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Pollution, Skin damage, and Dry eye

June 2017

Skin damage

Screening for Skin Cancer: US Preventive Services Task Force Recommendation Statement.

IMPORTANCE: Basal and squamous cell carcinoma are the most common types of cancer in the United States and represent the vast majority of all cases of skin cancer; however, they rarely result in death or substantial morbidity, whereas melanoma skin cancer has notably higher mortality rates. In 2016, an estimated 76,400 US men and women will develop melanoma and 10,100 will die from the disease .OBJECTIVE: To update the 2009 US Preventive Services Task Force (USPSTF) recommendation on screening for skin cancer. EVIDENCE REVIEW: The USPSTF reviewed the evidence on the effectiveness of screening for skin cancer with a clinical visual skin examination in reducing skin cancer morbidity and mortality and death from any cause; its potential harms, including any harms resulting from associated diagnostic follow-up; its test characteristics when performed by a primary care clinician vs a dermatologist; and whether its use leads to earlier detection of skin cancer compared with usual care. FINDINGS: Evidence to assess the net benefit of screening for skin cancer with a clinical visual skin examination is limited. Direct evidence on the effectiveness of screening in reducing melanoma morbidity and mortality is limited to a single fair-quality ecologic study with important methodological limitations. Information on harms is similarly sparse. The potential for harm clearly exists, including a high rate of unnecessary biopsies, possibly resulting in cosmetic or, more rarely, functional adverse effects, and the risk of overdiagnosis and overtreatment. CONCLUSIONS AND RECOMMENDATION: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adults (I statement).

JAMA. 2016 Jul 26;316(4):429-35

Screening program reduced melanoma mortality at the Lawrence Livermore National Laboratory, 1984 to 1996.

BACKGROUND: Worldwide incidence of cutaneous malignant melanoma has increased substantially, and no screening program has yet shown reduction in mortality. We evaluated results of an educational campaign designed to promote self-examination and targeted screening at the Lawrence Livermore National Laboratory (LLNL). METHODS: Thickness and crude incidence of melanomas detected during 3 phases of increasing melanoma surveillance were studied. These periods were: (1) preawareness (1969-1975), (2) early awareness of increased melanoma risk (1976-1984); and (3) screening program (1984-1996). Melanoma mortality was derived from data recorded in the National Death Index search. The expected annual number of deaths from melanoma among LLNL employees was calculated by using California mortality data matched by age, sex, and race/ethnicity and adjusted to exclude deaths from melanoma diagnosed before the program began or before employment at LLNL. RESULTS: Crude incidence of melanomas thicker than 0.75 mm decreased during the 3 periods from 22.1 to 15.13 to 4.62 cases per 100,000 person-years (P = .001 by chi-square for trend) with the larger decrease from the active screening program. The crude incidence of melanoma measuring less than 0.75 mm in thickness increased and then decreased slightly without a significant linear trend, and crude incidence of in situ melanoma increased substantially. No eligible melanoma deaths occurred among LLNL employees during the screening period, whereas the expected number of deaths was calculated to be 3.39 deaths (P = .034). LIMITATIONS: The study design was not randomized or controlled. The methodology for adjusting expected mortality for the exclusion of employees diagnosed with melanoma before the screening period was devised for this study.

DISCUSSION: Increasing community awareness of melanoma was associated with a progressive decreasing incidence of thicker melanoma. The education, self-examination, and selective program generated the larger reduction in incidence of melanoma thicker than 0.75 mm. This campaign decreased the melanoma-related mortality to zero. The statistically significant decrease in mortality persisted for at least 3 years after employees retired or otherwise left the laboratory.

J Am Acad Dermatol. 2008 May;58(5):741-9

Patterns of detection in patients with cutaneous melanoma.

BACKGROUND: Despite the importance of early detection in preventing mortality from melanoma, little is known regarding how patients with the disease come to diagnosis. METHODS: The authors prospectively evaluated 471 newly diagnosed melanoma patients between 1995 and 1998. Patients completed a questionnaire that included 1) identification of the person who detected the lesion, 2) the anatomic location of the lesion, and 3) family history of melanoma. Logistic regression analysis was performed to examine the relation between detection patterns and lesion thickness, adjusting for age, gender, anatomic site of the primary lesion, and family history of melanoma. RESULTS: The majority of patients detected their own melanoma (n = 270; 57%). Females were more likely to self-detect than males (69% vs. 47%; P < 0.0001). Physicians detected the melanoma in 16% of patients (n = 74), followed by "spouse" in 11% of patients (n = 51). Within this group, detection by wives was 7.5 times more common than detection by husbands (P < 0.0001). Logistic regression analysis revealed that physicians were 3.6 times more likely to detect thin lesions (</=0.75 mm) compared with nonphysician detectors (95% confidence interval [95% CI], 2.1, 6.5; P = 0.0001). In addition, patients who reported a family history of melanoma had a 2.7-fold increased likelihood of presenting with a thin lesion (95% CI, 1.6, 4.7; P = 0.0003). CONCLUSIONS: Physician detection and a report of a family history of melanoma are associated with the presentation of patients with early melanoma, suggesting that awareness of the disease among physicians and the public is critical for preventing mortality from melanoma. Increasing melanoma awareness in males may be a particularly effective means of secondary prevention.

Cancer. 2000 Jul 15;89(2):342-7

Clinical whole-body skin examination reduces the incidence of thick melanomas.

Survival from melanoma is strongly related to tumour thickness, thus earlier diagnosis has the potential to reduce mortality from this disease. However, in the absence of conclusive evidence that clinical skin examination reduces mortality, evidence-based assessments do not recommend population screening. We aimed to assess whether clinical whole-body skin examination is associated with a reduced incidence of thick melanoma and also whether screening is associated with an increased incidence of thin lesions (possible overdiagnosis). We conducted a population-based case-control study of all Queensland residents aged 20-75 years with a histologically confirmed first primary invasive cutaneous melanoma diagnosed between January 2000 and December 2003. Telephone interviews were completed by 3,762 eligible cases (78.0%) and 3,824 eligible controls (50.4%). Whole-body clinical skin examination in the three years before diagnosis was associated with a 14% lower risk of being diagnosed with a thick melanoma (>0.75 mm) (OR = 0.86, 95% CI = 0.75, 0.98). Risk decreased for melanomas of increasing thickness: the risk of being diagnosed with a melanoma 0.76-1.49 mm was reduced by 7% (OR = 0.93, 95% CI 0.79, 1.10), by 17% for melanomas 1.50-2.99 mm (OR = 0.83, 95% CI = 0.65, 1.05) and by 40% for melanomas > or =3 mm (OR = 0.60, 95% CI = 0.43, 0.83). Screening was associated with a 38% higher risk of being diagnosed with a thin invasive melanoma (< or =0.75 mm) (OR = 1.38, 95% CI = 1.22, 1.56). This is the strongest evidence to date that whole-body clinical skin examination reduces the incidence of thick melanoma. Because survival from melanoma is strongly related to tumour thickness, these results suggest that screening would reduce melanoma mortality.

Int J Cancer. 2010 Jan 15;126(2):450-8

Dermatologist detection and skin self-examination are associated with thinner melanomas: results from a survey of the Italian Multidisciplinary Group on Melanoma.

OBJECTIVE: To investigate patterns of detection and variables associated with early diagnosis of melanoma in a population at intermediate melanoma risk. DESIGN: Survey. SETTING: Hospital and university centers belonging to the Italian Multidisciplinary Group on Melanoma. PATIENTS: Eight hundred sixteen patients who were consecutively diagnosed as having melanoma and treated at 11 participating centers. MAIN OUTCOME MEASURE: Relationship between patterns of detection and patient's and physician's delay with melanoma thickness, assessed by multivariate analysis. RESULTS: A statistically significant association with early diagnosis was found for female sex (odds ratio [OR] for a lesion >1 mm in thickness, 0.70; 95% confidence interval [CI], 0.50-0.97), higher educational level (OR, 0.44; 95% CI, 0.24-0.79), residence in northern and central Italy (compared with southern Italy) (OR, 0.44; 95% CI, 0.30-0.65 and OR, 0.24; 95% CI, 0.15-0.37, respectively), and the habit of performing a skin self-examination (OR, 0.65; 95% CI, 0.45-0.93). When adjusted for all the previously mentioned variables, only melanoma detection made by a dermatologist, maybe incidentally, was associated with a statistically significant additional effect on early diagnosis (OR, 0.45; 95% CI, 0.28-0.73). No significant effect of anatomical site (trunk compared with other sites: OR, 0.83; 95% CI, 0.59-1.17), presence of atypical nevi (OR, 0.78; 95% CI, 0.52-1.17), and patient's delay (>3 months compared with < or =3 months: OR, 1.12; 95% CI, 0.78-1.60) was found. CONCLUSION: Future melanoma early diagnosis strategies should adequately stress the role of skin self-examination among the adult population, and should recommend that dermatologists perform a total skin examination to identify suspect lesions (such an examination should also be performed during consultations for other reasons).

Arch Dermatol. 2003 May;139(5):607-12

Self-detected cutaneous melanomas in Italian patients.

Self-detection of suspicious pigmented skin lesion combined with rapid referral to dermatologic centres is the key strategy in the fight against melanoma. The investigation of factors associated with pattern of detection of melanoma (self- vs. nonself-detection) may be useful to refine educational strategies for the future. We investigated the frequency of melanoma self-detection in a Mediterranean population at intermediate melanoma risk. A multicentric survey identified 816 consecutive cases of cutaneous melanoma in the period January to December 2001 in 11 Italian clinical centres belonging to the Italian Multidisciplinary Group on Melanoma. All patients filled a standardized questionnaire and were clinically examined by expert dermatologists. Self-detected melanomas were 40.6%, while the remaining lesions were detected by a dermatologist (18.5%), the family physician (15.2%), other specialists (5%), the spouse (12.5%), a friend or someone else (8.2%). Variables associated with self-detected melanomas were female sex, young age, absence of atypical nevi, knowledge of the ABCD rule, habit of performing skin self-examination. Self-detected melanomas did not differ from nonself-detected tumours in term of lesion thickness; however, patients with self-detected melanomas waited a longer period before having a diagnostic confirmation (patient's delay) (> 3 months: odds ratio, 3.89; 95% confidence interval, 2.74-5.53). In order to reduce the patients' delays, educational messages should adequately stress the need for a prompt referral to a physician once a suspicious pigmented lesion is self-detected.

Clin Exp Dermatol. 2004 Nov;29(6):593-6

Is physician detection associated with thinner melanomas?

CONTEXT: In cutaneous melanoma, tumor depth remains the best biologic predictor of patient survival. Detection of prognostically favorable lesions may be associated with improved survival in patients with melanoma. OBJECTIVE: To determine melanoma detection patterns and relate them to tumor thickness. DESIGN: Interview survey. SETTING AND PATIENTS: All patients with newly detected primary cutaneous melanoma at the Melanoma Center, Johns Hopkins Medical Institutions, between June 1995 and June 1997. MAIN OUTCOME MEASURE: Tumor thickness grouped according to detection source. RESULTS: Of the 102 patients (47 men, 55 women) in the study, the majority of melanomas were self-detected (55%), followed by detection by physician (24%), spouse (12%), and others (10%). Physicians were more likely to detect thinner lesions than were patients who detected their own melanomas (median thickness, 0.23 mm vs 0.9 mm; P<.001). When grouped according to thickness, 11 (46%) of 24 physician-detected melanomas were in situ, vs only 8 (14%) of 56 patient-detected melanomas. Physician detection was associated with an increase in the probability of detecting thinner (< or =0.75 mm) melanomas (relative risk, 4.2; 95% confidence interval, 1.4-11.1; P=.01). CONCLUSIONS: Thinner melanomas are more likely to have been detected by physicians. Increased awareness by all physicians may result in greater detection of early melanomas.

JAMA. 1999 Feb 17;281(7):640-3

Melanoma in middle-aged and older men: a multi-institutional survey study of factors related to tumor thickness.

OBJECTIVES: To identify factors related to the detection of melanoma and to determine those that differ between thinner vs thicker tumors in middle-aged and older men. DESIGN: Survey. SETTING: Three institutional melanoma clinics. PARTICIPANTS: Men 40 years or older who had newly diagnosed invasive melanoma. MAIN OUTCOME MEASURES: Differences in melanoma awareness, skin examination practices, discovery patterns, and social/medical care factors relative to tumor thickness. RESULTS: Two hundred twenty-seven men completed surveys within 3 months of melanoma diagnosis; 57 (25.1%) had thicker tumors (>2.00 mm). Thicker tumors were associated with nodular histologic features (43.9%), a lack of atypical nevi, having less than a high school education, and patient vs physician (dermatologist or nondermatologist) detection. Knowledge of melanoma (P = .007), attention to skin cancer detection information (P = .02), an interest in health topics (P = .003), and knowing the importance of physician skin examination (P = .05) were more common in those with thin tumors. Tumor thickness did not correlate with age, anatomic location, marital/cohabitation status, prior skin cancer, or sun sensitivity. Overall patient awareness of melanoma warning signs, skin self-examination practices, and Internet use were poor (<20%, <50%, and <14%, respectively). CONCLUSIONS: Physician discovery, the patient's higher level of education and detection-promoting awareness and attitudes, and the presence of clinically atypical nevi were related to thinner melanomas. Innovative outreach strategies and novel educational campaigns incorporating these factors, coupled with sharper messages regarding the importance of physician screening, are needed to improve early detection in middle-aged and older men.

Arch Dermatol. 2009 Apr;145(4):397-404

A Phase 3 Randomized Trial of Nicotinamide for Skin-Cancer Chemoprevention.

BACKGROUND: Nonmelanoma skin cancers, such as basal-cell carcinoma and squamous-cell carcinoma, are common cancers that are caused principally by ultraviolet (UV) radiation. Nicotinamide (vitamin B3) has been shown to have protective effects against damage caused by UV radiation and to reduce the rate of new premalignant actinic keratoses. METHODS: In this phase 3, double-blind, randomized, controlled trial, we randomly assigned, in a 1:1 ratio, 386 participants who had had at least two nonmelanoma skin cancers in the previous 5 years to receive 500 mg of nicotinamide twice daily or placebo for 12 months. Participants were evaluated by dermatologists at 3-month intervals for 18 months. The primary end point was the number of new nonmelanoma skin cancers (i.e., basal-cell carcinomas plus squamous-cell carcinomas) during the 12-month intervention period. Secondary end points included the number of new squamous-cell carcinomas and basal-cell carcinomas and the number of actinic keratoses during the 12-month intervention period, the number of nonmelanoma skin cancers in the 6-month postintervention period, and the safety of nicotinamide. RESULTS: At 12 months, the rate of new nonmelanoma skin cancers was lower by 23% (95% confidence interval [CI], 4 to 38) in the nicotinamide group than in the placebo group (P=0.02). Similar differences were found between the nicotinamide group and the placebo group with respect to new basal-cell carcinomas (20% [95% CI, -6 to 39] lower rate with nicotinamide, P=0.12) and new squamous-cell carcinomas (30% [95% CI, 0 to 51] lower rate, P=0.05). The number of actinic keratoses was 11% lower in the nicotinamide group than in the placebo group at 3 months (P=0.01), 14% lower at 6 months (P<0.001), 20% lower at 9 months (P<0.001), and 13% lower at 12 months (P=0.001). No noteworthy between-group differences were found with respect to the number or types of adverse events during the 12-month intervention period, and there was no evidence of benefit after nicotinamide was discontinued. CONCLUSIONS: Oral nicotinamide was safe and effective in reducing the rates of new nonmelanoma skin cancers and actinic keratoses in high-risk patients. (Funded by the National Health and Medical Research Council; ONTRAC Australian New Zealand Clinical Trials Registry number, ACTRN12612000625875.).

N Engl J Med. 2015 Oct 22;373(17):1618-26