Oklahoma City dermatologist Mark Naylor, M.D., won’t soon forget the teen-aged patient who showed up in his office a few years ago to have him check a suspicious growth on her buttocks which, on pathology, was found to be a melanoma. “It turned out that she was working in a tanning salon, where one of the so-called ‘benefits’ was free tanning,” Dr. Naylor recalls. And in early January, Dr. Naylor removed an atypical nevus from another teen who also happened to work in a tanning facility.
“Ten years ago it was a rare thing to see a teen with an atypical mole or a melanoma, but it’s getting pretty common here now,” says Dr. Naylor, a melanoma specialist and researcher with the Oklahoma Medical Research Foundation. “We all know that melanoma rates in general are going up, but it seems we’re seeing a real blip in this demographic — young women in their teens and slightly older.”
The issue of what might be leading to an increase in pediatric melanoma is controversial and won’t be readily resolved because there are few controlled scientific studies on risk factors and UV exposure in this patient population.
Here, read about what pediatric dermatologists and skin cancer experts are finding in practice and what they caution are important points to consider in detecting these cases.
What Might Be Contributing to the Rise?
Two recent survey-driven studies of adults — a Scandinavian lifestyle study of 106,000 women and the well-known Australian Genes, Environment and Melanoma Study (GEM) study — both suggest that tanning-bed use increases the risk of developing melanoma, based on results reported last September at the Sixth World Congress on Melanoma in Vancouver, British Columbia.
At the least, researchers reported, the study data support a dose-response to tanning equipment use. The Swedish study, for example, found a nearly 60% higher risk of melanoma in 20- to 29-year-old participants who reported having used tanning equipment at least once a month during the initial 5-year study period.
That growing pursuit of “intentional tanning” doesn’t surprise Dr. Naylor, who says that he frequently hears from young patients who are cheerleaders, for example, that their coaches have encouraged them to go to the tanning booth before performances.
“I almost don’t have to ask anymore — and it doesn’t take a genius to figure out what’s going on here,” says Dr. Naylor, who admits that if it were up to him, there would be a ban on tanning for children under age 18. His concern is that as long as tanned skin is equated with sexual attractiveness, it will be an uphill battle to curb abuse of tanning beds in the teen and young adult population.
What Dermatologists Are Seeing in Practice
What may be most telling regarding the suspected increased incidence of melanoma in young people, ultimately, is the aggregate, if somewhat anecdotal, recent experience of dermatologists, especially those in academic centers. Their reports bear out Dr. Naylor’s suspicion — as do new data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) database. A study on the SEER data from 1973 to 2001, published in the July 20 issue of the Journal of Clinical Oncology, reported an increase in melanoma rates of 3% per year for the period, in adolescents and young adults.
“Although the numbers are still small — only about 2% of melanomas occur in kids under age 20 — I do think we’re seeing more, especially in the teens and pre-pubertal kids,” says Amy Paller, M.D., Professor and Chair of Dermatology in the Department of Dermatology at Northwestern University’s Feinberg School of Medicine in Chicago. “We’ve seen five cases of it [melanoma] in kids in the last few years. What we don’t really know is why the increase is occurring.”
Lawrence Eichenfield, M.D., Chief of the Division of Pediatric and Adolescent Dermatology at Children’s Hospital, San Diego, concurs with Dr. Paller. He and his colleagues have “diagnosed at least five melanomas or melanoma-like tumors in the last 18 months alone,” he says, the majority of them in adolescents.
“One could wonder whether we’re just improving capture of melanomas, but that’s probably not an adequate explanation for what’s going on. It’s probably true that there are more pediatric melanomas — certainly many of us in pediatric dermatology practice have been suspicious about that because of our own experiences,” says Dr. Eichenfield, who is a member of the American Academy of
Dermatology’s Youth Education Committee.
The scarcity of study data on the pediatric population — most of the literature consists of case reports, retrospective population studies and metanalyses of small studies — makes it difficult to identify reasons for the increased rates dermatologists are seeing. But that hindrance shouldn’t deter the dermatology community from being more vigilant about looking for melanoma in the pediatric population, according to Jane Grant-Kels, M.D., Dermatology Chair and Director of the Melanoma Program Lab at the University of Connecticut in Farmington.
“I think the message to general dermatologists is out there — that childhood melanoma does occur — but I am still urging my colleagues to keep a low threshold for biopsy,” says Dr. Grant-Kels. “If a lesion looks atypical in a child, it will probably look atypical histologically. And if a mother tells you that a mole is changing, believe her.”
She also is trying to spread the word in the community at large, among those who might encounter children with lesions that should be checked out. In recent years, Dr. Grant-Kels has lectured to pediatricians, parents and teachers, in efforts to increase awareness of childhood melanoma. She thinks a more concerted effort is warranted. “The Academy [of dermatology] and the Skin Cancer Foundation have done a good job making people more aware of [evaluating] changing moles, but I still think that there’s an under-appreciation that melanoma can occur in children,” she says. “The pediatricians probably haven’t bellied up, so we need to increase their awareness.”
Darrell Rigel, M.D., Clinical Professor of Dermatology at NYU Medical Center in New York City, agrees with Dr. Eichenfield’s assessment that the “increase is real.” He also concurs with Dr. Grant-Kels’ recommendation that community-practice dermatologists take the time to increase awareness among both pediatricians and parents whose children may come in to the office for other skin issues such as acne — especially if there’s evidence that the children are, intentionally or otherwise, receiving high UV exposure.
“One of the problems is that with teens, the suspicion of lesions isn’t as high as it would be in adults,” Dr. Rigel says. “In part, that’s a pediatrics issue . . . it has been discussed that melanomas do get missed [by pediatricians]. And unfortunately, by the time they’re diagnosed, often they’re more advanced than you would expect.”
Presentation and Prognosis in Children: Similarities and Differences
Opinions differ somewhat regarding the presentation of melanoma and melanoma-like lesions in children. Overall, the cancer manifests and progresses in a similar manner, most experts maintain. But subtle differences can occur between pediatric and adult patients, and those differences can contribute to delayed diagnosis in children.
Overall, about 50% of childhood melanomas can be traced to pre-existing lesions and about 30% to de novo lesions associated with the deadly giant congenital melanocytic nevus (CNM) — more than half of which emerge before puberty, according to the recent childhood melanoma update co-authored by Dr. Grant-Kels and published in the International Journal of Dermatology.
For one, children tend to have relatively more amelanotic lesions than adults do, and lesions size changes and “behavior” may occur more rapidly than in adults. “In young children, that’s probably the most common presenting finding — the sudden increase in size of a lesion,” says Dr. Grant-Kels. “The second most common is that a lesion starts to bleed.” Third on the list, in order of appearance, is color change in a lesion, she adds.
“If you compare apples to apples, it’s probably still the same tumor. But the main issue is that the diagnosis tends to occur later in kids,” says Dr. Rigel.
Recent studies, including Dr. Grant-Kels’ and multiple-case reports from the United States and abroad, also indicate that tumor depth and other characteristics may be slightly different in children than in adults.
Dr. Paller notes that studies point to nodular, deeper melanomas in the pediatric population, but it’s difficult to say whether that’s because of delayed diagnosis or the patient’s age. In other cases, she explains, melanomas may present in a strikingly similar manner to the highly vascular benign pyogenic granulomas.
Some studies have suggested that proliferation patterns of melanoma lesions differ in children, compared to adults. In adults, about two-thirds of melanomas are the superficial spreading variety and less than 20% are nodular. In children, Dr. Grant-Kels says, nodular melanomas account for up to 30% of lesions.
“There are some more unusual appearances in these [pediatric] melanomas, compared to adults. But one of the main problems is that the melanomas in kids tend to be deeper,” Dr. Paller says, which, as in adults, translates into a worse prognosis. “Evidence from a few studies in the last few years suggests that in melanoma in kids, the ABCDs of melanoma detection [asymmetry, border irregularity, color variation and diameter larger than 6 mm] we use may not be as valuable in children as in adults.” On the plus side, relative to depth, children tend to have slightly better 5-year survival rate — between approximately 63% and 79% for localized disease — prognosis than adults.
Another confounding issue is that even with better diagnostic tools, distinguishing between spitz nevus moles and melanoma remains difficult and controversial. That has led to confusion regarding correct diagnosis and recommended treatment, event though experts generally agree that so-called “spitzoid changes” should be “considered melanoma and dealt with accordingly,” Dr. Paller says.
When melanoma is diagnosed, its treatment in children differs little from that used in adults. Surgical excision, with the same margins recommended for adults, is the first line when disease is localized. “The criteria for surgery are the same, margins are the same and when to do lymph node or sentinel node biopsy are the same,” Dr. Grant-Kels says. “We don’t have any double-blinded controlled studies to show that there’s any difference between the way we should treat kids and adults, so basically the treatment is the same.” For regional or distant metastases, immuno-therapy and biochemotherapy may be recommended, but as with adults, “neither works very well,” she adds.
What’s Needed Now to Reduce Melanoma Rates
Rather than waiting to see whether future studies or reports bear out the suspected rising rates of melanoma in children, dermatologists should focus on mechanisms for improving awareness of the disease and its early detection, experts urge. That entails creating closer ties to the dermatology community, and reinforcing sun-protection messages to all affected “constituents,” from parents to pediatricians, and daycare providers to camp counselors, according to Dr. Grant-Kels and Dr. Rigel.
“I do think it’s an appropriate time for a joint effort of the AAD and the American Academy of Pediatrics. I’m sure they would both be receptive, because we’re all seeing more of this [melanomas in children],” says Dr. Rigel, adding that he himself has seen non-congenital-type melanomas in children as young as 12 in recent years. “Overall, it’s gone from nearly zero to something — and the trends are that that ‘something’ will get bigger.” In the end, Dr. Rigel asserts, that makes the case for more proactive counseling of high-risk families — those in which there’s a documented history of melanoma or a number of fair-skinned individuals — about sun protection and better screening of at-risk children.
The AAD’s ad-hoc task force on skin-cancer prevention is “reworking its sun-protection messaging,” Dr. Eichenfield notes, and is pursuing both short- and longer-term projects to drive home the connection between UV light exposure and melanoma. “There is a major focus on looking at how we can come up with more preventative messages — to communicate more effectively with people who might be able to mediate the overall course and the diagnosis [of melanoma],” he says.
For his part, Dr. Naylor offers another type of practical advice to community practicing dermatologists. Any young patient who comes in for acne or acne-related problems and who shows some evidence of having pursued intentional tanning, should be counseled about the dangers. “If you seen a teen with dark skin who has obviously been UV-exposed recently, bring up the issue of tanning beds,” he says, “because many of these kids are using them.” Teens who admit to the practice should also be checked for atypical moles, he adds.
Oklahoma City dermatologist Mark Naylor, M.D., won’t soon forget the teen-aged patient who showed up in his office a few years ago to have him check a suspicious growth on her buttocks which, on pathology, was found to be a melanoma. “It turned out that she was working in a tanning salon, where one of the so-called ‘benefits’ was free tanning,” Dr. Naylor recalls. And in early January, Dr. Naylor removed an atypical nevus from another teen who also happened to work in a tanning facility.
“Ten years ago it was a rare thing to see a teen with an atypical mole or a melanoma, but it’s getting pretty common here now,” says Dr. Naylor, a melanoma specialist and researcher with the Oklahoma Medical Research Foundation. “We all know that melanoma rates in general are going up, but it seems we’re seeing a real blip in this demographic — young women in their teens and slightly older.”
The issue of what might be leading to an increase in pediatric melanoma is controversial and won’t be readily resolved because there are few controlled scientific studies on risk factors and UV exposure in this patient population.
Here, read about what pediatric dermatologists and skin cancer experts are finding in practice and what they caution are important points to consider in detecting these cases.
What Might Be Contributing to the Rise?
Two recent survey-driven studies of adults — a Scandinavian lifestyle study of 106,000 women and the well-known Australian Genes, Environment and Melanoma Study (GEM) study — both suggest that tanning-bed use increases the risk of developing melanoma, based on results reported last September at the Sixth World Congress on Melanoma in Vancouver, British Columbia.
At the least, researchers reported, the study data support a dose-response to tanning equipment use. The Swedish study, for example, found a nearly 60% higher risk of melanoma in 20- to 29-year-old participants who reported having used tanning equipment at least once a month during the initial 5-year study period.
That growing pursuit of “intentional tanning” doesn’t surprise Dr. Naylor, who says that he frequently hears from young patients who are cheerleaders, for example, that their coaches have encouraged them to go to the tanning booth before performances.
“I almost don’t have to ask anymore — and it doesn’t take a genius to figure out what’s going on here,” says Dr. Naylor, who admits that if it were up to him, there would be a ban on tanning for children under age 18. His concern is that as long as tanned skin is equated with sexual attractiveness, it will be an uphill battle to curb abuse of tanning beds in the teen and young adult population.
What Dermatologists Are Seeing in Practice
What may be most telling regarding the suspected increased incidence of melanoma in young people, ultimately, is the aggregate, if somewhat anecdotal, recent experience of dermatologists, especially those in academic centers. Their reports bear out Dr. Naylor’s suspicion — as do new data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) database. A study on the SEER data from 1973 to 2001, published in the July 20 issue of the Journal of Clinical Oncology, reported an increase in melanoma rates of 3% per year for the period, in adolescents and young adults.
“Although the numbers are still small — only about 2% of melanomas occur in kids under age 20 — I do think we’re seeing more, especially in the teens and pre-pubertal kids,” says Amy Paller, M.D., Professor and Chair of Dermatology in the Department of Dermatology at Northwestern University’s Feinberg School of Medicine in Chicago. “We’ve seen five cases of it [melanoma] in kids in the last few years. What we don’t really know is why the increase is occurring.”
Lawrence Eichenfield, M.D., Chief of the Division of Pediatric and Adolescent Dermatology at Children’s Hospital, San Diego, concurs with Dr. Paller. He and his colleagues have “diagnosed at least five melanomas or melanoma-like tumors in the last 18 months alone,” he says, the majority of them in adolescents.
“One could wonder whether we’re just improving capture of melanomas, but that’s probably not an adequate explanation for what’s going on. It’s probably true that there are more pediatric melanomas — certainly many of us in pediatric dermatology practice have been suspicious about that because of our own experiences,” says Dr. Eichenfield, who is a member of the American Academy of
Dermatology’s Youth Education Committee.
The scarcity of study data on the pediatric population — most of the literature consists of case reports, retrospective population studies and metanalyses of small studies — makes it difficult to identify reasons for the increased rates dermatologists are seeing. But that hindrance shouldn’t deter the dermatology community from being more vigilant about looking for melanoma in the pediatric population, according to Jane Grant-Kels, M.D., Dermatology Chair and Director of the Melanoma Program Lab at the University of Connecticut in Farmington.
“I think the message to general dermatologists is out there — that childhood melanoma does occur — but I am still urging my colleagues to keep a low threshold for biopsy,” says Dr. Grant-Kels. “If a lesion looks atypical in a child, it will probably look atypical histologically. And if a mother tells you that a mole is changing, believe her.”
She also is trying to spread the word in the community at large, among those who might encounter children with lesions that should be checked out. In recent years, Dr. Grant-Kels has lectured to pediatricians, parents and teachers, in efforts to increase awareness of childhood melanoma. She thinks a more concerted effort is warranted. “The Academy [of dermatology] and the Skin Cancer Foundation have done a good job making people more aware of [evaluating] changing moles, but I still think that there’s an under-appreciation that melanoma can occur in children,” she says. “The pediatricians probably haven’t bellied up, so we need to increase their awareness.”
Darrell Rigel, M.D., Clinical Professor of Dermatology at NYU Medical Center in New York City, agrees with Dr. Eichenfield’s assessment that the “increase is real.” He also concurs with Dr. Grant-Kels’ recommendation that community-practice dermatologists take the time to increase awareness among both pediatricians and parents whose children may come in to the office for other skin issues such as acne — especially if there’s evidence that the children are, intentionally or otherwise, receiving high UV exposure.
“One of the problems is that with teens, the suspicion of lesions isn’t as high as it would be in adults,” Dr. Rigel says. “In part, that’s a pediatrics issue . . . it has been discussed that melanomas do get missed [by pediatricians]. And unfortunately, by the time they’re diagnosed, often they’re more advanced than you would expect.”
Presentation and Prognosis in Children: Similarities and Differences
Opinions differ somewhat regarding the presentation of melanoma and melanoma-like lesions in children. Overall, the cancer manifests and progresses in a similar manner, most experts maintain. But subtle differences can occur between pediatric and adult patients, and those differences can contribute to delayed diagnosis in children.
Overall, about 50% of childhood melanomas can be traced to pre-existing lesions and about 30% to de novo lesions associated with the deadly giant congenital melanocytic nevus (CNM) — more than half of which emerge before puberty, according to the recent childhood melanoma update co-authored by Dr. Grant-Kels and published in the International Journal of Dermatology.
For one, children tend to have relatively more amelanotic lesions than adults do, and lesions size changes and “behavior” may occur more rapidly than in adults. “In young children, that’s probably the most common presenting finding — the sudden increase in size of a lesion,” says Dr. Grant-Kels. “The second most common is that a lesion starts to bleed.” Third on the list, in order of appearance, is color change in a lesion, she adds.
“If you compare apples to apples, it’s probably still the same tumor. But the main issue is that the diagnosis tends to occur later in kids,” says Dr. Rigel.
Recent studies, including Dr. Grant-Kels’ and multiple-case reports from the United States and abroad, also indicate that tumor depth and other characteristics may be slightly different in children than in adults.
Dr. Paller notes that studies point to nodular, deeper melanomas in the pediatric population, but it’s difficult to say whether that’s because of delayed diagnosis or the patient’s age. In other cases, she explains, melanomas may present in a strikingly similar manner to the highly vascular benign pyogenic granulomas.
Some studies have suggested that proliferation patterns of melanoma lesions differ in children, compared to adults. In adults, about two-thirds of melanomas are the superficial spreading variety and less than 20% are nodular. In children, Dr. Grant-Kels says, nodular melanomas account for up to 30% of lesions.
“There are some more unusual appearances in these [pediatric] melanomas, compared to adults. But one of the main problems is that the melanomas in kids tend to be deeper,” Dr. Paller says, which, as in adults, translates into a worse prognosis. “Evidence from a few studies in the last few years suggests that in melanoma in kids, the ABCDs of melanoma detection [asymmetry, border irregularity, color variation and diameter larger than 6 mm] we use may not be as valuable in children as in adults.” On the plus side, relative to depth, children tend to have slightly better 5-year survival rate — between approximately 63% and 79% for localized disease — prognosis than adults.
Another confounding issue is that even with better diagnostic tools, distinguishing between spitz nevus moles and melanoma remains difficult and controversial. That has led to confusion regarding correct diagnosis and recommended treatment, event though experts generally agree that so-called “spitzoid changes” should be “considered melanoma and dealt with accordingly,” Dr. Paller says.
When melanoma is diagnosed, its treatment in children differs little from that used in adults. Surgical excision, with the same margins recommended for adults, is the first line when disease is localized. “The criteria for surgery are the same, margins are the same and when to do lymph node or sentinel node biopsy are the same,” Dr. Grant-Kels says. “We don’t have any double-blinded controlled studies to show that there’s any difference between the way we should treat kids and adults, so basically the treatment is the same.” For regional or distant metastases, immuno-therapy and biochemotherapy may be recommended, but as with adults, “neither works very well,” she adds.
What’s Needed Now to Reduce Melanoma Rates
Rather than waiting to see whether future studies or reports bear out the suspected rising rates of melanoma in children, dermatologists should focus on mechanisms for improving awareness of the disease and its early detection, experts urge. That entails creating closer ties to the dermatology community, and reinforcing sun-protection messages to all affected “constituents,” from parents to pediatricians, and daycare providers to camp counselors, according to Dr. Grant-Kels and Dr. Rigel.
“I do think it’s an appropriate time for a joint effort of the AAD and the American Academy of Pediatrics. I’m sure they would both be receptive, because we’re all seeing more of this [melanomas in children],” says Dr. Rigel, adding that he himself has seen non-congenital-type melanomas in children as young as 12 in recent years. “Overall, it’s gone from nearly zero to something — and the trends are that that ‘something’ will get bigger.” In the end, Dr. Rigel asserts, that makes the case for more proactive counseling of high-risk families — those in which there’s a documented history of melanoma or a number of fair-skinned individuals — about sun protection and better screening of at-risk children.
The AAD’s ad-hoc task force on skin-cancer prevention is “reworking its sun-protection messaging,” Dr. Eichenfield notes, and is pursuing both short- and longer-term projects to drive home the connection between UV light exposure and melanoma. “There is a major focus on looking at how we can come up with more preventative messages — to communicate more effectively with people who might be able to mediate the overall course and the diagnosis [of melanoma],” he says.
For his part, Dr. Naylor offers another type of practical advice to community practicing dermatologists. Any young patient who comes in for acne or acne-related problems and who shows some evidence of having pursued intentional tanning, should be counseled about the dangers. “If you seen a teen with dark skin who has obviously been UV-exposed recently, bring up the issue of tanning beds,” he says, “because many of these kids are using them.” Teens who admit to the practice should also be checked for atypical moles, he adds.
Oklahoma City dermatologist Mark Naylor, M.D., won’t soon forget the teen-aged patient who showed up in his office a few years ago to have him check a suspicious growth on her buttocks which, on pathology, was found to be a melanoma. “It turned out that she was working in a tanning salon, where one of the so-called ‘benefits’ was free tanning,” Dr. Naylor recalls. And in early January, Dr. Naylor removed an atypical nevus from another teen who also happened to work in a tanning facility.
“Ten years ago it was a rare thing to see a teen with an atypical mole or a melanoma, but it’s getting pretty common here now,” says Dr. Naylor, a melanoma specialist and researcher with the Oklahoma Medical Research Foundation. “We all know that melanoma rates in general are going up, but it seems we’re seeing a real blip in this demographic — young women in their teens and slightly older.”
The issue of what might be leading to an increase in pediatric melanoma is controversial and won’t be readily resolved because there are few controlled scientific studies on risk factors and UV exposure in this patient population.
Here, read about what pediatric dermatologists and skin cancer experts are finding in practice and what they caution are important points to consider in detecting these cases.
What Might Be Contributing to the Rise?
Two recent survey-driven studies of adults — a Scandinavian lifestyle study of 106,000 women and the well-known Australian Genes, Environment and Melanoma Study (GEM) study — both suggest that tanning-bed use increases the risk of developing melanoma, based on results reported last September at the Sixth World Congress on Melanoma in Vancouver, British Columbia.
At the least, researchers reported, the study data support a dose-response to tanning equipment use. The Swedish study, for example, found a nearly 60% higher risk of melanoma in 20- to 29-year-old participants who reported having used tanning equipment at least once a month during the initial 5-year study period.
That growing pursuit of “intentional tanning” doesn’t surprise Dr. Naylor, who says that he frequently hears from young patients who are cheerleaders, for example, that their coaches have encouraged them to go to the tanning booth before performances.
“I almost don’t have to ask anymore — and it doesn’t take a genius to figure out what’s going on here,” says Dr. Naylor, who admits that if it were up to him, there would be a ban on tanning for children under age 18. His concern is that as long as tanned skin is equated with sexual attractiveness, it will be an uphill battle to curb abuse of tanning beds in the teen and young adult population.
What Dermatologists Are Seeing in Practice
What may be most telling regarding the suspected increased incidence of melanoma in young people, ultimately, is the aggregate, if somewhat anecdotal, recent experience of dermatologists, especially those in academic centers. Their reports bear out Dr. Naylor’s suspicion — as do new data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) database. A study on the SEER data from 1973 to 2001, published in the July 20 issue of the Journal of Clinical Oncology, reported an increase in melanoma rates of 3% per year for the period, in adolescents and young adults.
“Although the numbers are still small — only about 2% of melanomas occur in kids under age 20 — I do think we’re seeing more, especially in the teens and pre-pubertal kids,” says Amy Paller, M.D., Professor and Chair of Dermatology in the Department of Dermatology at Northwestern University’s Feinberg School of Medicine in Chicago. “We’ve seen five cases of it [melanoma] in kids in the last few years. What we don’t really know is why the increase is occurring.”
Lawrence Eichenfield, M.D., Chief of the Division of Pediatric and Adolescent Dermatology at Children’s Hospital, San Diego, concurs with Dr. Paller. He and his colleagues have “diagnosed at least five melanomas or melanoma-like tumors in the last 18 months alone,” he says, the majority of them in adolescents.
“One could wonder whether we’re just improving capture of melanomas, but that’s probably not an adequate explanation for what’s going on. It’s probably true that there are more pediatric melanomas — certainly many of us in pediatric dermatology practice have been suspicious about that because of our own experiences,” says Dr. Eichenfield, who is a member of the American Academy of
Dermatology’s Youth Education Committee.
The scarcity of study data on the pediatric population — most of the literature consists of case reports, retrospective population studies and metanalyses of small studies — makes it difficult to identify reasons for the increased rates dermatologists are seeing. But that hindrance shouldn’t deter the dermatology community from being more vigilant about looking for melanoma in the pediatric population, according to Jane Grant-Kels, M.D., Dermatology Chair and Director of the Melanoma Program Lab at the University of Connecticut in Farmington.
“I think the message to general dermatologists is out there — that childhood melanoma does occur — but I am still urging my colleagues to keep a low threshold for biopsy,” says Dr. Grant-Kels. “If a lesion looks atypical in a child, it will probably look atypical histologically. And if a mother tells you that a mole is changing, believe her.”
She also is trying to spread the word in the community at large, among those who might encounter children with lesions that should be checked out. In recent years, Dr. Grant-Kels has lectured to pediatricians, parents and teachers, in efforts to increase awareness of childhood melanoma. She thinks a more concerted effort is warranted. “The Academy [of dermatology] and the Skin Cancer Foundation have done a good job making people more aware of [evaluating] changing moles, but I still think that there’s an under-appreciation that melanoma can occur in children,” she says. “The pediatricians probably haven’t bellied up, so we need to increase their awareness.”
Darrell Rigel, M.D., Clinical Professor of Dermatology at NYU Medical Center in New York City, agrees with Dr. Eichenfield’s assessment that the “increase is real.” He also concurs with Dr. Grant-Kels’ recommendation that community-practice dermatologists take the time to increase awareness among both pediatricians and parents whose children may come in to the office for other skin issues such as acne — especially if there’s evidence that the children are, intentionally or otherwise, receiving high UV exposure.
“One of the problems is that with teens, the suspicion of lesions isn’t as high as it would be in adults,” Dr. Rigel says. “In part, that’s a pediatrics issue . . . it has been discussed that melanomas do get missed [by pediatricians]. And unfortunately, by the time they’re diagnosed, often they’re more advanced than you would expect.”
Presentation and Prognosis in Children: Similarities and Differences
Opinions differ somewhat regarding the presentation of melanoma and melanoma-like lesions in children. Overall, the cancer manifests and progresses in a similar manner, most experts maintain. But subtle differences can occur between pediatric and adult patients, and those differences can contribute to delayed diagnosis in children.
Overall, about 50% of childhood melanomas can be traced to pre-existing lesions and about 30% to de novo lesions associated with the deadly giant congenital melanocytic nevus (CNM) — more than half of which emerge before puberty, according to the recent childhood melanoma update co-authored by Dr. Grant-Kels and published in the International Journal of Dermatology.
For one, children tend to have relatively more amelanotic lesions than adults do, and lesions size changes and “behavior” may occur more rapidly than in adults. “In young children, that’s probably the most common presenting finding — the sudden increase in size of a lesion,” says Dr. Grant-Kels. “The second most common is that a lesion starts to bleed.” Third on the list, in order of appearance, is color change in a lesion, she adds.
“If you compare apples to apples, it’s probably still the same tumor. But the main issue is that the diagnosis tends to occur later in kids,” says Dr. Rigel.
Recent studies, including Dr. Grant-Kels’ and multiple-case reports from the United States and abroad, also indicate that tumor depth and other characteristics may be slightly different in children than in adults.
Dr. Paller notes that studies point to nodular, deeper melanomas in the pediatric population, but it’s difficult to say whether that’s because of delayed diagnosis or the patient’s age. In other cases, she explains, melanomas may present in a strikingly similar manner to the highly vascular benign pyogenic granulomas.
Some studies have suggested that proliferation patterns of melanoma lesions differ in children, compared to adults. In adults, about two-thirds of melanomas are the superficial spreading variety and less than 20% are nodular. In children, Dr. Grant-Kels says, nodular melanomas account for up to 30% of lesions.
“There are some more unusual appearances in these [pediatric] melanomas, compared to adults. But one of the main problems is that the melanomas in kids tend to be deeper,” Dr. Paller says, which, as in adults, translates into a worse prognosis. “Evidence from a few studies in the last few years suggests that in melanoma in kids, the ABCDs of melanoma detection [asymmetry, border irregularity, color variation and diameter larger than 6 mm] we use may not be as valuable in children as in adults.” On the plus side, relative to depth, children tend to have slightly better 5-year survival rate — between approximately 63% and 79% for localized disease — prognosis than adults.
Another confounding issue is that even with better diagnostic tools, distinguishing between spitz nevus moles and melanoma remains difficult and controversial. That has led to confusion regarding correct diagnosis and recommended treatment, event though experts generally agree that so-called “spitzoid changes” should be “considered melanoma and dealt with accordingly,” Dr. Paller says.
When melanoma is diagnosed, its treatment in children differs little from that used in adults. Surgical excision, with the same margins recommended for adults, is the first line when disease is localized. “The criteria for surgery are the same, margins are the same and when to do lymph node or sentinel node biopsy are the same,” Dr. Grant-Kels says. “We don’t have any double-blinded controlled studies to show that there’s any difference between the way we should treat kids and adults, so basically the treatment is the same.” For regional or distant metastases, immuno-therapy and biochemotherapy may be recommended, but as with adults, “neither works very well,” she adds.
What’s Needed Now to Reduce Melanoma Rates
Rather than waiting to see whether future studies or reports bear out the suspected rising rates of melanoma in children, dermatologists should focus on mechanisms for improving awareness of the disease and its early detection, experts urge. That entails creating closer ties to the dermatology community, and reinforcing sun-protection messages to all affected “constituents,” from parents to pediatricians, and daycare providers to camp counselors, according to Dr. Grant-Kels and Dr. Rigel.
“I do think it’s an appropriate time for a joint effort of the AAD and the American Academy of Pediatrics. I’m sure they would both be receptive, because we’re all seeing more of this [melanomas in children],” says Dr. Rigel, adding that he himself has seen non-congenital-type melanomas in children as young as 12 in recent years. “Overall, it’s gone from nearly zero to something — and the trends are that that ‘something’ will get bigger.” In the end, Dr. Rigel asserts, that makes the case for more proactive counseling of high-risk families — those in which there’s a documented history of melanoma or a number of fair-skinned individuals — about sun protection and better screening of at-risk children.
The AAD’s ad-hoc task force on skin-cancer prevention is “reworking its sun-protection messaging,” Dr. Eichenfield notes, and is pursuing both short- and longer-term projects to drive home the connection between UV light exposure and melanoma. “There is a major focus on looking at how we can come up with more preventative messages — to communicate more effectively with people who might be able to mediate the overall course and the diagnosis [of melanoma],” he says.
For his part, Dr. Naylor offers another type of practical advice to community practicing dermatologists. Any young patient who comes in for acne or acne-related problems and who shows some evidence of having pursued intentional tanning, should be counseled about the dangers. “If you seen a teen with dark skin who has obviously been UV-exposed recently, bring up the issue of tanning beds,” he says, “because many of these kids are using them.” Teens who admit to the practice should also be checked for atypical moles, he adds.
