Teaching self-detection of melanoma by skin self-examination is one of the major purposes of the A-B-C-D melanoma education program of the American Academy of Dermatology, National Cancer Institute, American Cancer Society and other organizations (Click on Self-Examination for a description of criteria for skin self-examination).

The program is also directed to family members of persons at risk for melanoma because detection of melanoma should be a family affair, especially in families with members at increased risk for melanoma (Click on Risk Factors to learn more about familial and environmental risk factors for melanoma)—for example, family history of melanoma, dysplastic nevi, large numbers of moles, white skin that burns rather than tans, freckling. Self-examination enhanced by family awareness and family assistance in performing an A-B-C-D skin examination can be very helpful in identifying suspicious lesions that should be examined by a dermatologist. Regularly scheduled examinations by a dermatologist is recommended for persons with increased risk for melanoma.

As important as it is to self-examine using A-B-C-D criteria, there are substantial reasons for (a) enlisting the help of family members or close friends, and (b) making certain that a full evaluation of the skin is included in every physical examination performed by your family physician:

1. You may be unaware of a suspicious lesion that you cannot see—for example, on your back, or under the hairline at the nape of the neck;

2. You may be aware of the lesion, but not concerned that recent changes in shape, color or size render it suspicious for transformation to melanoma; and

3. You may be both aware and suspicious of a lesion, but need prompting by family members to have the lesion examined by a dermatologist.

Visual examination of the skin by family members, physicians or nurses can result in early detection of melanoma and treatment while the melanoma is still in an early stage of development. Identification of a melanoma that is still thin improves the likelihood for survival (Click on Thickness for a discussion of the relationship between melanoma thickness and survival).

Some recently published studies reinforce the value of family involvement in skin self-examination:

• An Australian study of 513 melanoma patients and 498 controls (persons without melanoma) published in 2000 (Am J Epidemiol 2000; 151:72,) found that self-counting of common moles and atypical moles tended to substantially underestimate the numbers of both types of moles. Self-examination was compared against whole-body examination by a dermatologist, which more accurately assessed the numbers of both types of moles.

• Another study found that wives were more likely to self-detect suspicious lesions than were their husbands, and were more accurate than husbands in detecting melanoma on the skin of a spouse (Cancer 2000; 89: 342,).

• In a study of skin self-examination in high-risk patients, 25% were unable to detect an obvious increase in the size of an existing nevus (mole), and 38% incorrectly identified a change where no change occurred (J Am Acad Dermatol 2000; 42:754,).

• A study of 549 white-skinned persons reported, among other findings, that the likelihood of skin self-examination tended to decline with older age and college or postgraduate education (Cancer Epidemiol Biomarkers Prev 1999; 8:971). This study contrasted with a 1991 Australian study that associated low educational status with poor self-screening for melanoma (Arch Dermatol 1991; 127: 356,).

Previous studies conducted during the 1995-2000 period reported differing results regarding the melanoma detection rate from skin self-examination. In some studies, patients did not follow A-B-C-D criteria for skin self-examination, even when they were in a high-risk category. In high-risk patients who lapse in skin examination by self of family members, the value of regular skin examination by a dermatologist becomes even more important.

The fact that the overall 5-year survival rates for melanoma have been improving in the decades since the 1940s is generally taken as an indication that melanoma detection rates are improving and melanomas are being detected earlier—i.e., before lesions invade deeper tissue. A major factor in improved melanoma detection is the melanoma education effort carried out by the American Academy of Dermatology (AAD) since the 1980s. The AAD education program is directed toward (1) educating the public regarding melanoma risk factors, prevention and detection, (2) education of the public in criteria for A-B-C-D skin self-examination for melanoma, (3) education of physicians on the importance of full skin examination as a necessary part of every physical examination, and (4) national melanoma screening programs conducted voluntarily by dermatologists over a period of several years, which resulted in detection of numbers of previously unsuspected melanomas. Public education and physician education programs are complementary in detecting melanoma, just as the value of skin self-examination is enhanced when family members take part.

Even though survival has been improving on an overall basis, other statistics give cause for continuing concern. Incidence rates for melanoma are high, and in some countries and age groups are increasing. This is particularly true in Caucasian (white-skinned, light-haired, blue or green-eyed) populations. The highest melanoma incidence rate in the world occurs in Australia—specifically in persons of white European ancestry in Queensland, the northeastern part of Australia that borders on the Great Barrier Reef. During the 1980s the melanoma incidence rate in this population doubled in males and more than doubled in females. The reasons for this very substantial increase in incidence are not entirely clear.

Worldwide increase in the incidence of newly diagnosed melanoma has been 3% to 8% per year throughout the 1980s and ‘90s. Improved survival rates despite increasing incidence rates appears to indicate that public education programs are helping people to recognize melanomas earlier. An exception may be in African-Americans, Asians and other darker-skinned people who are more likely than whites to have melanomas diagnosed at later (thicker) stages, when prognosis for survival is poorer. The reason may be difficulty in assessing pigmented lesions in darkly pigmented skin.

When world-wide increase in melanoma incidence is related to risk factors, both genetic and environmental factors are shown to be important:

• Skin pigmentation (light-colored skin, blond or red hair, blue or green or gray eyes)

• Tendency to burn rather than tan when exposed to sun for long or intense periods

• Tendency to freckle

• Family history of melanoma

• Family history of having many moles and/or atypical (dysplastic) moles

• Melanocytic nevi

• Multiple nevi/prominent nevi

• Atypical (dysplastic) nevi

• Congenital nevi—e.g., giant congenital melanocytic nevi and small congenital nevi

• Moles that change in size, shape, color, or begin to itch or bleed

• Living in geographic region of high-intensity sunlight—e.g., Florida, Caribbean, northern Australia

• Many high-intensity sun exposures and sunburn in childhood

• Unprotected exposure to high-intensity sunlight and multiple sunburns in childhood increase risk

History of a Prior Melanoma

• Immunosuppressive drugs to prevent rejection of a transplanted organ

• Immunosuppression due to AIDS, other immunodeficiency disease or lymphoma

The interaction between the genetic or other risk factors such as exposure to intense ultraviolet radiation is complex and not entirely understood.

In self-examination for melanoma, however, one should not limit the examination to areas of the body most often exposed to the sun. While epidemiologic data show solar radiation to be a risk factor for melanoma, especially in white-skinned persons, genetic factors may be equally or even more important as risk factors. Most melanomas occur in areas of the body seldom or intermittently exposed to the sun.

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