Melanoma Surveillance in "High-Risk" Individuals

Among cancers,melanoma is uniquely amenable to early visual detection and simple curative therapy. Screening may therefore reducemortality, and this logichas led topopulationbased surveillance efforts in Germany, with initial results in the state of Schleswig-Holstein suggesting a nearly 50% decrease in melanoma mortality.1 The US Preventive Services Task Force (USPSTF) guidelines do not currently recommendpopulation-basedmelanomascreening.2Although the USPSTF identifies certain patient groups at substantially increased risk for melanoma, namely fairskinnedmen andwomen older than 65 years and individuals withatypicalmolesormore thana total of 50moles, they state that the benefits of screening these patients continue to remain uncertain.2 In this issue of JAMA Dermatology, Moloney et al3 illustrate the potential impact of surveillance in some of the highest risk melanoma groups. It also adds to a growing body of literature supporting the role of technology in aiding melanoma detection. What are some of the lessons derived from the experience of Moloney et al?3 We suggest that (1) the rates of melanoma among these very high-risk populations seem sufficient to justify screening; (2) while melanoma overdiagnosis associated with this degree of surveillance cannot be quantified, it is apparent that a significant subset of these lesionswas of a histologic type associated with mortality if not detected early; (3) technology in the form of total body photography (TBP),dermoscopy,andsequentialdigitaldermoscopic imaging (SDDI) can assist, andmay improve, themanagement of these high-riskpatients; (4) evenamongmelanomasassociatedwith rapid growth (ie, nodular), surveillance resulted in fairly early detection; and (5) in the setting of active professional surveillance, self-detection remains an important and unique aspect of melanoma diagnosis. While the benefits of melanoma screening in the general population remain controversial, the 18.2%cumulativemelanoma risk at year 4 in this study3 lends support for surveillance in patients with a personal history ofmelanoma, a very strong familyhistory ofmelanoma,high-penetranceCDKN2A and CDK4 genetic mutations, or a floridly expressed atypical nevus phenotype. It is possible, as notedby the authors,3 that the increased incidence of melanoma in the initial study period may be the result of the harvesting of indolent lesions. Nonetheless, becausemany of the lesions were invasive cancers detected on the basis of change, it can be reasonably inferred that thesewere trulydynamic lesionswithat least some potential for progression to metastatic and fatal disease. The benefits of surveillance in individualswithother knownmelanomarisk factors, suchassevereactinicdamage, increasednevi but fewatypical nevi, andapositive but less pronounced family history of melanoma, requires further study. The fact that 62.3% of detected melanomas demonstrated histologic evidence of an associated nevus and 37.7% were de novo melanomas underscores the utility of surveillance techniques that permit detection of both changing and new lesions. Thevalueof technology is supportedby the finding that 39.3%and37.7%of postbaselinemelanomasweredetected either exclusively or aided by SDDI and TBP, respectively. Melanomas diagnosed with these imaging techniques were identifiedmost frequently as in situ or earlymicroinvasive tumors.Admittedly, it is impossible to knowwhether this accelerated detection significantly changed mortality. However, what is evident from the experience ofMoloney et al3 is the favorable impact on morbidity. Application of dermoscopy in combinationwithSDDI andTBPpermittedearlymelanoma detection with very few unnecessary excisions of ultimately benign melanocytic lesions, even among patients with particularly atypical and complex nevus phenotypes. These data are consistent with the 10-year experience of Salerni et al,4 who found that the combined use of TBP and SDDI in patients at high risk for melanoma allowed detection of melanoma at early stages with very low rates of benign excisions. Based on a meta-analysis of 9 prospective studies demonstrating a higher diagnostic accuracy for primary melanoma detection with dermoscopy compared with naked eye examination alone,5 Australia, New Zealand, Germany, and Italy have recently issued clinical guidelines strongly recommending the training in and use of dermoscopy for examination of pigmented skin lesions.6-8 Knowledge of the dermoscopic evaluation of skin lesions is not at present formally recommendedbyanyUSauthority.Although the reporteduse of dermoscopy by US chief residents increased from 50.6% in 2000 to84.3% in 2009 (P = .001),9 only 52% reported satisfaction with the training received in dermoscopy during residency,10 and 85.6% would have preferred additional training.9 It is worthwhile to note that the experience of Moloney et al3 occurred in Australia, where dermoscopy is commonlyusedbya largeproportionofdermatologists11 and isemphasized in the national training curriculum.12 TheexperienceofMoloneyetal3highlights important limitations and opportunities associated withmelanoma screening.Evenwith frequent follow-upusingTBP,dermoscopy, and SDDI, clinically featurelessor inconspicuousmelanomas, such as amelanotic anddesmoplasticmelanomas,maynot be readily amenable toearlydetection.However,manynodularmelanomas were diagnosed at a thickness of less than 1 mm, sugRelated article page 819 Opinion