Older men whose melanoma is detected by a physician are more likely to have thinner and therefore more treatable tumors at diagnosis, according to results of a new survey. A second analysis of the same survey data finds that physician detection of thin melanoma is more common in those who are 65 or older, have cancers on their backs or who have a history of atypical moles.
Melanoma is becoming more common and mortality rates from melanoma are steadily increasing among older men, according to background information in one of the articles. Tumor thickness at diagnosis strongly predicts the management and outcomes of melanoma, and the thickest tumors (4 millimeters or thicker) are increasingly common in white men age 60 and older. "Rigorous assessment of behavioral, social and medical access factors that differ between men 40 years or older with thinner vs. thicker melanomas may identify potential modifiable variables," the authors write. "A clearer understanding of these factors provides fundamental knowledge for additional studies and public health messages aimed at earlier melanoma detection in this high-risk subset of men."
In one study, Susan M. Swetter, M.D., of Stanford University Medical Center, Calif., and colleagues surveyed 227 men age 40 and older between 2004 and 2006, within three months of their melanoma diagnosis. The men responded to questions about their previous melanoma awareness, skin examination practices, how their cancer was discovered and social and medical care factors.
Of the 227 men, 57 (25.1 percent) had tumors thicker than 2 millimeters. These men were more likely to have less than a high school education, less likely to have a history of atypical nevi (moles) and their melanomas were more often discovered by the patient themselves or a friend or family member than by a physician. Men with thinner melanomas were more likely to have previous knowledge of melanoma, have paid attention to skin cancer detection information, be interested in health topics and be aware of the importance of physician skin examination. Tumor thickness was not associated with patients' age, whether or not they were married or lived with a partner, skin cancer history, sun sensitivity or the anatomic location of the cancer.
Overall, few patients were aware of melanoma warning signs (less than 20 percent), practiced skin self-examination (less than 50 percent) or used the Internet (less than 14 percent) as a source of skin cancer information.
"For men 40 years or older, who constitute more than half of all melanoma deaths in the United States, we have identified at least two key variables (physician skin examination and improved public awareness, particularly for patients in lower socioeconomic groups) as major targets for new interventions to promote earlier melanoma detection," the authors write. "Public education, in particular targeting less-educated, middle-aged and older men for improved self-examination and physician skin surveillance, should become an integral component of skin cancer risk reduction strategies promoted by cancer advocacy organizations."
In another study, Alan C. Geller, M.P.H., R.N., of Boston University, and colleagues report a separate analysis of the same survey data. Patients whose melanomas were detected by a physician tended to be older—57 percent were 65 years or older, compared with 42 percent of patients who detected cancer themselves and 34 percent whose cancer was detected by another non-physician. This may be because older patients visit their physicians more frequently, providing more opportunities for skin examination, and they may rely more heavily on physician skin evaluation because they tend to have poorer eyesight and are less likely to have a partner.
Forty-six percent of physician-detected melanomas, 16 percent of self-detected melanomas and 57 percent of melanomas detected by other means were on the patient's back; these back-of-the-body melanomas were smaller than 2 millimeters in 92 percent of physician-detected cases, 63 percent of self-detected cases and 76 percent of those detected by other means.
"Skin screenings of at-risk middle-aged and older American men can be integrated into the routine physical examination, with particular emphasis on hard-to-see areas, such as the back of the body," the authors conclude. "'Watch your back' professional education campaigns should be promoted by skin cancer advocacy organizations and should incorporate the importance of physician screening and the benefit of spouse or partner assistance for early detection of melanoma, particularly in the high-risk population of middle-aged and older men."
Editorial: Physicians Must Help Men Overcome Barriers to Care
"A growing body of sex-specific studies shows a trend among men, especially white middle-class men, of delaying seeking help when they become ill," writes June K. Robinson, M.D., of Northwestern University Feinberg School of Medicine, Chicago, and editor of Archives of Dermatology, and colleagues in an accompanying editorial. "By delaying seeking care, men present at a later stage of melanoma when it is no longer treatable."
"The tasks associated with seeking help from physicians, such as relying on others, admitting a need for help or appearing vulnerable, may be in conflict with some individuals' societal and normative beliefs that men are self-reliant, physically tough, invincible and in control of their destiny. For example, some men may be thought of as the 'strong, silent type'; thus, they are reluctant to make a fuss over a little mole or to admit their fear that something could be wrong, even to themselves."
"This latter issue leads to the question of how physicians can interact with their patients in a manner that overcomes some of these interpersonal and psychological barriers to improve treatment outcomes," the authors write. Building strong, trusting physician-patient relationships, using appropriate patient education materials, asking patients about their concerns and demonstrating empathy may improve the care of all patients with melanoma.
This study was supported in part by a National Cancer Institute grant to Dr. Robinson.
- Swetter et al. Melanoma in Middle-aged and Older Men: A Multi-institutional Survey Study of Factors Related to Tumor Thickness. Archives of Dermatology, 2009; 145 (4): 397 DOI: 10.1001/archdermatol.2008.603
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