Elsevier

Clinics in Dermatology

Volume 28, Issue 3, May–June 2010, Pages 281-286
Clinics in Dermatology

Melanoma epidemic: Facts and controversies

https://doi.org/10.1016/j.clindermatol.2009.06.021Get rights and content

Abstract

The presence of a true melanoma epidemic has been a controversial topic for the past decade. A dramatic increase in the incidence of cutaneous malignant melanoma in developed countries is well documented, but mortality rates have not risen as rapidly. This has generated much discussion about whether there is a true increase in disease, or more of an apparent phenomenon that may be explained by multiple biases and other factors. The increase in incidence may be due to aggressive surveillance with increased detection of melanomas that are histologically worrisome but biologically benign. This argument, however, does not account for increased incidence of both thin and thicker melanomas. The controversy lies in the interpretation of these facts. This contribution reviews epidemiologic studies from the United States and worldwide to summarize the arguments for and against the debate about whether a melanoma epidemic exists.

Section snippets

Incidence and mortality trends of cutaneous malignant melanoma

Many epidemiologic studies have evaluated the incidence and mortality statistics of MM in the United States (U.S.) and worldwide. Since 1973, the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute has been collecting and publishing data from population-based cancer registries and currently covers 26% of the U.S. population. MM is one of only 14 cancer types that has been increasing in incidence during the past few decades.

In general, cancer incidence is

Is this real?

Those who believe that this worldwide melanoma incidence increase represents a true epidemic take the statistics at face value, with res ipsa loquitur (“the thing speaks for itself”)7 and “if it quacks like a duck...”5 accurately summing up the primary argument for a true epidemic.2,3, 4, 5, 6, 7 Those who are more skeptical of an epidemic have posed multiple explanations for the incidence data, including (1) length-time bias, (2) increased surveillance intensity, (3) diagnostic uncertainty,

If real, then why?

One would be hard-pressed to find a dermatologist who does not agree that sun exposure contributes in some manner to the development of MM. Increased sun exposure related to increased tanning bed use throughout the 1990s and degradation of the ozone layer have been offered as explanations of why the incidence of melanoma is increasing.12 This may be especially relevant to young women, because there has been a sharp increase in melanoma incidence in the past 10 years in women aged 25 to 29 years

Future directions

Although experts in the field disagree on the epidemic proportion of melanoma, it is inarguable that this is an insidious cancer that is preventable in most cases. Rigel insists that “an ounce of prevention is worth a pound of cure,” and breaks down the criteria for diseases for which standard screening is cost-effective: (1) early detection must positively affect outcomes, (2) the screening process must be straightforward, and (3) the screening must be cost-effective.34 MM and nonmelanoma skin

Conclusions

The question posed of whether a melanoma epidemic truly exists is difficult to answer definitively in the absence of randomized controlled trials to evaluate the true effect of increased surveillance and biopsies on mortality rates. We will also never know what would have become of the 1-mm melanoma once it is fixed in formalin. Until we have new methods for determining the malignant potential of pigmented neoplasms, or a time machine, we must keep in mind the grim yet real possibility that the

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      Dramatic increases in the incidence of cutaneous melanoma have occurred among populations in the United States and other parts of the world in the last half of the 20th century, with rates increasing 3- to 5-fold over the span of only two to three decades (Dennis, 1999; Garbe and Leiter, 2009; Giblin and Thomas, 2007; Hall et al., 1999; Jemal et al., 2001; Levell et al.; 2009). Although these increases have raised public health concerns (US Department of Health and Human Services Office of the Surgeon General, 2014), they have also sparked controversy as to whether they represent a true melanoma epidemic or an artifact of expanded screening programs (De Giorgi et al., 2012; Dennis, 1999; Erickson and Driscoll, 2010; Levell et al., 2009; Swerlick and Chen, 1996; Swerlick and Chen, 1997). To inform answers to this question, we previously published a study of invasive cutaneous melanoma occurrence during the period of 1988 through 2002 among non-Hispanic whites in California, in which we conducted the first examination of incidence trends across small-area (census tract) neighborhoods categorized by socioeconomic status (SES) (Linos et al., 2009).

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