Malignant melanoma: to screen or not to screen? An evaluation of the Euromelanoma Day in Belgium

ARTICLE

Auteur(s) : Carla Truyers¹, Emmanuel Lesaffre¹, Eliane Kellen¹, Stefaan Bartholomeeusen¹, Bert Aertgeerts², Frank Buntinx³

¹Department of General Practice, Katholieke Universiteit Leuven, Kapucijnenvoer 33 - Blok j - bus 7001, 3000 Leuven Belgium
³L-Biostat, Katholieke Universiteit Leuven, Erasmus University Rotterdam
²University Center for Cancer Prevention, Leuven, Belgium

Since 1999, the yearly Euromelanoma Day is organised in Belgium and other European countries. Anyone who has a suspicious looking lesion can have it examined by a participating dermatologist for free. In Belgium, about 50% of all dermatologists participate [1]. Since prognosis largely depends on stage at diagnosis, early detection is indeed important [2].

Intego is a general practice (GP) based morbidity registration network [3]. In 2008, the database contains data from 90 GPs, over 2.3 million diagnoses, and covers almost 2% of the population in Flanders, the northern Dutch speaking part of Belgium. The patient population is representative for the Flemish population with respect to age-, gender- and social class distributions. The database was used to compare the pre- and post- Euromelanoma Day yearly incidence of melanoma. Additionally, a post-intervention increase of diagnoses in the Euromelanoma month of May is examined. For reasons of comparison, an equal number of monthly periods before (January 1995 to April 1999) and after (May 1999 to August 2003) the start of the Euromelanoma initiative is used. The seasonal impact of GP visits was corrected by using the proportion of melanoma diagnoses per total number of monthly diagnoses. Two hypotheses were tested using autoregressive, integrated moving average models (ARIMA): first an abrupt and only temporary change as a result of the Euromelanoma Day (rise in incidence in May and/or June of 1999). Secondly an abrupt and sustained change after the Euromelanoma Day (rise in May and/or in the subsequent months, June and/or July, as of 1999 which was not present before) [4].

Throughout the registration period (1994-2007), 105 melanomas were registered, representing an incidence rate of 8 per 100,000 patient-years, and 6.45 and 9.7 for males and females. In recent years the sex ratio “in favour of” women diminished (figure 1 A). Most melanomas occur in older age groups, especially above 65 years of age, most pronounced in men.

If the Euromelanoma Day has a significant effect, one would expect a higher melanoma incidence rate in the period after 1999. However, no higher incidence is noted in the period after 1999 compared to before. On the contrary, a lower rate is apparent (figure 1A). When looking at the monthly data there is no evidence for a temporary (p = 0.58-0.92) or sustained increase (p = 0.31-0.64) in the month May or the months subsequent to the initiative (figure 1B). Overall, Intego data showed no effect due to the Euro-melanoma Day.

Organized screening should clearly define the target population; provide sufficient coverage; specify adequate tests, diagnosis, treatment and follow-up facilities; quality control and evaluation of the program [5]. It is clear that the Euromelanoma day does not fulfil this. There are, however, other benefits that might arise from these initiatives. Primary prevention, focussing on aetiological factors, and making people aware of the risk factors can have important benefits. However, any effect will not be seen for many years, because of the long latency time between risk exposure and diagnosis. Remarkably, in 10 years not even 0.5% of the Belgian population was screened. Also a significant drop in the number of participating dermatologists (n = 11, p = 0.04) occurred every year [1]. In 1999 about 60% of all dermatologists participated, dropping to less than 40% in 2007.

Is it not clear how much of the screened population is represented in the Intego population. It is also assumed that all diagnoses of melanoma are reported to the GP. Because the national Belgian Cancer Registry only has complete coverage of cancer after 2004, a comparison is hard to establish. But the Limburg Cancer Registry recently reported similar results [6].

Acknowledgments

Reference

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3 Bartholomeeusen S, Truyers C, Buntinx F. Diseases in general practice in Flanders. Leuven: Academisch Centrum voor Huisartsgeneeskunde. KU Leuven, 2004.

4 Fuller WA. Introduction to statistical time series. 2 ed. John Wiley & Sons, 1996.

5 Hakama M, Coleman MP, Alexe DM, Auvinen A. Cancer screening: evidence and practice in Europe 2008. Eur J Cancer 2008; 44: 1404-13.

6 Vanstraelen D, Deleu H, Van Robays J, et al. Melanoma Incidence Trends in Limburg After Screening and Prevention Campaigns. Arch Public Health 2010; (Accepted).