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Benefits, harms of routine skin cancer screening uncertain
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NEW YORK — Whether public skin cancer screening or awareness campaigns have led to the observed improvements in melanoma detection and mortality rates in Western Europe remains an unanswered question, according to a presenter at HemOnc Today Melanoma and Cutaneous Malignancies.
“Melanoma survival in Europe has increased over the years to 90% in Germany and some other Western European countries,” Axel Hauschild, MD, PhD, professor and head of the Interdisciplinary Skin Cancer Center at University Hospital Schleswig-Holstein in Kiel, Germany, said during his presentation. “But the range is still around 50% survival in some Eastern European countries, which is a dilemma. We believe this is due to the early detection of melanoma.”
Axel Hauschild
Germany is the only country in Europe where broad public screening is available, according to Hauschild. Thus, he surmised that increases in survival must be caused by other factors, in addition to screening.
General perceptions of screening and early detection have changed over time.
“In 1974, Der Spiegel wrote that it believed cancer was cured by early detection,” Hauschild said. “In the newer days, the same magazine said it was a risk to screen patients. There is a paradigm change in Germany from believing that screening is something good to believing that it is harmful.”
Cancer screenings have always been a balance between potential benefits and risks, according to Hauschild.
“However, the harms of skin cancer screening are less important when compared with breast cancer screening, and particularly prostate screening,” Hauschild said.
Early awareness campaigns have been linked to survival improvements over time. For example, a screening awareness campaign in the Czech Republic led to a 20% melanoma survival improvement over the course of 20 years.
Hauschild referenced the SCREEN trial (Breitbart EW, et al. J Am Acad Dermatol. 2012;doi:10.1016/j.jaad.2010.11.1016) during his presentation.
Under the SCREEN trial, between 30% and 40% of the German population (approximately 18 million individuals) voluntarily underwent skin cancer screening. The majority of insurance companies allowed individuals to begin screening at the age of 20 years.
The trial — which was conducted in Northern Germany — showed a 34% increase in the incidence of invasive melanoma in the wake of systematic screening implementation. However, the researchers also reported a 48% decrease in melanoma mortality within 5 years.
However, Hauschild noted some limitations to SCREEN.
“The science is not that good at the moment, because it was not a prospective randomized trial,” Hauschild said. “There are no clear data whether the success in mortality rate is due to early awareness or if we have screened the patients.”
He further noted that during the same period in which SCREEN was conducted (2000-2007), surrounding countries in Europe did not experience significant changes to incidence or mortality rates.
Opinions on screening programs in other countries, including the United States, continue to vary, Hauschild said. No screening studies of individuals without an increased or familial risk for melanoma have been conducted.
Dermatologic oncologists at Memorial Sloan Kettering Cancer Center endorsed screening among individuals with a personal history of melanoma, as well as those identified during routine care who meet risk criteria for additional screening. However, they did not recommend routine skin cancer screening.
Lingering questions in this conversation include whether to screen for melanoma only or to include nonmelanoma skin cancers; whether screening should be limited to high-risk individuals; whether screening should be performed by general practitioners or by specialized dermatologists; and how potential screening programs should be financed.
“The evidence of the benefits of early melanoma detection are insufficient to reliably conclude that early detection screening makes sense,” Hauschild concluded. “The harms of early detection include misdiagnosis and overdiagnosis, with the resulting adverse events associated with biopsy and unnecessary treatment. But compared with the invasive screenings for breast cancer or PSA, the harms are much smaller.” – by Cameron Kelsall
Reference:
Hauschild A. Screening for Melanoma. Presented at: HemOnc Today Melanoma and Cutaneous Malignancies; March 18-19, 2016; New York.
Disclosure: Hauschild reports no relevant financial disclosures.