San Antonio Military Medical Center, TX (Dr. Wohltmann); Uniformed Services University of the Health Sciences, Bethesda, MD (Dr. Servey) jessica.servey@usuhs.edu
The authors reported no potential conflict of interest relevant to this article.
The views expressed here are those of the authors and do not reflect the official views or policy of the Department of Defense or its components.
Patient education should include sun safety (wearing sun-protective clothing, using broad-spectrum sunscreen, and avoiding sun exposure during peak times of the day). The US Preventive Services Task Force (USPSTF) says the level of evidence is insufficient to support routine skin cancer screening in adults.46 However, the USPSTF recommends discussing efforts to minimize UV radiation exposure to prevent skin cancer in fair-skinned individuals 10 to 24 years of age.
Current National Comprehensive Cancer Network (NCCN) guidelines have outlined the follow-up frequency for all melanoma patients. TABLE 232 outlines those recommendations in addition to self-examination and patient education.
Melanoma epidemic or overdiagnosis?
Over the past 2 decades, a marked rise in the incidence of melanoma has been reported in developed countries worldwide, although melanoma mortality rates have not increased as rapidly, with melanoma-specific survival stable in most groups.47-50 Due to conflicting evidence, significant disagreement exists as to whether this is an actual epidemic caused by a true rise in disease burden or is merely an artifact stemming from overdiagnosis.47
Evidence supporting a true melanoma epidemic includes population-based studies demonstrating greater UV radiation–induced carcinogenesis (from the sun and tanning bed use), a larger aging population, and increased incidence regardless of socioeconomic status.47 Those challenging the validity of an epidemic instead attribute the rising incidence to early-detection public awareness campaigns, expanded screenings, improved diagnostic modalities, and increased biopsies. They also credit lower pathologic thresholds that help identify thinner tumors with little to no metastatic potential.48 Additionally, multiple studies report an increased incidence in melanomas of all histologic subtypes and thicknesses, not just thinner, more curable tumors.49,51,52 Although increased screening and biopsies are effective, they alone cannot account for the sharp rise in melanoma cases.47 This “melanoma paradox” of increasing incidence without a parallel increase in mortality remains unsettled.47
CASE
Your patient had Stage IIA disease and a WE was performed with 1-cm margins. Ultrasound of the axilla identified an enlarged node, which was removed and found not to be diseased. He has now returned to have you look at another lesion identified by his spouse. His review of symptoms is negative. His initial melanoma was removed 2 years earlier, and his last dermatology skin exam was 5 months prior. You look at the lesion using a dermatoscope and do not note any worrisome features. You recommend that the patient photograph the area for reexamination and follow-up with his dermatologist next month for a 6-month follow-up.
