WAIKOLOA, HAWAII – An organized program of population-based total body skin examination screening for skin cancer has been shown to significantly reduce melanoma mortality.
"This is quite astounding. It is very impressive to see that a total body skin exam can reduce mortality. It forces us all to think about whether we should do this in a very, very large population, as we now do in Germany," said Dr. Andreas Blum, professor of dermatology at the University of Tübingen (Germany).
Dr. Andreas Blum
He presented highlights of the SCREEN (Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany) project, in which all residents of the state of Schleswig-Holstein were eligible for a standardized total body skin exam during a 1-year study period. This was to date the world’s largest systematic population-based skin cancer screening program, he said.
Nineteen percent of the Schleswig-Holstein adult population – more than 360,000 citizens – participated. A total of 3,103 skin cancers were found, including 585 melanomas, for a rate of 1.6 melanomas per 1,000 persons screened. Basal cell carcinomas were detected at a rate of 5.4 malignancies per 1,000, and squamous cell carcinomas at 1.1 per 1,000 people screened. Five lesion excisions had to be performed to detect one malignancy.
Using the incidence of melanoma in Schleswig-Holstein during the 2 years prior to the SCREEN project as a baseline, the incidence of melanoma during the SCREEN project increased by 16% in men and by 38% in women.
The key study finding was a significant decrease in melanoma mortality documented 5 years after SCREEN ended. The observed melanoma mortality rate in men was 0.79 per 100,000 population, compared with an expected 2.0 per 100,000. Among women, the observed mortality was 0.66 per 100,000, compared with an expected 1.3 per 100,000. Thus, the observed mortality because of earlier detection of melanoma in the screened area was less than 50% of expected, Dr. Blum said at the Hawaii Dermatology Seminar sponsored by the Skin Disease Education Foundation (SDEF).
The screening project had a two-tiered structure. Most participants were first screened by a primary care physician or other nondermatologist. In the event of suspicious findings and/or skin cancer risk factors, the participant was referred to a dermatologist who performed the biopsies. All participating physicians first had to attend an 8-hour training course. Of note, 116 of the 118 dermatologists in Schleswig-Holstein participated in SCREEN, as did nearly two-thirds of eligible nondermatologists (J. Am. Acad. Dermatol. 2012;66:201-11).
Following up on the unprecedented success of the SCREEN project, German dermatologists next proposed a randomized controlled trial in order to provide the highest-level evidence that mass skin cancer screening reduces melanoma mortality. However, government health officials found SCREEN persuasive and nixed the idea of a large and costly randomized trial. Instead, Germany has launched a national skin cancer screening program, according to Dr. Blum. All 45 million Germans aged 35 years and older are now eligible to be screened for skin cancer once every 2 years; whether the health care system can cope with the demand remains to be seen.
Another recent project evaluating the benefits of total body skin examination for skin cancer screening also reported favorable results, he noted.
Investigators in a multicenter study screened more than 14,000 patients with a total body skin exam. Participants were consecutive adults presenting with a localized dermatologic problem, such as a skin infection, that wouldn’t ordinarily result in a total body skin exam. The total body skin exams detected 40 patients (0.3%) with melanoma. Five benign lesions were excised for each melanoma detected. Another 2.1% of patients had at least one nonmelanoma skin cancer detected by total body skin exam. On average, 400 patients had to be examined by total body skin exam in order to find 1 melanoma (J. Am. Acad. Dermatol. 2012;66:212-9).
"I see around 150 new patients per week, so that means every third week I see a new melanoma," Dr. Blum said.
Total body skin examination has long been a controversial issue. The U.S. Preventive Services Task Force found insufficient evidence to recommend screening adults for skin cancer (Ann. Intern. Med. 2009;150:188-93). That stance will now need to be revisited in light of these two large projects, said Dr. Blum.
He predicted that the cost involved in routine total body skin examinations is likely to be a critical source of controversy. Using the National Cancer Institute’s estimate that 12.5% of melanomas are fatal, and assuming the cost of a total body skin exam to be $50, he estimated that routine total body skin exams in the SCREEN project cost $240,000 per melanoma death avoided.