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Melanoma Mortality Following Skin Cancer Screening in Germany

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Melanoma Mortality Following Skin Cancer Screening in Germany Open Access Research BMJ Open: first published as 10.1136/bmjopen-2015-008158 on 15 September 2015. Downloaded from Melanoma mortality following skin cancer screening in Germany Mathieu Boniol,1,2 Philippe Autier,1,2 Sara Gandini3 To cite: Boniol M, Autier P, ABSTRACT Strengths and limitations of this study Gandini S. Melanoma Objectives: In 2003, a skin cancer screening mortality following skin campaign based on total body skin examination was ▪ cancer screening in Germany. The present study replicates, with a follow-up launched in the federal state of Schleswig-Holstein, BMJ Open 2015;5:e008158. time doubled, the analysis that was conducted in doi:10.1136/bmjopen-2015- Germany. 20% of adults aged 20 and over were the region of Schleswig–Holstein, Germany, 008158 screened. In 2008, a 48% decline in melanoma showing a 48% decline in cutaneous melanoma mortality was reported. In the same year, skin mortality 5 years after initiation of a skin cancer screening was extended to the rest of Germany. ▸ Prepublication history for screening campaign based on total body skin We evaluated whether melanoma mortality trends this paper is available online. examination. To view these files please decreased in Germany as compared with surrounding ▪ In addition, this study evaluates using a similar visit the journal online countries where skin screening is uncommon. We also method, with 5 years of follow-up, the impact in (http://dx.doi.org/10.1136/ evaluated whether the initial decreasing mortality trend the whole of Germany where a skin cancer bmjopen-2015-008158). observed in Schleswig-Holstein was maintained with a screening programme was introduced since longer follow-up. 2008. Received 13 March 2015 Setting and participants: Regional and national ▪ A limitation of such an approach, as in the ori- Revised 25 August 2015 melanoma mortality data from 1995 to 2013 were ginal approach that was used in Schleswig- Accepted 26 August 2015 extracted from the GEKID database and the Federal Holstein, is the ecological design. Statistical Office. Mortality data for Germany and ▪ Another limitation is that there is currently a lack surrounding countries from 1980 to 2012 were of useful process and outcome evaluation of the extracted from the WHO mortality database. skin cancer screening. This represents a major Primary and secondary outcome measures: failure of the German screening programme. Age-adjusted (European Standard Population) mortality ▪ However, the current unique situation in rates were computed and joinpoint analysis performed Germany represents a quasi-experimental setting for Schleswig-Holstein, Germany and surrounding in Europe to evaluate whether such a massive countries. introduction of total body skin examination in the http://bmjopen.bmj.com/ Results: In Schleswig-Holstein, melanoma mortality general population is effective in decreasing mel- rates declined by 48% from 2003 to 2008, and from anoma mortality. 2009 to 2013 returned to levels observed before screening initiation. During the 5 years of the national programme (2008–2012), melanoma mortality rates recommend skin cancer screening. This prac- increased by 2.6% (95% CI −0.1 to 5.2) in men and tice, however, tends to increase: 14.5% of 0.02% (95% CI −1.8 to 1.8) in women. No inflexion adults in the USA in 2000 had at least one point in trends was identified after 2008 that could total body skin examination (TBSE), this on September 28, 2021 by guest. Protected copyright. have suggested a decreasing melanoma mortality. figure increased to 19.8% in 2010.1 Trends of cutaneous melanoma mortality in Germany In 2003, a skin cancer screening campaign from 1980 to 2012 did not differ from those observed (the SCREEN (Skin Cancer Research to in surrounding countries. Provide Evidence for Effectiveness of Conclusions: The transient decrease mortality in Screening in Northern Germany) project) Schleswig-Holstein followed by return to pre-screening 1 – University of Strathclyde was initiated in the federal state of Schleswig levels could reflect a temporal modification in the 2 Institute of Global Public reporting of death causes. An in-depth evaluation of Holstein in Germany. This campaign was Health at iPRI, International the screening programme is required. based on TBSE offered from July 2003 to Prevention Research Institute, June 2004 to individuals aged 20 and over by Lyon, France 2International Prevention dermatologists and by non-dermatologist Research Institute (iPRI), practitioners who had followed an 8 h train- Lyon, France ing course. These TBSE were fully covered by 3European Institute of INTRODUCTION health insurances; physicians received a finan- Oncology, Milan, Italy Many public health agencies like the United cial incentive of €15 per screening. No invita- Correspondence to States Preventive Services Task Force tion or follow-up system was implemented, Professor Mathieu Boniol; (USPSTF) or the National Institute for Health but the population was informed about the [email protected] and Care Excellence (NICE) in the UK do not campaign by a large-scale mass media Boniol M, et al. BMJ Open 2015;5:e008158. doi:10.1136/bmjopen-2015-008158 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2015-008158 on 15 September 2015. Downloaded from campaign. The participation rate was 19% (27% in period 1980–2012, and for the period 2008–2012, that is women and 10% in men) to 21.5%.34In 2008, melan- for the 5 years following the introduction of screening in oma mortality rates were reported to have dropped by Germany. 47% and 49% in Schleswig–Holstein men and women, Temporal trends of melanoma mortality were analysed respectively.5 from 1980 to 2012 in Germany and surrounding coun- Many considered that the 5-year results of the SCREEN tries using joinpoint regression.12 Joinpoint software fits project represented compelling evidence that skin cancer a series of straight lines connected on a common point, screening based on TBSE could be effective.56In 2008, a called ‘joinpoint’, on a logarithmic scale to the annual national programme was implemented in Germany, age-standardised rates. The selected number of lines including Schleswig–Holstein, following screening proce- and points of inflexion, if any, is based on the simplest dures adopted in the SCREEN project but starting at age model that the data allow.13 The programme uses per- 35.7 Simulation studies foresaw that biennial TBSE of the mutation analysis with a grid search algorithm to identify German population aged 35–85 years and a 20% participa- inflexions in trends with an overall statistical significance tion would reduce melanoma mortality by 45% 20 years level of 0.05. We kept default settings in the programme, after screening implementation.8 Screening in the that is, allowing up to five possible joinpoints during national programme experienced divergences from the 1980–2012, with three observations from a joinpoint to initial programme as some insurance companies agreed to either end of the data and four observations between reimburse additional services proposed by practitioners. two joinpoints. We reported trends for the last uninter- Screening could be performed in adults less than 35 years rupted segment identified in the joinpoint regression by of age with a shorter interval between screening rounds, age groups: less than 60, 60–74, and 75 and over. and assessment of pigmented lesions could be carried out using computer or video technologies.9 In this study, we evaluated whether the reported RESULTS – decreases in melanoma mortality in Schleswig–Holstein Melanoma mortality in Schleswig Holstein were maintained over time. Then we analysed changes Melanoma mortality dropped in the years immediately in melanoma mortality in Germany in the 5 years follow- following the pilot project that took place in 2001 fi ing implementation of the national programme using ( gure 1). In 2008, melanoma mortality rates were well – statistical methods similar to those used for the evalu- below the rates reported for Germany. In 2009 2010, a ation of the SCREEN project in Schleswig–Holstein. We doubling of mortality rates took place, and in 2012 and also computed melanoma mortality trends in Germany 2013, the melanoma rates were close to the rates for different age groups and compared them with trends observed before the pilot project. in surrounding countries where a similar skin cancer Melanoma incidence and mortality in Germany screening programme does not exist. http://bmjopen.bmj.com/ Schleswig–Holstein has a population size of 2 806 000 people, it represents 3.5% of all Germany. In Schleswig– MATERIAL AND METHODS Holstein before the SCREEN project started (1998– Incidence and regional mortality data in Germany were 1999), the age-standardised melanoma mortality rate extracted from the GEKID database.10 Melanoma inci- (World Standard Population) was 1.9 per 100 000 for dence data were available for the period 2003–2011. men and 1.4 per 100 000 for women. Melanoma mortal- Melanoma mortality was extracted for the whole of ity declined by 47% to 1.0 per 100 000 men and by 49% – Germany as well as for Schleswig Holstein from the to 0.7 per 100 000 women by 2008/2009. The APC in on September 28, 2021 by guest. Protected copyright. GEKID database for the period 1995–2012 and from the the period 2000–2009 was −7.5% (95% CI −14.0 to Federal Statistical Office for the period 1998–2013.11 The −0.5) for men and −7.1% (95% CI −10.5 to −2.9) for latter data source was used for completing the GEKID women. In each of the four adjacent regions and in the database for the year 2013. Both data sources, GEKID and rest of Germany, the mortality rates were stable.5 Federal Statistical Office, reported identical figures for Overall, in Germany, the average participation rate in years they had in common, ie 1998–2012.
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