In this interview, Dr Elliott Campbell discussed the rise in melanoma among middle-aged women, attributing it to factors like sun exposure and past tanning bed use. Additionally, he addressed higher male mortality, exploring causes beyond late diagnosis. Dr Campbell highlights advancements in treatment, reduced mortality, and the need for ongoing efforts in early detection and sun protection for both genders.

Elliott Campbell, MD, FAAD is a dermatologist and micrographic surgery and dermatologic oncology fellow at Mayo Clinic in Rochester, MN.

Transcript

The Dermatologist: The study shows a significant increase in the incidence of cutaneous melanoma in middle-aged women over the past few decades. What are some potential hypotheses or factors that might explain the substantial rise specifically among this demographic?

Dr Campbell: There are many different types of melanomas, however, most are believed to have at least a component of ultraviolet exposure as an etiologic factor. This sun exposure is accumulated over an individual's lifetime. Our team theorizes that a major driving factor for increased incidence in females is secondary to previous increase in tanning bed use in our female population. It's also been postulated that estrogen and melanomas could be related. However, this has never been substantiated.

The Dermatologist: What are some plausible reasons for the stabilization of cutaneous melanoma incidence in middle-aged men in recent years, and how does this pattern differ from the observed trends in middle-aged women?

Dr Campbell: Overall based on anecdotal reports from our patients, there is an encouraging trend towards decreased sun exposure in our population, both in males and females. Our patients commonly recall "Back when I was young, we would lay out in the sun for hours with tinfoil and baby oil. We didn't know any better." Although we have a long way to go, our population has acquired healthy photoprotective measures. The bolus of UV exposure that occurred during the tanning bed era predominantly in females has likely mitigated the impact of these general photoprotective practices in that subset of the population.

The Dermatologist: The study identifies male sex as a significant risk factor for mortality due to melanoma. What are some potential biological, behavioral, or social reasons that might explain this gender disparity in melanoma-related deaths?

Dr Campbell: Initially, one might predict that this is due to later presentation with more advanced melanomas. However, our study used a multi-variate analysis which controlled for these additional factors and there was still a statistically significant increased disease specific mortality in males. This would suggest that there are other driving factors beyond advanced stage at diagnosis, which are driving this increased mortality. One potential contributing factor is a lack of follow-up surveillance in this population or non-compliance with recommended long-term management. However, this has not been substantiated and it's difficult to draw any conclusions based on our data. Another consideration is that men die earlier overall. Perhaps treatment limitations due to other comorbidities or pharmacotherapy intolerance might play a role when controlling for age. This data is important to consider when counseling males with a diagnosis of melanoma on surveillance in the future.

The Dermatologist: What are some potential interventions or advancements in melanoma treatment and management that might have contributed to the linear decrease in mortality from cutaneous melanoma over the study period?

Dr Campbell: Our study's clear reduction in mortality over time is extremely encouraging and has not been observed in some study populations. This is likely multifactorial, but some of the improvement is almost certainly in part due to the development and implementation of targeted therapy and immunotherapy, which have both demonstrated significant mortality benefit. Melanoma surgery utilizing comprehensive margin assessment is also contributing. One example of this is Mohs micrographic surgery for special site melanomas, including head and neck tumors that we know are higher risk of recurrence and poor outcomes. We would like to think that screening with earlier detection of clinically meaningful and biologically significant tumors is also contributing to the reduction in mortality. There's good evidence that melanomas caught at an earlier stage are associated with significantly improved outcomes.

The Dermatologist: What factors might contribute to the decreased risk of death among individuals with a more recent diagnosis of melanoma, and how can this information guide efforts to enhance early detection and prompt treatment for those at risk for developing melanoma?

Dr Campbell: As discussed in the previous question, we have observed a linear reduction in mortality over time. Therefore being diagnosed more recently pertains to a better prognosis. This information should encourage patients and providers to continue with the efforts that are currently underway. This includes continued surveillance of at least high risk populations. We now have indications for immunotherapy for high risk tumors that are still localized to the skin and have not yet metastasized to lymph nodes or broadly.

Use of Mohs micrographic surgery for appropriate tumors, especially in areas where tissue conservation is critical and the risk of recurrence and mortality is higher, such as the head and neck. And continued multidisciplinary care of patients with high risk advanced stage melanomas. Metastatic melanoma is no longer as bleak of a diagnosis as it was 15 years ago. We have many pharmacotherapies and surgical options in our armamentarium to combat this tumor. I always tell my patients that there is no better time in history to have a melanoma skin cancer.

The Dermatologist: Are there tips or insights you would like to share with your dermatology colleagues about the increasing incidence and decreasing mortality of cutaneous melanoma among middle-aged adults?

Dr Campbell: There are clearly driving factors outside of over-diagnosis that is responsible for the rise of melanoma in our population. If over-diagnosis is the driving factor which has been suggested by other authors, this would likely be impacting both males and females equally, unless of course females are increasing their screening over time compared with males, which we do not have data to support. We need to continue to evaluate potential etiologies for this rise in incidence in females and patients should be encouraged to avoid tanning beds. Males and females should continue to be encouraged to protect against the sun. And lastly, our field should be proud that we are drastically and consistently improving the mortality rate of this prevalent tumor over time. We should continue these efforts through clinical care research in collaboration with other specialties.

Reference
Campbell EH, Reinhart JP, Crum OM, et al. Increasing incidence and decreasing mortality of cutaneous melanoma in middle-aged adults: An epidemiologic study in Olmsted County, Minnesota. Mayo Clin Proc. 2023;98(5):713-722. doi:10.1016/j.mayocp.2022.10.029