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Original Investigation |

Survival for Patients With Single and Multiple Primary Melanomas:  The Genes, Environment, and Melanoma Study

Anne Kricker, PhD1; Bruce K. Armstrong, MD, DPhil1; Chris Goumas, MPH1; Nancy E. Thomas, MD, PhD2; Lynn From, MD, PhD3; Klaus Busam, MD4; Peter A. Kanetsky, PhD5; Richard P. Gallagher, MA6; Loraine D. Marrett, PhD7; Pamela A. Groben, MD2; Stephen B. Gruber, MD, PhD8; Hoda Anton-Culver, PhD9; Stefano Rosso, PhD10; Terence Dwyer, MD, PhD11,13; Marianne Berwick, PhD12 ; for the GEM Study Group
[+] Author Affiliations
1Cancer Epidemiology and Services Research, Sydney School of Public Health, University of Sydney, Sydney, Australia
2Department of Dermatology, Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill
3Department of Pathology, Women’s College Hospital, Toronto, Ontario, Canada
4Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
5Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
6Cancer Control Research Centre, British Columbia Cancer Research Centre, Vancouver, British Columbia, Canada
7Population Studies and Surveillance, Cancer Care Ontario, Toronto
8University of Southern California Norris Comprehensive Cancer Center, Los Angeles
9Department of Epidemiology, University of California, Irvine
10Piedmont Cancer Registry, Cancer Prevention Center, Turin, Italy
11Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, Australia
12Division of Epidemiology, University of New Mexico, Albuquerque
13now with the International Agency for Research on Cancer, Lyon, France
JAMA Dermatol. 2013;149(8):921-927. doi:10.1001/jamadermatol.2013.4581.
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Importance  Little is known about survival after a diagnosis of a second or higher-order (multiple) primary melanoma, and no study has explored survival in a population-based sample that included patients with single primary melanomas (SPMs) and multiple primary melanomas (MPMs) of any stage. Because people with a first primary melanoma are known to have an increased risk of being diagnosed with another, evidence for prognosis is needed.

Objective  To determine whether survival after diagnosis was better in patients with MPMs than with SPMs, as suggested in a recent study.

Design  Survival analysis with median follow-up of 7.6 (range, 0.4-10.6) years.

Setting  The Genes, Environment, and Melanoma Study enrolled incident cases of melanoma from population-based cancer registries in Australia, Canada, Italy, and the United States. Multiple primary melanomas were ascertained during a longer period than SPM.

Participants  Two thousand three hundred seventy-two patients with SPM and 1206 with MPM.

Exposure  Diagnosis with melanoma.

Main Outcomes and Measures  Melanoma-specific fatality hazard ratios (HR) and 95% confidence intervals associated with clinical and pathological characteristics of SPM, MPM, and both in Cox proportional hazards regression models.

Results  Melanoma thickness was the main determinant of fatality (HR for >4 mm, 7.68 [95% CI, 4.46-13.23]); other independent predictors were ulceration, mitoses, and scalp location. After adjustment for these other predictors, we found little difference in fatality between MPM and SPM (HR for MPM relative to SPM, 1.24 [95% CI, 0.91-1.69; P = .18]). Thicker SPM, however, had higher fatality (HR for >4 mm, 13.56 [95% CI, 6.47-28.40]) than thicker MPM (2.93 [1.17-7.30]).

Conclusions and Relevance  Although overall fatalities due to SPM and MPM were similar, relative fatality for thicker SPM was greater than that for thicker MPM. This finding may offer support for a difference in outcome between patients with SPM and MPM related to factors other than closer surveillance and earlier diagnosis. The better outcomes are worth further exploration.

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Figure 1.
Cumulative Percentage Distributions of Cases in the Genes, Environment, and Melanoma Study

A, Distribution by age at diagnosis of single primary melanoma (SPM) or by age at diagnosis of the selected lesion in multiple primary melanoma (MPM). B, Distribution of melanoma-related deaths by age at death in 2372 SPM patients (152 melanoma-related deaths) and 1206 MPM patients (103 melanoma-related deaths).

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Figure 2.
Kaplan-Meier Survival Curves

The curves show melanoma-specific survival for patients with melanomas thicker than 2.00 mm who received a diagnosis before age 70 years or when age 70 years or older. A, Men and women combined. B, Men. C, Women.

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