skin cancer and, in particular, primary melano- understand this tumor, recognizing its melanocytic ori- nlas. gin and began to classify it and recognize its distinct clinical features. Not all evidence readily links ultraviolet light to mela- noma, however. In some countries the incidence of ma- Cutaneous melanoma is a visible tumor and therefore lignant melanoma, i.e. Europe, does not rise with perhaps more easily discovered in an asymptomatic increasing proximity to the equator, but this may be phase than any other type of cancer. The early detection 248 JOURNAL OF INSURANCE MEDICINE VOLUME 26, No. 2 SUMMER 1994 and recognition of malignant melanoma is the key to Lentigo Maligna possible cure! This often starts as a tan macule that extends peripher- Melanoma writes its message in the skin with its own ally and darkens and eventually develops a black nod- ink and is there for all to see. ule. The growth is extremely slow and insidious and often occurs over 5-20 years. It is found equally in men The ABCD rule has been established for the possible and women usually in their 60/70 decade, most fre- diagnosis of melanoma in any pigmented lesion.
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