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Frequency of Excisions and Yields of Malignant Skin Tumors in a Population-Based Screening Intervention of 360 288 Whole-Body Examinations

Frequency of Excisions and Yields of Malignant Skin Tumors in a Population-Based Screening Intervention of 360 288 Whole-Body Examinations

DermatologistsBlog.com Authors’ Interview:

Dr. Annika Waldmann, PhD and Dr. Sandra Nolte, PhD

Institute for Cancer Epidemiology, University of Luebeck, Germany

Introduction:

The SCREEN project (Skin Cancer Screening Research to Provide Evidence for the Effectiveness of Screening) is one of the largest population-based skin cancer screening interventions implemented world-wide. Data from this pilot project served as a base for the decision to implement a skin cancer screening program at the national level in Germany in 2008. During the one-year project period, more than 85% of the population of the federal-state of Schleswig-Holstein in Germany being 20 years were eligible for the screening. Overall, 98% of all dermatologists and ~64% of all practice-based non-dermatologists in Schleswig-Holstein participated in the mandatory 8-hour training course and were allowed to screen persons for skin cancer by means of a whole-body skin inspection.

DermatologistsBlog.com :What are the main findings of the study?

In total, 19% of all eligible inhabitants of Schleswig-Holstein participated in the SCREEN project and received a whole-body skin inspection. Of these, 15,983 screenees had an excision of at least one suspicious lesion (4.4% of all screenees). After histopathological examination, 3,103 malignant skin lesions were confirmed in 2,911 screenees.

Malignant melanomas (MM) were found in 858 persons, squamous cell carcinomas (SCC) in 392 persons, basal cell carcinomas (BCC) in 1,961 persons, and 165 persons had other forms of malignant skin tumors.

In order to detect one skin cancer, 116 persons needed to be screened (NNS; Yield-S) and five persons needed to have an excision (NNE, Yield-E). The yields varied with skin cancer type, age, and sex of the screenees.

One in every 620 screenees (Yield-S) and one in every 28 person with an excision (Yield-E) was diagnosed with a melanoma. Yields were higher in older men than in younger men, e.g. to find one MM more than 50 excisions were performed in men aged 20-34 years, while 20 excisions were needed in men aged 65 years or older. Respective Yield-E’s were 1 in 41 young women and 1 in every 22 women aged 65+ years.

To find one SCC, 920 persons needed to be screened (Yield-S) and 41 needed to have an excision (Yield-E). Again, yields differed with age and sex. Only 14 women and 12 men aged 65 years and older needed to have an excision to find one SCC compared to 72 women and 48 men, respectively, in the age-group 50-64 years (Yield-E).

One in every 184 screenees (Yield-S) and one in every nine persons with an excision (Yield-E) was diagnosed with a BCC. Male screenees were more likely to be diagnosed with BCC than female screenees (Yield-S in women: 1 in 252, Yield-S in men: 1 in 105). The overall Yield-E differed only slightly with sex (Yield-E in women: 1 in 10; Yield-E in men: 1 in 7), while differences were higher for sex-specific age-group comparisons. In women aged 50-64 years, eight excisions were needed, while in women aged 65 years or older four excisions needed to be performed to detect one BCC. In men, the corresponding Yield-E’s were 1 in 7 and again 1 in 4.

DermatologistsBlog.com : Were any of the findings unexpected?

The normal distribution (ratio) of incident melanomas to non-melanocytic skin cancer (NMSC) in Germany is 1 MM to 9 NMSC’s or 1 MM to 2 SCCs to 7 BCCs. In our study the distribution was as follows: 1 MM to 0.5 SCC to 2.3 BCCs. That is, a higher number of MM (n=858) in relation to NMSC was detected. This fact may partly be explained by the mass media campaigns that preceded and accompanied the SCREEN project as it focused on MM rather than NMSC. This campaign may have led to a higher participation of persons at increased risk for melanoma or with prevalent melanomas.

As skin cancer becomes more common with increasing age, Yield-S must vary with age, under the precondition that an unselected proportion of the population participated in the SCREEN project. However, the Yield-E should be relatively stable across the age-groups, under the assumption that physicians are able to detect malignant lesions in young persons as accurately as in older persons. Thus, the low Yield-S’s in young screenees compared to the high Yield-S’s in older persons were an unexpected finding. We cannot differentiate whether a high number of excisions was conducted due to patients’ preferences or whether a high number of excisions was conducted due to physicians’ decisions who were concerned about the safety especially of younger screenees, i.e. definitely rule out a malignancy that can only be confirmed by histopathological examination.

DermatologistsBlog.com :What should clinicians and patients take away from this study?

Population-based skin cancer screening is feasible. Non-dermatologists should be included to manage the high number of screenings being conducted in such a setting. Even in young screenees a relevant number of melanomas, and to a lesser extent also NMSC, were found. Future efforts should target physicians’ education with the aim to reduce the number of excisions in young persons – that is to optimize the ratio of tumor findings to excisions (Yield-E).

DermatologistsBlog.com : What recommendations do you have for future research as a result of your study?

Future research could:

(1) aim at answering the question why so many excisions were performed in young screenees, i.e. due to patient or physician preferences;

(2) evaluate yields in persons at increased risk for skin cancer to explore the benefits of risk-group screening versus population-based screening.

Citation:

Frequency of Excisions and Yields of Malignant Skin Tumors in a Population-Based Screening Intervention of 360 288 Whole-Body Examinations

Annika Waldmann, PhD; Sandra Nolte, PhD; Alan C. Geller, MPH, RN; Alexander Katalinic, MD; Martin A. Weinstock, MD, PhD; Beate Volkmer, PhD; Ruediger Greinert, PhD; Eckhard W. Breitbart, MD

Arch Dermatol. 2012;148(8):903-910. doi:10.1001/archdermatol.2012.893.

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