Primary and secondary prevention are considered the cornerstones for thwarting deaths due to melanoma. A major Australian study recently demonstrated that primary prevention through systematic sunscreen use could indeed halve people’s risk of developing the disease (see The Melanoma Letter, volume 30, No. 2). However, the benefits of secondary skin cancer prevention via population-based physician screening have remained to be proven.
Clearly, avoiding the sequelae of advanced cancers through early detection remains the holy grail of “secondary prevention” efforts. Mounting evidence over the past several decades is providing strong support for the effectiveness of screening for cancers of the cervix, colon, and breast. Considerable attention has also been given to the possible negative consequences of screening, including overdiagnosis and overtreatment, but more so than with some other cancers, the lifesaving potential of melanoma screening appears to make it a favorable, justifiable trade-off.
Part of what recommends skin cancer screening is its relative noninvasiveness. Unlike colonoscopy or mammography, the melanoma screening examination consists of simple visual inspection with little cost and no risk. Similarly, the risk of overdiagnosis is mitigated by the limited morbidity associated with skin biopsies and removal of most early melanoma lesions. Still, in the absence of hard data showing that screening reduces mortality, concerns about risks and cost-effectiveness have prevented authorities from recommending routine melanoma screening.
New research out of Europe, however, may tip the balance in favor of melanoma screening. In this issue of The Melanoma Letter, Dr. Katalinic and colleagues describe a nationwide one-year melanoma screening program conducted in the German state of Schleswig-Holstein from July 2003 to June 2004. This public health campaign, predicated on the intuitive benefits of melanoma screening, was not formally designed to test its impact on mortality. Nonetheless, given the extent of the campaign and its finding that melanoma mortality declined after initiation of screening by as much as 50 percent in Schleswig-Holstein (while remaining unchanged in three adjacent, unscreened German states or in Germany as a whole), the German experience may well change the landscape of melanoma screening dramatically worldwide.
Continued observation and formal analysis of the impact of screening (now being done nationwide in Germany) presents a unique and important opportunity to inform public health decisions in the US and elsewhere. The methods used in the German screening campaign will also likely serve as an important yardstick for others looking to implement broad-based melanoma screening programs.
Allan C. Halpern, MD
Ashfaq A. Marghoob, MD