SCREENING FOR CUTANEOUS MELANOMA BY SKIN SELF-EXAMINATION

Background: Although some evidence indicates that early detection prot ects against the development of lethal melanoma, no randomized clinica l trials have been conducted to measure the efficacy of early detectio n (or screening) in preventing death from this disease. Since melanoma incidence in the United States is relatively rare, a randomized clini cal trial to test the efficacy of screening would be extremely expensi ve. Purpose: As an alternative to a randomized clinical trial, we cond ucted a population-based, case-control study to investigate whether ea rly detection through skin self-examination (SSE) is associated with a decreased risk of lethal melanoma (includes the presence of advanced disease with distant metastases in addition to death from melanoma). M ethods: SSE (conducting a careful, deliberate, and purposeful examinat ion of the skin) was assessed in all subjects by use of a structured q uestionnaire and personal interviews. The major exposure variable, SSE , was defined following focus-group interviews with melanoma patients and healthy control subjects. The final study population consisted of 1199 Caucasian residents of the state of Connecticut enrolled from Jan uary 15, 1987, through May 15, 1989; 650 individuals were newly diagno sed with cutaneous melanoma, and the remaining 549 individuals were ag e- and sex-frequency matched control subjects from the general populat ion. During the study interviews, nevi on the arms and backs of subjec ts were counted. In 5 years of follow-up (through March 1994), 110 let hal cases of melanoma were identified. The study design allowed separa te estimation of the impact of SSE on reduced melanoma incidence (prim ary prevention) and survival among incident cases (secondary preventio n). Odds ratios (ORs) were used to measure the associations between SS E and melanoma and between SSE and lethal melanoma. Results: SSE, prac ticed by only 15% of all subjects, was associated with a reduced risk of melanoma incidence (adjusted OR = 0.66; 95% confidence interval [CI ] = 0.44-0.99; comparing case patients with control subjects). The dat a indicated further that SSE may reduce the risk of advanced disease a mong melanoma patients (unadjusted risk ratio = 0.58; 95% CI = 0.31-1. 11); however, longer follow-up is required to confirm this latter esti mate. If both estimates are correct, they suggest, in combination, tha t SSE may reduce mortality from melanoma by 63% (adjusted OR = 0.37; 9 5% CI = 0.16-0.84; comparing lethal cases with general population cont rols). Conclusions and Implications: SSE may provide a useful and inex pensive screening method to reduce the incidence of melanoma, SSE may also reduce the development of advanced disease. The results of this s tudy need to be replicated before strategies to increase the practice of SSE are further developed and promoted.