Elsevier

European Journal of Cancer

Volume 40, Issue 16, November 2004, Pages 2355-2366
European Journal of Cancer

Current Perspective
Cutaneous malignant melanoma in Europe

https://doi.org/10.1016/j.ejca.2004.06.003Get rights and content

Abstract

Cutaneous malignant melanoma is on the rise in fair skinned societies. Both its incidence and mortality rates have been incresing in Europe over the past decades, the latter seem to stabilise in Scandinavia. The main cause of melanoma is intermittent exposure to ultraviolet radiation, especially in combination with endogenous factors like skin type and genetic predisposition. Evidence on an association between sunbed use and melanoma is inconclusive, but seems to point to a slightly increased risk associated with sunbed use. Within Europe, considerably variation in patterns of melanoma incidence and mortality existed. In this paper, we discuss the possible explanations for the observed trends and options for primary and secondary prevention. Early detection seems the most promising way to combat the relatively poor survival rates in Southern and Eastern Europe.

Introduction

Descriptive epidemiology: Cutaneous malignant melanoma (melanoma) (CMM) is less common than the familiar basal and squamous cell tumours of the skin, but is much more fatal. It is mainly a disease of white people, but people with a more pigmented skin can also develop melanomas. It develops by the malignant transformation of melanocytes. In Europe, it is the 17th most commonly diagnosed cancer in males and eighth most common in females [1]. In 2000, approximately 26 100 males and 33 300 females were diagnosed with melanomas in Europe, and around 8300 males and 7600 females died of their disease [1]. In the Netherlands, a country with a relatively high incidence compared with European standards, the cumulative incidence rate before the age of 75 years in 2000 was 1% in males and 1.25% in females. Melanoma is one of the most important cancers in terms of `years of potential life lost per death' (Fig. 1), as it is diagnosed in relatively young people [2], [3], [4]. In the US, a person dying of melanoma would die approximately 17 years before the age of 65 years [2], in Denmark 14–15 years and in Belgium 6–8 years [3], [4].

Section snippets

Ultraviolet radiation

In white populations, exposure to ultraviolet radiation (UVR) is the main cause of all common skin cancers, including melanomas [5]. It can induce skin cancers by three mechanisms: it directly damages DNA leading to mutations; it produces activated oxygen molecules that in turn damage DNA and other cellular structures; and it leads to a localised immuno-suppression, thus blocking the body's natural anti-cancer defences [6], [7].

Risk factors for melanoma

Intermittent exposure to UVR is the major environmental risk factor for melanoma, especially in combination with endogenous factors (skin types I and II, immune-deficient status, genetic predisposition) [5]. Patients with genetic abnormalities like Xeroderma Pigmentosum are at a 1000-fold increased risk [8]. If melanoma runs in the family, the relative risk of developing another skin cancer is 2–3 [9] and familiary forms of melanoma (familial atypical multiple mole syndrome) have been

Melanoma in non-caucasians

Melanoma is uncommon in negroid people (Table 4), Asians and Middle- and South-American populations, probably due to a better protection of the skin by a larger amount of pigment in the skin and possibly different (`wiser') sun-exposure patterns. In many African and Asian societies, it is considered beautiful to have a light skin and people try to avoid sun-exposure.

UVR is considered a less important risk factor for skin cancer in coloured people. In non-whites, melanomas appear more often on

Ultraviolet radiation from sunbed use (risks and behaviour)

The increased use of sunbeds, emitting significant amounts of UV-A and/or UV-B radiation, is of concern, especially since a substantial proportion of young people use sunbeds [19]. Although the risks of melanoma associated with sunbed use have not been unequivocally established, it is likely that the effects on the skin are equal for all sources of UVR. Studies on the risk of sunlamp use for the development of skin cancer, have suffered from various methodological and practical problems (Table 5

Prognostic indicators

Melanoma thickness, body site, histological type of the melanoma, gender of the patient and ulceration are important indicators of patient prognosis (Table 7). By far the most important prognostic indicator of melanoma survival is thickness. Generally, older patients do less well than younger patients with the same tumour thickness, even after correcting for age, and females do better than males. Superficial spreading melanomas generally have a better prognosis compared with other histological

Geographical variation in melanoma incidence and mortality in Europe

Melanoma has shown a rapid rate of secular increase in incidence for white populations, whereas in pigmented people its incidence has remained rather stable. Generally, melanoma incidence rates in white populations increase with proximity to the Equator [27] but in Western Europe, the inverse pattern is observed, with the highest incidence rates noted in the North [28], (Fig. 2, Fig. 3). Exceptions are the mountainous countries of Switzerland and Austria, which exhibit high incidence rates

Trends in incidence and mortality

Since the 1970s, there have been reports of `alarming' increases, initially in melanoma mortality [34], closely followed by reports on melanoma incidence [31]. These reports observed a doubling in the rates of melanoma every 10 to 20 years (annual increments of between 3% and 7%) in populations of European origin for both genders [4]. Generally, the incidence rates increased markedly for the intermittently exposed body sites (trunk, legs, etc.), whereas increases on the face and neck were

Explanation of the trends – are the increases real or partly due to an artefact?

The strong increases in melanoma incidence and mortality over recent decades also indicates the growing problem of the burden of skin cancer prevalence on the health-care system, even though many patients are truly cured. To assess the causes of these trends, whether they are real or artificial and if rising incidence rates can be prevented, is therefore important [49] (Table 8).

Causes of the real increases in melanoma rates

The `real' increases in melanoma rates are most commonly attributed to changes in lifestyle with increasing intermittent exposure to UV radiation, due to the popularity of sunbathing and tanning since the late 19th century. Before the Industrial Revolution, wealthy people had a pale skin: they worked or stayed indoors, lower classes were mainly outdoors. During the industrialisation of society (1750–1800), machines appeared, and the working classes started working indoors in the factories. Only

Stabilisations

Recent stabilisations in melanoma mortality rates (in some cases followed by incidence rates) are reported in high-incidence countries, such as Australia, USA, Sweden, Norway and Germany [4], [28], [37], [42], [47]. Only the mortality rates levelled off initially, starting in the late 1970s, with increasing incidence rates. This was most likely because of an improved patient survival [41], [42], [55] due to earlier detection, as there were no major improvements in systemic melanoma treatments.

Primary and secondary prevention

The fashion of tanning has contributed substantially to the increases in skin cancer incidence. However, undoubtedly incidence rates may have increased due to the greater awareness of people about the risks of sunbathing and their growing knowledge about the need to inspect the skin for suspected lesions. In the late 1970s and the 1980s, projects were initiated to increase awareness (starting in Australia, followed by Scotland, Scandinavia, and other European countries) which increased the

Protection against UV radiation

Given the positive and negative effects of UV radiation, balanced messages should inform people about `safe' ways to be in the sun. There are several ways to protect your skin against the harmful effects of UV-radiation: natural protection; tanning, avoiding the sun, clothes/hats, sunscreens.

Secondary prevention

Early detection of skin tumours seems useful, as a relatively simple surgical treatment in early stages dramatically improves the prognosis of patients and an effective treatment for metastases is not yet available. Early detection aims at reducing `patient delay', limiting mutilation and preventing death. Early stage melanoma is recognised by patients and their partners and by dermatologists, general practitioners and doctors doing physical examinations on their patients.

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Future perspectives

In many countries where incidence is high and where awareness and (secondary) prevention campaigns have often been organised, moderations in the increases of melanoma mortality rates are observed within a few years, followed by moderations in melanoma incidence in younger age groups after more than 10 years, corresponding with the observed birth cohort effects in the mortality rates [28], [44], [46], [47], [56], [58], [59], [60], [61], [62], [63]. If these trends persist, and efforts to improve

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