WAIKOLOA, HAWAII – Momentum is building – perhaps unstoppably – for creation of a national, population-based melanoma screening program.
"Demand for screening is going up as we speak. The incidence of melanoma is going up dramatically, and it’s really important to understand that this is happening in the absence of formal screening for melanoma. So imagine what would happen if we did screen for melanoma routinely," Dr. Allan C. Halpern observed at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
Also, public awareness is increasing dramatically.
"We’ve spent a lot of time as dermatologists educating the public. And there may be as many as a million people walking around the U.S. right now who’ve personally had melanoma. We want to see them in follow-up visits, and their family members want to see us as well," said Dr. Halpern, chief of the dermatology service at Memorial Sloan Kettering Cancer Center in New York.
The current position of the U.S. Preventive Services Task Force (Ann. Intern. Med. 2009;150:194-8), the American Cancer Society, and other influential organizations is that formal guidelines for population-based screening for melanoma are not warranted at this time, because there is no randomized clinical trial evidence of net benefit. That position could change, however, even in the absence of such evidence. For example, the U.S. Preventive Services Task Force strongly supports cervical cancer screening, even though it has never been subjected to a randomized trial. The task force became convinced that cervical cancer screening works on the basis of observational data showing that by the time 80% of women were screened, mortality due to cervical cancer dropped by nearly 50%, Dr. Halpern noted.
The ‘extraordinary’ German example
The ongoing German national experience with melanoma screening may provide a big push for a shift in U.S. health policy in favor of routine screening for melanoma, according to Dr. Halpern.
The German melanoma screening program is one of the most extraordinary stories in dermatology, he said. The program is mainly the work of one determined and persuasive German dermatologist – Dr. Eckhard Breitbart – who has been pushing for melanoma screening in Germany for 45 years. Dr. Breitbart received funding for a pilot study conducted in Germany’s northernmost state, Schleswig-Holstein. The state’s primary care physicians were persuaded to conduct the first-tier screening of all Schleswig-Holstein residents. They received a financial incentive on a per-case basis, provided they first completed an 8-hour training course. The bottom line: After just 2 years of screening, mortality caused by melanoma dropped by 48% over the next 7 years while remaining unchanged in the neighboring states (Cancer 2012;118:5395-402).
Armed with the data, Dr. Breitbart persuaded the German federal government to expand screening nationally. That program began in 2005.
"I don’t think melanoma mortality will come down by 50% across all of Germany, but if the German data show it comes down by 20%-30%, then it’s the cervical cancer story revisited. I think that would be very strong endorsement that screening for melanoma can save lives," Dr. Halpern said.
He injected a cautionary note, however.
"I must warn you; the German experience may not give us definitive answers. It turns out that Eckhard Breitbart was so persuasive when he went to convince the German government to do the screening program that they ‘knew’ for a fact that it was going to work. So they didn’t allocate any money for an assessment of whether it actually works," Dr. Halpern explained.
Also, the study was limited by the German government’s concern about medical records privacy.
"Trying to get the data on who was screened versus who got melanoma and died of it is proving amazingly difficult. There are actually a bunch of melanoma experts here in the states, including Marty Weinstock and Alan Geller, who have been working closely with the German group to try to get some of the data. We’ll just have to wait and see how the German experience plays out," Dr. Halpern continued.
As pressure for routine melanoma screening mounts in the United States, it’s apparent that there is a major supply-and-demand issue involved. The supply of the medical dermatology workforce is shrinking relative to the growing demand, Dr. Halpern said. Going forward, the most promising solution in his view is to train primary care physicians and physician extenders to perform the screening, as is done in Germany. There is an enormous opportunity here for these nondermatologists to harness the emerging automated imaging and molecular sensing technologies for detection of lesion changes and diagnosis of melanoma, he added.