Counselling preventative behaviours in the melanoma patient

Abstract

Melanoma is a malignancy of the pigment producing melanocytes in the skin which affects approximately 2% of adults in the United States. In 2015, there were an estimated 74,000 new cases of invasive melanoma in the United States. This estimate is likely lower than the actual incidence as many melanoma in situ and superficial melanomas may not be reported to the National Cancer Institute Surveillance, Epidemiology, and End Results Program.[1] Five-year survival rate for patients with thin melanomas is approximately 95%, while primary tumors greater than 4.0 mm in depth have a 67% 5-year survival rate. There is no effective treatment once distant metastasis has occurred, with 5-year survival rates as low as 19% for patients with cutaneous or subcutaneous metastases.[2] In a study of 3310 patients with primary melanoma, they had a 25 times increased risk for developing a second primary melanoma compared to the general population.[3] Unlike the majority of other malignancies, development of skin cancer correlateswithmodifiable risk factors. History of sunburns and chronic intermittent sun exposure both have a causal relationship with the development of melanoma.[4] Multiple large studies have also identified intrinsic risk factors in the development of melanoma. These include light hair and eye color, freckling, increased number of melanocytic nevi, history of dysplastic nevi, and firstdegree family members with melanoma.[5,6] There is a huge potential role of physician counseling in the prevention of melanoma. The following goals should be considered when providing patient education on melanoma: awareness of genetic risk factors for melanoma development, impact of tanning behaviors, risk of significant morbidity and mortality from melanoma, and importance of skin self-examination (SSE). The physician should be cognizant of the patient’s level of education, baseline medical knowledge, perceived threat of their behaviors and the consequences of developing melanoma, and existing barriers to behavior change. This article will review the evidence behind incorporation of each of these counseling components in detail. The EDIFICE Melanoma study was a large French study polling 1502 adults on their perceived risk of melanoma. The study asked about the presence of the following risk factors: light skin, family history of melanoma, and number of nevi. Twenty-five percent of participants had one or more intrinsic risk factors for melanoma. Seventy-three percent of subjects had a true correlation between perception of risk and actual risk. Ten percent had an overestimation of level of risk, and 17% had an underestimation of risk. In the population of subjects who underestimated their level or risk, they had a significantly lower level of education compared to the other subgroups and a trend toward more frequent use of tanning beds. Surprisingly, the group who overestimated their risk of melanoma used significantly less sunscreen than those who had a lower perceived risk of melanoma. Therefore, the perception of increased risk for developing melanoma did not change the subjects’ behavior.[7] This has been corroborated by multiple other studies showing many patients continue to have positive or neutral attitudes towards tanning even after diagnosis of melanoma.[8] In one large international study of 11,000 people from Europe, United States, and Middle East, 38% of people with prior history of melanoma had intentionally tanned within the past year. Young adults under 25 years of age were less likely to perceive risk and more likely to prefer a deeper tan and had more intentional tanning than older cohorts.[9] These studies suggest a disturbing notion that the desire for a tan is more important to a patient than the risk of developing another skin cancer.[10] The strong desire to continue to tan despite a cancer diagnosis raises questions related to health psychology. It may be that young patients tend to view themselves EXPERT REVIEW OF QUALITY OF LIFE IN CANCER CARE, 2016 VOL. 1, NO. 1, 1–4 http://dx.doi.org/10.1080/23809000.2016.1135034