Malignant melanoma is a significant cause of morbidity and mortality worldwide (AIHW & AACR, 2004). Australia is considered in the world to have the highest number of incidences of melanoma. It is noted that, the people diagnosed with melanoma in 2005 was estimated to be 10,014 Australians whereby 4309 were women and 5705 were men (Australian Bureau of Statistics (ABS) 2007). Moreover, in Australia, melanoma in women was found to be the most third common cancer after colorectal and breast cancer, and in men was also the third common after colorectal and prostrate cancer in 2005.
Unfortunately, the number of deaths from melanoma in 2005 in Australia was 862 men and 411 women (ABS, 2007). Melanoma is not only experienced in Australia but also in other countries such as US whereby malignant melanoma is considered to be a significant problem in public health whereby its has the greatest number of incidences increasing everyday as compared to other types of cancer. Today, 1 in 74 Americans is considered to develop melanoma cancer in his or her lifetime (American cancer society, 2008).
The risk of melanoma is determined by ethnic origin whereby its incidence greatly differs in various ethnic groups living in the same region. In Australia, melanoma is detected in both Caucasian and non Caucasian populations whereby the incidences are lower in Non Caucasians than in Caucasians. The clinical outcome of melanoma in non Caucasians is poorer in presenting its signs in acral sites. Therefore as the non Caucasian population is rapidly growing in Australia there is a need for awareness of melanoma in this group.
It is noted that 16 percent of Australian population has non Caucasian ancestry whereby it is on the increase due to the increasing number of immigrants from Central and southern Asia, and sub Saharan Africa (Johnson, et al, 2003). Incidence of melanoma is also affected by geographical location which depends on the length and intensity of sun exposure in certain geographical areas. For instance, several studies indicate that populations that had lower incidence of melanoma, the incidence rate increased after migrating to Australia.
Populations in different geographical locations mostly have different genetic characteristics which are risk factors related to occurrence of melanoma. These characteristics include skin, eyes and hair color whereby people with light skin, green or blue eyes, and red or blonde hair their risk of getting melanoma are very high. More investigations are being conducted in order to determine the role played by genetic factors which are acquired through the environment especially exposure to sunlight in occurrence of melanoma.
It is noted that people who live near to the equator where intensity of sunlight is very high and usually sunburn easily and rarely tan are at high risk of suffering from Melanoma (Brantsch, et al, 2008). Although high risk of developing melanoma is associated with people with light skin, those with darker complexions are however not immune. SPTs (Skin photo types) classification system has been established according to skin sensitivity to sunlight. This varies from the lightest skin including other factors (SPT 1) to the darkest skin (1V) (Popular Health Division, 2007).
Photo aging skin diseases are associated with people with skin types I and 11, however, people of all skin shades can be affected by premature aging from sunlight (Berker, et al, 2007). The diagram below indicates the classification system for skin photo types (Rhodes, et al, 1987). Increased risk for melanoma in airline pilots is uncertain since it is not differentiated whether it is due to high exposure to ionizing radiation at high altitudes or it is due to more opportunities they spend in sunny regions (Koh, et al, 1992).
Risk of melanoma varies with population lifespan whereby aging is considered to weaken the body’s immunity in preventing melanoma and other cancers incidences. It is noted that Langerhans cells that assist the body to fight off early skin cancers are lost as a person grows old. As the immune cells decrease with age, the skin cancers have a higher incidence rate in later life. Melanoma affects people at all stages of life but it is mostly found in people over 40 years with average diagnosis at the age of 57 years (Condon, et al, 2003).
Findings from some of the researches suggest that women after the age of 50 have low incidence rates of melanoma due to menopause which is thought to have some sort of protective effects. Moreover men are found to have fatal and invasive melanoma than women which is associated with men’s ignorance to diagnose suspicious changes on the skin before they become worse. For children with less than 10 years, melanoma is very rare. Results from some researches indicate that incidence rate in children aged between 10 and 14 is 0. 3 per 100,000 children, and for ages between 14 and 19 there is no big difference with 1.
3 incidences per 100,000 children (Burton & Armstrong, 1994). Therefore parents should not worry much about minor skin defects on their children but they are advised to note that melanoma is serious in both children and adults thus early detection is still very significant in children. Interventions for Melanoma Case fatality rates are noticed to have reduced in the recent decades due to early detection of melanoma (Abbasi, et al, 2004). The impacts of early detection of melanoma are known to reduce population mortality rates if only used effectively.
The main targets of this kind of prevention are people who either have already melanoma or are at high risk of melanoma. Most of the countries implementing public health program to control melanoma have adopted early detection approach. Early detection is a form of secondary prevention of melanoma whereby it allows for detection of the cancer tumor at an early stage in its primary tissue thus it provides for easy treatment avoiding secondary dissemination which is more lethal within the patient’s expected lifetime (Healsmith, et al, 1994).
Excision of a tumor when it is thin influences the survival from invasive melanoma. The ability of early detection approach to detect early and thin tumors is the reason behind its success. In order for the tumor cells to be detected, they should exhibit abnormal characteristics which should develop in a rate that gives them time to be noticed and cured before the tumor develops to appoint that it becomes lethal. Therefore the principle in early detection approach is that, the melanoma should be seen publicly and then health professionally removed.
Lentigo maligna melanomas and superficial spreading melanomas are examples of tumors which relatively develop slowly over a period of time, that is, months to years, in a thin stage known as lateral growth phase and eventually develop deeply invasive known as the vertical growth phase (Binder, et al, 1995). As the tumors continue to grow, they develop characteristics that are noticeable thus suggesting a need for urgent attention. In order for one to conduct an effective early detection of a tumor he or she needs to have a clear understanding of early melanoma clinical signs as shown by the table below (Keefe, et al, 1990).
On the other hand, there are other types of tumors which develop very fast such as Nodular melanoma which are difficult to detect in an early curable phase since they may fail to develop the typical characteristics of melanoma. Most of the fatality cases occur because detection occurs at a later stage when the tumor is thicker as compared to Lentigo maligna melanoma and superficial spreading melanoma thus contributing a higher percent in mortality data (Holman, et al, 1986). The desirable target group therefore for the early detection approach is the population at high risk of developing melanoma tumors.
Risk factors are known to assist in pinpointing the specific people who are at increased risk of suffering from melanoma. Skin color is considered to be the most risk factor for melanoma whereby it is high in people with light skin and rare in black people. Additional risk factors are history of melanoma in the family, unprotected skin exposure to strong sunlight, tendency to freckle, excessive sunlight burns in the past, age and country where one spent his or her childhood. There are several techniques employed in early detection of melanoma which are outlined in the table below (Banky, et al, 2005).
In order to ensure effective prevention programs, evaluation of the early detection approach is very significant. The main objective of early detection of melanoma is to minimize mortality rate as a result of tumors. Early detection is very important since it relives a person from management stress of melanoma and all its consequences. Each and every step involved in early detection should be put in account during evaluation of the program beginning from the public adherence to assessment procedures, removal of tumors and rates of morbidity and mortality associated with melanoma.
Motivation and awareness of the target group and the health care providers is the first step in early detection intervention whereby an outcome measure for this phase should be assessment by change in attitudes, knowledge, and beliefs associated with melanoma and its treatment. Thickness of removed tumors after public awareness on melanoma is a short term outcome measure whereby an increase in number of tumors removed while in thin category is an evidence of a successful intervention.
However some of the thick tumors removed may be as a result of the awareness hence their detection may bias assessment of success of the invention (Giles, et al, 1996). The long term outcome required in early detection of melanoma intervention is the reduction in the mortality rate as a result of reduction of thick tumors detected in the population over a period of time after their tumors are detected early therefore they don’t get an opportunity to develop into thick and lethal lesions (Giles, et al, 1996).
In order to eliminate the lead time bias associated with removal of thin tumors, 10 year survival data will be useful to monitor success rather than five year survival data (Khlat, et al, 1992). Analysis of cost effectiveness of the intervention is important which can be expressed in terms of cost of life saved, time wasted and cost of extensive management and terminal care eliminated. Feasibility of early detection approach for those at high risk of melanoma
Due to the increasing prevalence of melanoma world wide, there is need for improved strategies for early detection (Swetter, et al, 2009). Untargeted early detection approaches are considered to be ineffective since they result into large numbers of people seeking medical services for skin lesions which are clearly benign therefore it is suggested to include selective screening targeting high risk individuals (Welch & Black, 2010). It is noted that some individuals are poor at assessing their risk status thus are unable to assign themselves to a high risk category.
There is limited study on the implications of individuals’ attitudes and self assessments of their own risk status for early detection focusing on the group at high risk of melanoma. The impact of the intervention depends on the attitudes to screening and perceived susceptibility related to acceptance of screening for melanoma and self assessed phenotypic risk factors. Therefore a proposed study is suggested to report on these. Research design The study will employ a population based cross sectional survey.
A sample of 900 individuals aged between 25 and 69 years will be stratified using social deprivation score of wards and then will be selected randomly from a population of 5000. The data will be collected through questionnaires focusing on risk factors for melanoma which will be posted to the sample group who will also be invited to attend a clinic for free screening for melanoma at the local hospital. Individuals to attend the screening clinic will be examined by consultant dermatologist. The questionnaire will include the demographic details of the participants such as date of birth and sex.
Data collection and analysis Participants will be required to describe themselves regarding to risk factors to melanoma particularly color of the hair, skin sensitivity to sunlight exposure, freckling, and the general amount of moles (Gruber, et al, 1993). The responses will be coded by grouping them into categories which the dermatologist will use during the clinical assessments. The color of the hair will be rated as black, blond, brown and red. The skin sensitivity will be rated as per classification system for skin photo types (Rhodes, et al, 1987).
The general amount of moles and freckling will be coded in terms of few/none, moderate and many (Abbasi, et al, 2008). Other sections contained in the questionnaire include self assessment confidence which will be determined in three items, that is,” I don’t find it difficult to say how much my skin is sensitive to the sunlight exposure; amount of freckles on my skin; amount of moles on my skin”. The responses will be rated on a five point scale ranging from “I strongly agree” (1) to “I strongly disagree” (5).
Another aspect included in the questionnaire is to examine the willingness of the individuals to seek for medical help which will be assessed through four items, that is, “I would feel stupid and uncomfortable to attend a clinic for my skin to be examined if there is nothing wrong with me; I would fear to allow the doctor to check any abnormal moles or marks on my skin incase something is diagnosed which I don’t want to hear; if I detect any abnormal marks on my skin I will seek medical advice as soon as possible; and I am confident that any diagnosed abnormal marks on my skin the doctor has the capacity to tell whether they need treatment”.
The codes of the responses will range from 1 to 5 with the highest score be coded to the greatest preparedness to seek medical help immediately. Assessment of relative optimism will be done through one item, that is, “I know my risk of developing melanoma is….. when I compare myself with other people of my gender and age in this country”. The responses will be coded and grouped into five categories whereby (-2) is “very high” while (+2) is “very minimal”.
In summary, the impacts of targeted screening of melanoma is considered to be felt in the community if people at higher risk of developing melanoma could accurately and confidently assess their own risk factors and make an informed decision of seeking clinical attention appropriately (ACN & NHMRC, 1999). Early detection therefore has a great benefit to the health of a population whereby treatment is mostly effective when melanoma tumors are detected early and melanoma is terminated before it develops to lethal stages whereby its detection at an early stage saves lives.
It is noted that there is a steady decline in five- year survival rates as the tumor continues to thicken in terms of millimeters and as its stage increases (Abbasi, et al, 2008). Individuals whose tumors are detected while in thin stage 1 lesions experience cure and longer disease -free survival as compared to those with thicker tumors detected in later stage lesions who are likely to die from metastatic disease (Burton & Armstrong, 1994). Bibliography Abbasi, N. R. , et al. , 2004. Early diagnosis of cutaneous melanoma. Revisiting the ABCD criteria, 292, p. 2771. Abbasi, N. R. , et al.
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