NEW YORK – A national, population-based melanoma screening program underway in Germany may provide the data to drive similar initiatives elsewhere, including the United States, but complex issues surround cancer screening programs of any kind, Dr. Allan C. Halpern said in a key address at the American Academy of Dermatology summer meeting.
Even if reduced mortality from the melanoma screening program in Germany equals the numbers seen in the regional initiative that prompted the national program, Dr. Halpern, chief of the dermatology service and co-leader of Memorial Sloan-Kettering Cancer Center (New York) melanoma disease management team, cautioned that U.S. policy makers will face several issues before adopting a similar program.
"We have begun to understand that no matter what you are screening for, you end up finding a lot of indolent disease, or what we now call overdiagnosis," Dr. Halpern said. In these cases, clinicians diagnose cancer or precancerous conditions "in patients who were never going to be hurt by their disease" but may incur harm from treatments or from the psychosocial stress of the diagnosis.
Courtesy of Memorial Sloan-Kettering Cancer Center
Dr. Allan C. Halpern
Melanoma is the only cancer for which mortality is increasing, despite simple and effective screening strategies, Dr. Halpern said. One problem is that only a proportion of those patients known to be at high risk for melanoma, such as those with a personal or family history of this disease, undergo regular surveillance. Despite a clear need for rigorous screening in high risk individuals, he suggested that "[dermatology] as a profession has not figured out how to do this consistently."
However, the program in Germany is not restricted to high-risk individuals. It was initiated after a screening program in Schleswig-Holstein, one of 16 German states, was credited with reducing melanoma mortality by 47% in women and 49% in men, based on rates 5 years after screening, compared with rates 4 years before screening (Cancer 2012;118:5395-402). Mortality rates in adjacent states over this period were unchanged.
In the German program, approximately 1,700 general practitioners were trained to provide whole body assessments for melanoma. Individuals aged 20 years and older were eligible, and more than 360,000 residents of Schleswig-Holstein were screened. Dr. Halpern said that the development of the program was largely because of the initiative of Dr. Eckhard W. Breitbart, a Schleswig-Holstein dermatologist who convinced public health authorities to provide funding.
The evidence of benefit was sufficient to generate a national program. So far, 13 million Germans have already been screened, Dr. Halpern said. Although the mortality reduction from the national program may not reach the magnitude seen at the regional level, any large reduction would provide "a huge endorsement for melanoma screening," Dr. Halpern noted.
Melanoma screening data are needed, Dr. Halpern added. The U.S. Preventive Services Task Force "specifically does not recommend melanoma screening for the population at large" because of lack of randomized, controlled trial evidence that it would provide an overall benefit, he said. Such trials have been proposed, and a pilot study was completed in Australia, Dr. Halpern said, but he said he does not believe a large scale trial is forthcoming. Rather, he said he believes that a study similar to the German study may be the best opportunity to show a benefit from screening.
Similar policy changes occurred after a Scandinavian initiative to screen cervical cancer demonstrated a large mortality benefit, according to Dr. Halpern, who called that experience the "poster child" for cancer screening initiatives. The mortality benefit data from the population-based program was so compelling that screening programs for cervical cancer are now broadly accepted worldwide, although a randomized controlled trial was never conducted. If the German data provide similar evidence of the benefits of melanoma screening, "this may be how we get to melanoma screening in this country," Dr. Halpern said.
Melanoma screening is "intuitively attractive," Dr. Halpern added, but he acknowledged the rationale for caution. While he said he believes there is a need to increase screening in high-risk populations, the risk of harm, including psychosocial harm, from population-based screening is not trivial. The German experience may provide the data to help determine whether population-based screening makes sense.
Dr. Halpern disclosed financial relationships with multiple companies including Canfield Scientific, DermTech International, Quintiles, Roche, and SciBase.