SCREEN: Melanoma Deaths Reduced by Half in Largest Study Ever

RALEIGH, N.C. – A population-based total-body skin cancer screening program reduces melanoma mortality, according to the results of a landmark German project presented at the annual meeting of the Society for Investigative Dermatology.

"I would argue that this is the most important presentation anywhere at this meeting," Dr. Martin A. Weinstock said during his presentation of the SCREEN (Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany) project.

"The reason I make that argument is very simply because melanoma accounts for more deaths than anything else in the dermatology world. If we want to reduce that number of deaths, the best way is [through] early detection – and SCREEN provides the best evidence to date that we can do that," explained Dr. Weinstock, professor of dermatology and epidemiology at Brown University, Providence, R.I., and a SCREEN project organizer.

SCREEN was a population-based skin cancer screening program in which all residents over age 20 in the German federal state of Schleswig-Holstein were encouraged to undergo a standardized whole-body skin examination between July 2003 and June 2004. Nineteen percent of the state’s eligible population – 360,288 individuals – participated. Half of the 1,169 melanomas diagnosed in Schleswig-Holstein during the study period were detected via the SCREEN program.

Before the skin cancer screening period (1998-1999), the melanoma mortality rate was 1.9 per 100,000 men and 1.4 per 100,000 women. The key study finding was that melanoma mortality fell by 48% in Schleswig-Holstein by 2008-2009 to 1.0 per 100,000 men to 0.7 per 100,000 women.

Nothing parallel occurred in the rest of Germany, or in Schleswig-Holstein’s neighbor to the north, Denmark.

The observed melanoma mortality rate in Schleswig-Holstein during 2008-2009 was 1.0 per 100,000 for men and 0.7 per 100,000 for women, compared with 1.8 and 1.2, respectively, in Germany as a whole excluding Schleswig-Holstein.

During 2000-2009, the most recent 10-year period for which official German mortality statistics are available, melanoma mortality in Schleswig-Holstein declined by 7.4% annually. In contrast, melanoma mortality rates were stable over time in each of the four adjacent states to the north, south, east, and west, none of which had a skin cancer screening program.

A bump in the incidence of melanoma was recorded in Schleswig-Holstein during the screening year, but not elsewhere, according to Dr. Weinstock.

The standardized total-body skin examinations were performed by physicians, who had to complete an 8-hour, day-long training course in order to participate. Of note, 116 of the 118 dermatologists practicing in Schleswig-Holstein participated in SCREEN, as did 64% of primary care physicians. Physicians were paid to perform the screens, and the public was encouraged to undergo screening via an extensive multimedia campaign.

The screening had a two-tiered structure. More than three-quarters of individuals were initially screened by primary care physicians. Participants with suspicious findings were sent to a dermatologist, who performed a second whole-body skin examination and performed biopsies as warranted.

Total-body skin examination as a means of reducing melanoma mortality has long been a controversial issue. The U.S. Preventive Services Task Force has recommended that there is not enough evidence to recommend screening the general adult population (Ann. Intern. Med. 2009;150:188-93). However, according to Dr. Weinstock, the recommendation will need to be revisited in light of the new evidence from Germany.

He observed that although SCREEN was an observational study, and, hence, doesn’t constitute absolute proof that a skin cancer screening program saves lives, it was the most ambitious effort to screen for melanoma ever conducted anywhere in the world. And it provides what is probably the strongest evidence that will ever be available, in his view, given the great expense and many years of follow-up required for a randomized controlled trial of skin cancer screening.

As he and his coauthors wrote in a new report from the SCREEN project, "In the public health arena, absolute proof is not necessarily required when lives are at stake" (Cancer 2012 April 19 [doi: 10.1002/cncr.27566]).

German dermatologists, flush with the SCREEN success, had proposed to follow-up the project with a definitive randomized controlled trial of melanoma screening, but were overruled. Federal health officials found the SCREEN results so persuasive that they launched an ongoing national skin cancer screening program. All 45 million Germans aged 35 years and older are now eligible for a total-body skin examination every 2 years.

The SCREEN investigators ruled out improvements in melanoma therapy as a potential explanation for the observed reduction in mortality, since there were none during the study years. Nor were there any changes in coding practices in the Schleswig-Holstein statistics office. And no major melanoma primary prevention programs were introduced.

Melanoma mortality rates in Schleswig-Holstein were fairly constant from 1990 to 2003, then dropped during and immediately after introduction of the statewide SCREEN program. All of which points to the skin cancer screening program as the almost-certain explanation for the melanoma mortality reduction, he said.

Dr. Weinstock promised there will be much more information and analysis to come from the SCREEN project, including tumor thickness–specific incidence rates. Also, by examining the incidence of melanoma in Schleswig-Holstein in the years following the screening program, it will be possible to create models that provide an idea of the optimal screening interval.

In a presentation at the Hawaii Dermatology Seminar sponsored by the Skin Disease Education Foundation (SDEF) in Waikoloa, Hawaii, Dr. Andreas Blum noted that while the main purpose of whole-body skin examination is to save lives through early detection of melanoma, the SCREEN project also detected basal cell carcinomas at a rate of 5.4 malignancies per 1,000 persons screened, and squamous cell carcinomas at a rate of 1.1 per 1,000.

Five lesion excisions had to be performed in order to detect one malignancy, according to Dr. Blum, professor of dermatology at the University of Tübingen (Germany).

He predicted that the cost involved in routine total-body skin examinations is likely to be a critical source of controversy. Using the U.S. National Cancer Institute’s estimate that 12.5% of melanomas are fatal, and assuming the cost of a total-body skin exam to be $50 per person, he estimated that routine total-body skin exams in the SCREEN project cost $240,000 per melanoma death avoided.

Meanwhile, in a recently reported multicenter study in which more than 14,000 subjects underwent a total-body skin exam, 400 patients had to be screened in order to find 1 melanoma (J. Am. Acad. Dermatol. 2012;66:212-9). Again, assuming a cost of $50 per total-body skin exam, that would work out to roughly $140,000 per melanoma death avoided, Dr. Blum said.

He added that in his own specialized skin cancer clinic, where he and his colleagues see a relatively select patient population, routine total-body skin exams cost an estimated $65,000 per melanoma death avoided. And when he plugged in the numbers provided by session chair Dr. Ashfaq A. Margoob from the skin cancer clinic at Memorial Sloan-Kettering Cancer Center in New York, Dr. Blum once again came up with a figure of roughly $65,000 per melanoma death avoided, which is close to one-fourth of the estimated cost per melanoma death avoided in the SCREEN project.

"The range is quite large. I think the cost debate will continue," Dr. Blum said.

Dr. Weinstock and Dr. Blum reported having no financial conflicts.

SDEF and this news organization are owned by Elsevier.

RALEIGH, N.C. – A population-based total-body skin cancer screening program reduces melanoma mortality, according to the results of a landmark German project presented at the annual meeting of the Society for Investigative Dermatology.

"I would argue that this is the most important presentation anywhere at this meeting," Dr. Martin A. Weinstock said during his presentation of the SCREEN (Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany) project.

"The reason I make that argument is very simply because melanoma accounts for more deaths than anything else in the dermatology world. If we want to reduce that number of deaths, the best way is [through] early detection – and SCREEN provides the best evidence to date that we can do that," explained Dr. Weinstock, professor of dermatology and epidemiology at Brown University, Providence, R.I., and a SCREEN project organizer.

SCREEN was a population-based skin cancer screening program in which all residents over age 20 in the German federal state of Schleswig-Holstein were encouraged to undergo a standardized whole-body skin examination between July 2003 and June 2004. Nineteen percent of the state’s eligible population – 360,288 individuals – participated. Half of the 1,169 melanomas diagnosed in Schleswig-Holstein during the study period were detected via the SCREEN program.

Before the skin cancer screening period (1998-1999), the melanoma mortality rate was 1.9 per 100,000 men and 1.4 per 100,000 women. The key study finding was that melanoma mortality fell by 48% in Schleswig-Holstein by 2008-2009 to 1.0 per 100,000 men to 0.7 per 100,000 women.

Nothing parallel occurred in the rest of Germany, or in Schleswig-Holstein’s neighbor to the north, Denmark.

The observed melanoma mortality rate in Schleswig-Holstein during 2008-2009 was 1.0 per 100,000 for men and 0.7 per 100,000 for women, compared with 1.8 and 1.2, respectively, in Germany as a whole excluding Schleswig-Holstein.

During 2000-2009, the most recent 10-year period for which official German mortality statistics are available, melanoma mortality in Schleswig-Holstein declined by 7.4% annually. In contrast, melanoma mortality rates were stable over time in each of the four adjacent states to the north, south, east, and west, none of which had a skin cancer screening program.

A bump in the incidence of melanoma was recorded in Schleswig-Holstein during the screening year, but not elsewhere, according to Dr. Weinstock.

The standardized total-body skin examinations were performed by physicians, who had to complete an 8-hour, day-long training course in order to participate. Of note, 116 of the 118 dermatologists practicing in Schleswig-Holstein participated in SCREEN, as did 64% of primary care physicians. Physicians were paid to perform the screens, and the public was encouraged to undergo screening via an extensive multimedia campaign.

The screening had a two-tiered structure. More than three-quarters of individuals were initially screened by primary care physicians. Participants with suspicious findings were sent to a dermatologist, who performed a second whole-body skin examination and performed biopsies as warranted.

Total-body skin examination as a means of reducing melanoma mortality has long been a controversial issue. The U.S. Preventive Services Task Force has recommended that there is not enough evidence to recommend screening the general adult population (Ann. Intern. Med. 2009;150:188-93). However, according to Dr. Weinstock, the recommendation will need to be revisited in light of the new evidence from Germany.

He observed that although SCREEN was an observational study, and, hence, doesn’t constitute absolute proof that a skin cancer screening program saves lives, it was the most ambitious effort to screen for melanoma ever conducted anywhere in the world. And it provides what is probably the strongest evidence that will ever be available, in his view, given the great expense and many years of follow-up required for a randomized controlled trial of skin cancer screening.

As he and his coauthors wrote in a new report from the SCREEN project, "In the public health arena, absolute proof is not necessarily required when lives are at stake" (Cancer 2012 April 19 [doi: 10.1002/cncr.27566]).

German dermatologists, flush with the SCREEN success, had proposed to follow-up the project with a definitive randomized controlled trial of melanoma screening, but were overruled. Federal health officials found the SCREEN results so persuasive that they launched an ongoing national skin cancer screening program. All 45 million Germans aged 35 years and older are now eligible for a total-body skin examination every 2 years.

The SCREEN investigators ruled out improvements in melanoma therapy as a potential explanation for the observed reduction in mortality, since there were none during the study years. Nor were there any changes in coding practices in the Schleswig-Holstein statistics office. And no major melanoma primary prevention programs were introduced.

Melanoma mortality rates in Schleswig-Holstein were fairly constant from 1990 to 2003, then dropped during and immediately after introduction of the statewide SCREEN program. All of which points to the skin cancer screening program as the almost-certain explanation for the melanoma mortality reduction, he said.

Dr. Weinstock promised there will be much more information and analysis to come from the SCREEN project, including tumor thickness–specific incidence rates. Also, by examining the incidence of melanoma in Schleswig-Holstein in the years following the screening program, it will be possible to create models that provide an idea of the optimal screening interval.

In a presentation at the Hawaii Dermatology Seminar sponsored by the Skin Disease Education Foundation (SDEF) in Waikoloa, Hawaii, Dr. Andreas Blum noted that while the main purpose of whole-body skin examination is to save lives through early detection of melanoma, the SCREEN project also detected basal cell carcinomas at a rate of 5.4 malignancies per 1,000 persons screened, and squamous cell carcinomas at a rate of 1.1 per 1,000.

Five lesion excisions had to be performed in order to detect one malignancy, according to Dr. Blum, professor of dermatology at the University of Tübingen (Germany).

He predicted that the cost involved in routine total-body skin examinations is likely to be a critical source of controversy. Using the U.S. National Cancer Institute’s estimate that 12.5% of melanomas are fatal, and assuming the cost of a total-body skin exam to be $50 per person, he estimated that routine total-body skin exams in the SCREEN project cost $240,000 per melanoma death avoided.

Meanwhile, in a recently reported multicenter study in which more than 14,000 subjects underwent a total-body skin exam, 400 patients had to be screened in order to find 1 melanoma (J. Am. Acad. Dermatol. 2012;66:212-9). Again, assuming a cost of $50 per total-body skin exam, that would work out to roughly $140,000 per melanoma death avoided, Dr. Blum said.

He added that in his own specialized skin cancer clinic, where he and his colleagues see a relatively select patient population, routine total-body skin exams cost an estimated $65,000 per melanoma death avoided. And when he plugged in the numbers provided by session chair Dr. Ashfaq A. Margoob from the skin cancer clinic at Memorial Sloan-Kettering Cancer Center in New York, Dr. Blum once again came up with a figure of roughly $65,000 per melanoma death avoided, which is close to one-fourth of the estimated cost per melanoma death avoided in the SCREEN project.

"The range is quite large. I think the cost debate will continue," Dr. Blum said.

Dr. Weinstock and Dr. Blum reported having no financial conflicts.

SDEF and this news organization are owned by Elsevier.

RALEIGH, N.C. – A population-based total-body skin cancer screening program reduces melanoma mortality, according to the results of a landmark German project presented at the annual meeting of the Society for Investigative Dermatology.

"I would argue that this is the most important presentation anywhere at this meeting," Dr. Martin A. Weinstock said during his presentation of the SCREEN (Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany) project.

"The reason I make that argument is very simply because melanoma accounts for more deaths than anything else in the dermatology world. If we want to reduce that number of deaths, the best way is [through] early detection – and SCREEN provides the best evidence to date that we can do that," explained Dr. Weinstock, professor of dermatology and epidemiology at Brown University, Providence, R.I., and a SCREEN project organizer.

SCREEN was a population-based skin cancer screening program in which all residents over age 20 in the German federal state of Schleswig-Holstein were encouraged to undergo a standardized whole-body skin examination between July 2003 and June 2004. Nineteen percent of the state’s eligible population – 360,288 individuals – participated. Half of the 1,169 melanomas diagnosed in Schleswig-Holstein during the study period were detected via the SCREEN program.

Before the skin cancer screening period (1998-1999), the melanoma mortality rate was 1.9 per 100,000 men and 1.4 per 100,000 women. The key study finding was that melanoma mortality fell by 48% in Schleswig-Holstein by 2008-2009 to 1.0 per 100,000 men to 0.7 per 100,000 women.

Nothing parallel occurred in the rest of Germany, or in Schleswig-Holstein’s neighbor to the north, Denmark.

The observed melanoma mortality rate in Schleswig-Holstein during 2008-2009 was 1.0 per 100,000 for men and 0.7 per 100,000 for women, compared with 1.8 and 1.2, respectively, in Germany as a whole excluding Schleswig-Holstein.

During 2000-2009, the most recent 10-year period for which official German mortality statistics are available, melanoma mortality in Schleswig-Holstein declined by 7.4% annually. In contrast, melanoma mortality rates were stable over time in each of the four adjacent states to the north, south, east, and west, none of which had a skin cancer screening program.

A bump in the incidence of melanoma was recorded in Schleswig-Holstein during the screening year, but not elsewhere, according to Dr. Weinstock.

The standardized total-body skin examinations were performed by physicians, who had to complete an 8-hour, day-long training course in order to participate. Of note, 116 of the 118 dermatologists practicing in Schleswig-Holstein participated in SCREEN, as did 64% of primary care physicians. Physicians were paid to perform the screens, and the public was encouraged to undergo screening via an extensive multimedia campaign.

The screening had a two-tiered structure. More than three-quarters of individuals were initially screened by primary care physicians. Participants with suspicious findings were sent to a dermatologist, who performed a second whole-body skin examination and performed biopsies as warranted.

Total-body skin examination as a means of reducing melanoma mortality has long been a controversial issue. The U.S. Preventive Services Task Force has recommended that there is not enough evidence to recommend screening the general adult population (Ann. Intern. Med. 2009;150:188-93). However, according to Dr. Weinstock, the recommendation will need to be revisited in light of the new evidence from Germany.

He observed that although SCREEN was an observational study, and, hence, doesn’t constitute absolute proof that a skin cancer screening program saves lives, it was the most ambitious effort to screen for melanoma ever conducted anywhere in the world. And it provides what is probably the strongest evidence that will ever be available, in his view, given the great expense and many years of follow-up required for a randomized controlled trial of skin cancer screening.

As he and his coauthors wrote in a new report from the SCREEN project, "In the public health arena, absolute proof is not necessarily required when lives are at stake" (Cancer 2012 April 19 [doi: 10.1002/cncr.27566]).

German dermatologists, flush with the SCREEN success, had proposed to follow-up the project with a definitive randomized controlled trial of melanoma screening, but were overruled. Federal health officials found the SCREEN results so persuasive that they launched an ongoing national skin cancer screening program. All 45 million Germans aged 35 years and older are now eligible for a total-body skin examination every 2 years.

The SCREEN investigators ruled out improvements in melanoma therapy as a potential explanation for the observed reduction in mortality, since there were none during the study years. Nor were there any changes in coding practices in the Schleswig-Holstein statistics office. And no major melanoma primary prevention programs were introduced.

Melanoma mortality rates in Schleswig-Holstein were fairly constant from 1990 to 2003, then dropped during and immediately after introduction of the statewide SCREEN program. All of which points to the skin cancer screening program as the almost-certain explanation for the melanoma mortality reduction, he said.

Dr. Weinstock promised there will be much more information and analysis to come from the SCREEN project, including tumor thickness–specific incidence rates. Also, by examining the incidence of melanoma in Schleswig-Holstein in the years following the screening program, it will be possible to create models that provide an idea of the optimal screening interval.

In a presentation at the Hawaii Dermatology Seminar sponsored by the Skin Disease Education Foundation (SDEF) in Waikoloa, Hawaii, Dr. Andreas Blum noted that while the main purpose of whole-body skin examination is to save lives through early detection of melanoma, the SCREEN project also detected basal cell carcinomas at a rate of 5.4 malignancies per 1,000 persons screened, and squamous cell carcinomas at a rate of 1.1 per 1,000.

Five lesion excisions had to be performed in order to detect one malignancy, according to Dr. Blum, professor of dermatology at the University of Tübingen (Germany).

He predicted that the cost involved in routine total-body skin examinations is likely to be a critical source of controversy. Using the U.S. National Cancer Institute’s estimate that 12.5% of melanomas are fatal, and assuming the cost of a total-body skin exam to be $50 per person, he estimated that routine total-body skin exams in the SCREEN project cost $240,000 per melanoma death avoided.

Meanwhile, in a recently reported multicenter study in which more than 14,000 subjects underwent a total-body skin exam, 400 patients had to be screened in order to find 1 melanoma (J. Am. Acad. Dermatol. 2012;66:212-9). Again, assuming a cost of $50 per total-body skin exam, that would work out to roughly $140,000 per melanoma death avoided, Dr. Blum said.

He added that in his own specialized skin cancer clinic, where he and his colleagues see a relatively select patient population, routine total-body skin exams cost an estimated $65,000 per melanoma death avoided. And when he plugged in the numbers provided by session chair Dr. Ashfaq A. Margoob from the skin cancer clinic at Memorial Sloan-Kettering Cancer Center in New York, Dr. Blum once again came up with a figure of roughly $65,000 per melanoma death avoided, which is close to one-fourth of the estimated cost per melanoma death avoided in the SCREEN project.

"The range is quite large. I think the cost debate will continue," Dr. Blum said.

Dr. Weinstock and Dr. Blum reported having no financial conflicts.

SDEF and this news organization are owned by Elsevier.