examine the effect of skin surveillance on children or on patients with familial syndromes that confer a high risk of melanoma.

We also did not examine the value of routine diagnosis and treatment of skin cancer in clinical practice. In everyday primary care, the clinician sees the skin of every patient’s face and, in many, the extremities, chest, and back. Clinicians almost universally agree that incidental discovery of a suspicious skin lesion should prompt an evaluation, including a skin biopsy and a thorough inspection of the skin. The data we reviewed about screening do not address the value of attention to the skin as part of conscientious clinical care.

Other strategies to prevent skin cancer, such as promotion and counseling to reduce risky health behaviors and skin self-examination, are not addressed in this review. However, many studies combine screening with health promotion programs, and screening may itself contribute to primary prevention, since it provides the physician with an opportunity to increase awareness of skin cancer and to demonstrate examination techniques that patients can apply themselves.

EPIDEMIOLOGY AND BURDEN OF SUFFERING

Melanoma

In the United States, the lifetime risk of being diagnosed with melanoma is 1.74 percent in white men and 1.28 percent in white women. The lifetime risk of dying of melanoma is 0.36 percent in men and 0.21 percent in women. Between 1973 and 1995, the incidence of melanoma in the United States increased about 4 percent per year, from 5.7 per 100,000 in 1973 to 13.3 per 100,000 in 1995, according to data from the Surveillance, Epidemiology, and End Results program (SEER) of the National Cancer Institute.2 By comparison, the overall rate in Queensland, Australia is 55 per 100,000.

The elderly and, in particular, elderly men bear a disproportionate burden of morbidity and mortality from melanoma. As shown in Figure B-1, older men have the highest incidence of invasive melanoma. In 1995, the age-adjusted incidence rate was 68.7 per 100,000 in white men over age 65 and 30.6 per 100,000 in white women over 65. Men over 65 years of age, who constitute 5.2 percent of the U.S. population, have 22 percent of newly diagnosed malignant melanomas each year; women over 65 who constitute 7.4 percent of the population, have 14 percent.

Melanoma in the elderly is not only more common, but also more lethal than in younger populations. In Australia, where for many years public education about melanoma has been intense, 75 percent of “thick” (>3 mm) melanoma lesions and 75 percent of deaths occur in people over 50 years of age; 50 percent of deaths occur in men over 50.3 Similarly, in the United States, about 50 percent of deaths from melanoma are in men over 50 years of age.2Figure B-2



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