According to World Health Organization statistical data (WHO, 2018), cancer is one of the major causes of death worldwide, with skin cancers holding the fifth rank, and cutaneous melanoma (CM) causing most deaths of skin cancers [1
]. Timely referral to the doctor helps early detection and removal of thinner CMs (<1 mm), which leads to positive outcomes for the patients [2
]. Thus, early CM diagnosis is an essential target for national healthcare.
An earlier epidemiological study showed that the average melanoma thickness accounted for >4 mm at the first medical examination in Russia [3
]. A study in 2018 revealed several problems, such as: people were almost unaware of the disease; procedures for excisional biopsy were too complicated; insufficient special training of primary care personnel (in 2018, CM was detected in 31.9% of patients, comparable with 45.5% of patients with detected skin cancer [1
]). Pathological CM overdiagnosis or underdiagnosis have become a frequent problem worldwide including Russia [4
]. Each of these factors ultimately affects the final data of the early detected melanomas and the mortality rate from CM.
The Melanoma Professional Association (MPA) supported by BIOCAD (Biotech company, Russia) designed a social educational program “Life Fear-Free” (LFF) for early CM detection. The major goal was to evaluate the impact of the LFF program on early CM and non-melanoma skin cancer (NMSC) detection. In addition, the participants’ answers should provide the data for population awareness about skin melanoma, its risk factors, prevention, and early diagnosis. The program was implemented in four Russian cities in 2019.
Although screening high-risk patients for melanoma has been a hot issue over the decades, no randomized controlled trials have been presented and therefore, we cannot evaluate the effect of screening on disease-related mortality.
The most extensive studies demonstrated controversial results of CM screening [7
A two-stage program on melanoma and non-melanoma skin cancer (SCREEN) was introduced in Schleswig-Holstein, Germany, in 2003. Approximately 19% of the regional population participated in the program. The results showed an increase in invasive melanoma incidence by 34% among the SCREEN participants. Five years after the program completion, the researchers registered a significant reduction of the melanoma-related mortality. The authors of the program admitted they could not arrange a randomized controlled trial [17
]. The SCREEN results boosted a skin cancer screening program across Germany, however no decrease in melanoma-related mortality was registered at the federal level [18
A large melanoma screening program (1984–1996) involved the employees of the Lawrence Livermore National Laboratory in the United States. Any participant who detected a suspicious lesion during skin self-examination went for specialist’s medical examination. Participants with melanoma, as well as individuals of the high-risk group, underwent planned examinations every 3–24 months. The study showed a reduction in the rough incidence rate of melanoma with a depth of > 0.75 mm (22.1–4.62 cases per 100,000 for the study period and 15.13–4.62 cases per 100,000 during the screening period). Though the estimated expected mortality rate was 3.39, no melanoma-related deaths occurred over the observation period. The authors declared some correlation between the decrease in melanoma-related mortality and decrease in the incidence of mature melanoma (depth > 0.75 mm), the increase in the awareness of the studied population, the introduction of skin self-examination, and screening examinations for people at high risk. However, that study was neither randomized, nor controlled [19
Finally, a large randomized study of melanoma screening started in Australia. Phase I lasted 18 months and involved 18 community-based populations (the study arm—9 communities, and the control arm—9). The number of participants in the screening study arm was higher than that of the control arm; however, the study was discontinued due to funding problems [20
In addition, numerous reports describe social educational projects, such as Euromelanoma Day [21
]. The present LFF program seems very much similar to the latter in terms of its organization.
The results of the LFF program showed that the studied population had low awareness of CM and NMSC and their risk factors. Although the program included information and awareness-raising campaign, the study did not evaluate the follow up effect of the distributed educational materials. However, a 2-week information campaign involving various media tools ensured a large number of people participated in the program (3134 enrolled participants, with initially planned 3200).
As a result of active screening (i.e., invitation for skin examinations), the researchers could pool the patients and improve CM detection that reached 3 cases of 3143 participants. The result corresponds to the incidence of 95.45 per 100,000 people, while an average Russian rough incidence rate is 7.76 cases per 100,000 adult population; thus, the study results showed 12.3 times higher incidence than the average incidence rate in Russia. NMSC incidence data showed similar result.
Apparently, given such a small number of participants, the program could not ensure any essential effect on CM or NMSC-related mortality in the participating regions.
The age characteristics of the program participants under screening for melanoma differed significantly from the average age of CM patients at the time of diagnosis; in Russia, the average age of the first detected CM is 61.7 years [1
]. The Russian population with first detected NMSC is even older: the average age of patients with NMSC is 69.7 at the time of diagnosis [1
We believe that the younger age of examined program participants might have some impact on the CM and NMSC detection results. The CM detection rate in the studied population reached 0.10% (3 patients of 3143 participants), and the detection rate of NMSCs (BCC and SCC) accounted for 0.51% (16 patients out of 3143 participants).
We compared CM incidence registered in LFF program with the incidence in the Euromelanoma Day in Sweden, 2008 [21
]. A total of 24 patients of 2799 examined in Sweden had histologically confirmed CMs; therefore, the detection rate accounted for 0.9% [14
]. The available data of the Euromelanoma Day project introduced in 2009–2010 in 20 European countries showed that Sweden had the highest melanoma detection rate among the countries included in the analysis [15
Several factors may contribute to the lower CM detection rate in the LFF program. Firstly, the CM incidence in Sweden is significantly higher than that in Russia. The standardized incidence rates in Sweden were 23.5 in men and 26.2 in women per 100,000 in 2018 [22
]; while in Russia, the standardized incidence rates were 4.57 in men and 4.97 in women [1
Secondly, the average age of participants in the Swedish Euromelanoma Day was higher than that in the Russian LFF Program (53 and 43.7 years, respectively). During the Euromelanoma Day in Sweden, patients were charged for their visits, which could prevent people with no suspicion for skin cancers from participation in the project. The participants of Euromelanoma Day who had suspicious lesions underwent excision surgery on the examination day, which reduced the risk of missing histological confirmation of the diagnosis as a result of the participant’s non-appearance for the biopsy after examination. Thus, some participants of the LFF program with suspected melanoma or non-melanoma skin cancer, who had to undergo a biopsy, did not turn up for that appointment (25 people).
To increase the program effectiveness, the awareness-raising campaign should focus on the people at high risk (older people with sun-damaged skin) and therefore, the authors should analyze and adapt the information campaign.
We consider it important to pursue certain organizing measures to avoid “losses” during the inter-stage routing of the participants (initial examination—biopsy). One such measure is performing biopsy on the day of the examination.
In addition, the proficiency of dermatologists, oncologists, and pathologists in detecting skin malignancies remains one of the key factors. Possible misdiagnosis, such as incorrect phototypes or underestimated number of nevi, etc., should be minimized.
The improvement of these factors combined with administrative support can ensure the start of a CM screening program in different regions of the country.
The participants showed high interest in early skin cancer detection program. However, the study revealed that a high percentage of LFF program participants had an incorrect understanding of melanoma and skin cancer, their risk factors, and treatment methods.
The detectability of melanoma and non-melanoma skin cancers is comparable to that of skin cancers obtained in similar screening projects. The early stage disease was confirmed for the detected melanoma and skin cancer. The incidence rate of CM and NMSCs among the program participants was higher than in general public.
The results suggest that social educational programs should be continued and target high-risk population. The implementation of the program also demonstrated what should be improved in the campaign, and it revealed the need for high-qualified medical personnel. Firstly, the design and organizational efforts should focus on the higher risk groups to reach senior members of the society. Additionally, it appeared important to improve the patient routing to avoid discrepancies between the examination stage and biopsy completion so that, if necessary, biopsy could be performed on the examination day. Furthermore, the electronic system of collecting the examination results should be upgraded. Finally, the involved specialists, such as dermatologists, oncologists, and pathologists should have appropriate qualification and motivation to participate in such programs.
Further well-organized controlled studies are required to evaluate if CM screening could decrease melanoma mortality rate.