0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Study |

Striking Increase of Thin Melanomas Contrasts With Stable Incidence of Thick Melanomas FREE

Dan M. Lipsker, MD; Guy Hedelin, PhD; Ernest Heid, MD; Edouard M. Grosshans, MD; Bernard J. Cribier, MD, PhD
[+] Author Affiliations

From Laboratoire d'Histopathologie Cutanée, Clinique Dermatologique (Drs Lipsker, Heid, Grosshans, and Cribier), and Laboratoire d'Epidémiologie, Faculté de Médecine et Hôpitaux Universitaires de Strasbourg (Dr Hedelin), Strasbourg, France.


Arch Dermatol. 1999;135(12):1451-1456. doi:10.1001/archderm.135.12.1451.
Text Size: A A A
Published online

Objective  The aim of this study was to analyze the temporal evolution of melanoma incidence in the department of the Bas-Rhin, France, and to study the evolution of tumor thickness.

Design  Retrospective study including all histologically proven melanomas recorded at the cancer registry of the department of the Bas-Rhin between January 1980 and December 1992 and at the Cutaneous Histopathology Department of the University Hospitals, Strasbourg, between January 1980 and December 1997.

Setting  Population-based cancer registry and academic cutaneous histopathology department.

Patients  A total of 1254 patients with histologically proven melanomas.

Intervention  None.

Main Outcome Measures  Temporal evolution of melanoma incidence and tumor thickness.

Results  The mean (SD) and median tumor thicknesses were 1.48 (1.59) mm and 0.87 mm, respectively, and they decreased during the study period. The increase in the number of melanomas was mainly related to an increase of superficial spreading melanomas in both sexes. The number of intermediate melanomas (1-2 mm) in both sexes and the number of melanomas with a Breslow index between 2 and 4 mm in women increased only slightly. The number of melanomas with a Breslow index greater than 2 mm in men and greater than 4 mm in women remained stable during the reference period.

Conclusion  A striking increase in incidence of thin melanomas contrasts with a stable incidence of thick melanomas.

Figures in this Article

MELANOMA incidence is increasing worldwide between 3% and 7% per year in populations of European origin.19 Metastatic melanomas usually lead to death, whereas many persons with a thin stage I lesion can be cured.10,11 In most Western countries, this has encouraged prevention and early detection.1219 Detection is primarily aimed at the early diagnosis of thin melanomas,12,13 which is consistent with a common histopathologic entity, namely, the radial growth phase on the skin surface of the most common histologic type, the superficial spreading melanoma.12,20,21 Efficient screening for melanoma requires precise epidemiological data. Very few data are known for France.9 To address this question and to see how France compares with other Western countries, we studied the melanoma incidence in the department of the Bas-Rhin, France, and we evaluated the evolution of the Breslow index since 1980 in a cutaneous histopathology department in which all cases of melanoma were confirmed by 2 dermatopathologists (E.M.G. and B.J.C.).

This study describes the epidemiology of cutaneous melanoma between January 1980 and December 1997 in the department of the Bas-Rhin, France. All melanomas recorded in the population-based cancer registry of the Bas-Rhin (Registre des cancers du Bas-Rhin) between January 1980 and December 1992 were included. Investigators from the registry conduct a survey each year in all private and public pathology laboratories and record every new case of melanoma. The data recorded include year of diagnosis and sex and age of the patient. Mortality related to melanoma in the department of the Bas-Rhin was available for the study period through exhaustive reviewing of death certificates.

Sixty percent of the melanomas were diagnosed in a single pathology center, the Department for Cutaneous Histopathology, University Hospitals, Strasbourg, France. The diagnosis of melanoma was confirmed in all cases by 2 dermatopathologists. The melanomas diagnosed in this center were further analyzed for anatomic site, histopathology, tumor thickness, Clark level, and the delay in diagnosis of melanoma, which was defined as follows: (1) for a newly appearing lesion, the time from when the patient first noticed an abnormal lesion to the date of excision of the lesion; (2) for preexisting lesions that remained unchanged for at least 5 years, the time between the first clinical changes the patient noticed and excision. This information was obtained by personal interview of the patient. This detailed analysis also included the period from January 1993 through December 1997, which was not recorded in the cancer registry at the time of the present study.

Log-linear regression with Poisson error in an age×period model and χ2 tests were applied where appropriate, using GLIM 4, 1994.22 World standardized incidences were estimated using the EUROCIM 1.1 database 1998, International Agency for Research on Cancer (IARC).

GLOBAL EPIDEMIOLOGY OF MELANOMA IN THE DEPARTMENT OF THE BAS-RHIN, 1980 TO 1992 (DATA FROM THE CANCER REGISTRY OF THE DEPARTMENT OF THE BAS-RHIN)

The annual melanoma incidence, adjusted for age to the local standard population, increased in both women and men during the reference period. In women, world standardized incidence increased from 4.7 per 100,000 in 1980 to 8.46 per 100,000 in 1992 (P<.001) and in men from 3.33 per 100,000 to 6.24 per 100,000 (P<.001) (Figure 1). The highest standardized incidences were 10.18 per 100,000 for women in 1989 and 10.91 per 100,000 for men in 1990.

Place holder to copy figure label and caption
Figure 1.

World-standardized incidence of melanoma in the department of the Bas-Rhin.

Graphic Jump Location

The annual mortality rate for melanoma in the same period ranged from 1.34 per 100,000 to 1.63 per 100,000 in men and from 0.83 per 100,000 to 1.26 per 100,000 in women. There was no significant increase of mortality during the study period (P=.13).

DETAILED ANALYSIS OF MELANOMAS DIAGNOSED AT THE DEPARTMENT FOR CUTANEOUS HISTOPATHOLOGY, UNIVERSITY HOSPITAL, STRASBOURG BETWEEN 1980 AND 1997

Data included in this analysis also include the melanomas diagnosed between 1993 and 1997, which were not yet exhaustively recorded in the cancer registry data bank. During the reference period, 1294 melanomas were diagnosed in 1254 patients. Twenty-eight patients had more than 1 melanoma. There were 734 women and 520 men (woman-man ratio, 1.4) with a mean (SD) age of 54 (17) years. The number of melanomas diagnosed each year in this laboratory increased in both men and women during the study period (Figure 2). The mean (SD) and median tumor thicknesses were 1.48 (1.59) mm and 0.87 mm, respectively. Mean and median tumor thicknesses decreased steadily in both sexes between 1980 and 1997 (Figure 3). Clark level was known in 1082 melanomas; 119 (11%) were in situ Clark level I; 281 (26%) were Clark level II; 378 (35%), Clark level III; 239 (22%), Clark level IV; and 65 (6%), Clark level V. The 119 melanomas in situ occurred mainly in women (76%). Table 1 shows the anatomic sites of the melanomas according to sex. Most melanomas were located on the back in men (19%) and the legs in women (19%). There were 699 (54%) superficial spreading melanomas ; 272 (21%) were nodular melanomas; 130 (10%), lentigo maligna melanomas; 90 (7%), acrolentiginous melanomas; and the growth pattern was unknown in 103 (8%). The median Breslow index was 2.6 mm in the group of nodular melanomas compared with 0.65 in superficial spreading melanomas, 1.15 in acrolentiginous melanomas, and 0.58 in lentigo maligna melanomas. The increase in the number of melanomas was largely related to an increase of superficial spreading melanomas in both sexes (Figure 4 and Figure 5).

Place holder to copy figure label and caption
Figure 2.

New cases of melanoma diagnosed at the Department for Cutaneous Histopathology, University Hospitals, Strasbourg, France, between 1980 and 1997.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Tumor size as determined by mean and median Breslow index for both men and women.

Graphic Jump Location
Table Graphic Jump LocationAnatomic Site Distribution of Melanomas According to Sex
Place holder to copy figure label and caption
Figure 4.

New cases of melanoma in women according to histologic subtype. ALM indicates acrolentiginous melanoma; LMM, lentigo maligna melanoma; NOD, nodular melanoma; and SSM, superficial spreading melanoma.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

New cases of melanoma in men according to histologic subtype. ALM indicates acrolentiginous melanoma; LMM, lentigo maligna melanoma; NOD, nodular melanoma; and SSM, superficial spreading melanoma.

Graphic Jump Location

The number of thin melanomas (<1 mm) increased dramatically (P<.001). The number of intermediate melanomas (1-2 mm) increased slightly in both sexes (P<.001) as well as the number of melanomas between 2 and 4 mm in women (P<.001). The number of melanomas between 2 and 4 mm in men (P=.15) and larger than 4 mm in both sexes (P=.38) remained stable during the reference period (Figure 6 and Figure 7).

Place holder to copy figure label and caption
Figure 6.

New cases of melanoma in women according to tumor thickness.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

New cases of melanoma in men according to tumor thickness.

Graphic Jump Location

The delay in the diagnosis of melanoma was known in 445 patients. The mean (SD) and median values were 30 (32) months and 24 months, respectively. This delay was significantly shorter in thick (>2-mm) melanomas (mean [SD] delay, 18 [29] months; median delay, 12 months) than in thin (<1-mm) melanomas (mean [SD] delay, 35 [34] months; median delay, 24 months) (P<.001). There were more women in the group of subjects for whom information about the delay to diagnosis was available than in the rest of the study population (woman-man ratios, 1.5:1.3). The Breslow index in this group was slightly thinner (1.35 mm vs 1.5 mm; P=.04), but there was no significant statistical difference in age between the 2 groups.

This study showed a considerable increase in the number of thin melanomas in both sexes, which contrasted with only a slight increase of thick melanomas in women or even a stable number of thick melanomas in men. Strasbourg (located 48.35° N, 7.45° E) is the main city of the department of the Bas-Rhin, with about 1 million inhabitants. Data provided from the local and exhaustive cancer registry showed that melanoma incidence in the department of the Bas-Rhin increased in both sexes and reached more than 10 per 100,000 from the late 1980s on. This range of incidence is close to the incidence reported in other Western European countries.13,7,8

Using the recently reviewed and critiqued optimal cutoffs of tumor thickness,11 we evaluated incidence of tumors according to the Breslow index (Figure 6 and Figure 7). Melanoma incidence overall increased mainly as a result of an increased incidence of thin melanomas. The same senior dermatopathologist (E.M.G.) confirmed all diagnoses of melanoma in this study, using the same histopathologic criteria for all cases. These 2 facts combined suggest a real and not artifactual increase in incidence. Van der Esch et al23 have already shown similar results, although they did not include melanomas with a thickness less than 0.75 mm in the earliest period examined, which makes the relevance of their observations on thin tumors questionable. However, in our study the number of thick melanomas remained stable during this 18-year period. The contrast between a striking increase in incidence of thin melanomas and a stable incidence of thick melanomas has been reported by others.24 MacKie et al2 showed a major increase in incidence of thin melanomas in both sexes, while incidence of intermediate and thick melanomas was stable in women and increased only slightly in men. In the study by MacKie et al,2 incidence of melanoma stabilized in women younger than 65 years after 1986, which was not the case in our study (data not shown).

An increase in melanoma incidence has been reported in most Western countries.18,24 This might be related to many factors, including increased longevity, increased exposure to risk factors, increased concern in the general population, more accurate diagnosis, and increased use of immunochemistry to better diagnose poorly differentiated malignancies more specifically as melanomas.24 However, the increased incidences of thick and thin melanomas are different, and it seems that the excision of a growing number of thin melanomas has no effect on the incidence of thick melanomas, which are responsible for most of the mortality and morbidity. This fact suggests that thin (mainly superficial spreading) and thick (mainly nodular) melanomas might have different epidemiological features. In our study, the absence of a fall in incidence of thick melanomas after 18 years of observation may indicate that there has also been an increasing recognition of a form of melanoma that appears innocuous clinically and is unlikely to cause death if not treated. Other authors have suggested this possibility.25,26 The stability of the mortality related to melanoma in this population during the same period, which mimics the rate of thick melanomas, further supports this hypothesis.

We found an inverse association between the delay in diagnosis and tumor thickness. Indeed, the delay was shorter in the group with thick tumors. This finding has also been reported by others.3,27,28 Because this is a retrospective study, this delay was only approximate. Herd et al3 stated that "it is impossible to carry out a prospective study of delay to obtain hard data. There is too great a dependency on patients' memories, which are at best unreliable, and at worst quite random." We share this point of view. Nevertheless, in this study, thick melanomas seemed to be mostly fast-growing tumors leading to prompt excision with a mean delay of 18 months, while the mean delay of excision of thin tumors was 35 months. This inverse association between diagnostic delay and tumor thickness reflects the variability of melanoma biology, which, along with the fast-growing nodular melanomas, is the main pitfall for an overall efficient early detection program, even if the entire population were well informed.

Accepted for publication April 28, 1999.

Reprints: Dan M. Lipsker, MD, Clinique Dermatologique, 1 place de l'hôpital, F-67091 Strasbourg Cedex, France (e-mail: dlipsker@cybercable.fr).

Boyle  PMaisonneuve  PDoré  JF Epidemiology of malignant melanoma. Br Med Bull. 1995;51523- 547
MacKie  RMHole  DHunter  JAA  et al.  Cutaneous malignant melanoma in Scotland: incidence, survival, and mortality. 1979-94. BMJ. 1997;3151117- 1121
Link to Article
Herd  RMCooper  EJHunter  JAA  et al.  Cutaneous malignant melanoma: publicity, screening clinics and survival: the Edinburgh experience 1982-90. Br J Dermatol. 1995;132563- 570
Link to Article
MacLennan  RGreen  ACMcLeod  GRMartin  NG Increasing incidence of cutaneous melanoma in Queensland, Australia. J Natl Cancer Inst. 1992;841427- 1432
Link to Article
Laplanche  ABenhamou  E Estimation de l'incidence des cancers en France. Bull Cancer. 1991;78405- 414
Estève  JKricker  AFerlay  JParkin  DM Facts and figures of cancer in the European Community. IARC Monogr Eval Carcinog Risks Hum. 1993;
Thiele  HSchöls  AScuppe  HCJungblut  RMGoerz  G Das maligne melanom: klinische und diagnostische Erfahrungen. Z Hautkr. 1993;68311- 314
Rompel  RWeiss  HZöfel  PPetres  J Epidemiologie des malignen Melanoms in Stadt- und Landbevölkerung. Z Hautkr. 1997;7229- 33
Baccard  MHavard  SSouques  M Prospective study of the incidence of melanoma in the Paris region in 1994. Melanoma Res. 1997;7335- 338
Link to Article
Lipsker  DHeid  EGrosshans  ECribier  B Le mélanome au CHU de Strasbourg: etude sur 30 ans. Ann Dermatol Venereol. 1998;125241- 246
Buzaid  ACRoss  MIBalch  CM  et al.  Critical analysis of the current American Joint Committee on Cancer Staging System for Cutaneous Melanoma and Proposal of a New Staging System. J Clin Oncol. 1997;151039- 1051
Roush  GCBerwick  MKoh  HKMacKie  RM Screening for melanoma. Balch  CMHoughton  ANMilton  GWSober  AJSoong  SJeds.Cutaneous Melanoma. 2nd ed. Philadelphia, Pa Lippincott–Williams & Wilkins1992;70- 81
MacKie  RM Melanoma prevention and early detection. Br Med Bull. 1995;51570- 583
Doherty  VRMacKie  RM Experience of a public education programme on early detection of cutaneous malignant melanoma. BMJ. 1988;287388- 391
Link to Article
MacKie  RMHole  D Audit of public education campaign to encourage earlier detection of malignant melanoma. BMJ. 1992;3041012- 1015
Link to Article
Cristofolini  MBianchi  RSebastiana  B  et al.  Analysis of the cost-effectiveness ratio of the health campaign for the early diagnosis of cutaneous melanoma in Trentino, Italy. Cancer. 1993;71370- 374
Link to Article
Rampen  FHJvan Huystee  BEWLKiemeney  LALM Melanoma/skin cancer screening clinics: experiences in the Netherlands. J Am Acad Dermatol. 1991;25776- 777
Link to Article
Hoffmann  KDirschka  TSchatz  HSegerling  MTiemann  THoffmann  A A local education campaign on early diagnosis of malignant melanoma. Eur J Epidemiol. 1993;9591- 598
Link to Article
Koh  HKNorton  LAGeller  AC  et al.  Evaluation of the American Academy of Dermatology's national skin cancer and early detection and screening program. J Am Acad Dermatol. 1996;34971- 978
Link to Article
Guerry IV  DSynnestvedt  MElder  DESchultz  E Lessons from tumor progression: the invasive radial growth phase of melanoma is common, incapable of metastastis, and indolent. J Invest Dermatol. 1993;100 (suppl) 342S- 345S
Link to Article
Kerbel  RSKobayashi  HGraham  CHLu  C Analysis and significance of the malignant eclipse during the progression of primary cutaneous human melanomas. J Invest Dermatol. 1996;103183- 187
 edFrancis  B  edGreen  M  edPayne  C GLIM 4–The Statistical System for Generalised Linear Interactive Modelling.  Oxford, England Clarendon Press1994;
Van der Esch  EPMuir  CSNectoux  J  et al.  Temporal change in diagnostic criteria as a cause of the increase of malignant melanoma over time is unlikely. Int J Cancer. 1991;47483- 489
Link to Article
Berwick  M Epidemiology: current trends, risk factors, and enviromental concerns. Balch  CMHoughton  ANSober  AJSoong  SJeds.Cutaneous Melanoma. 3rd ed. St Louis, Mo Quality Medical Publishing Inc1998;551- 571
Burton  RCArmstrong  BK Recent incidence trends imply a nonmetastasizing form of invasive melanoma. Melanoma Res. 1994;4107- 113
Link to Article
Swerlick  RAChen  S The melanoma epidemic: is increased surveillance the solution or the problem? Arch Dermatol. 1996;132881- 884
Link to Article
Dunkley  MPMorris  AM Cutaneous malignant melanoma: audit of the diagnostic process. Ann R Coll Surg Engl. 1991;73248- 252
Helsing  PFaye  RLangmark  F Cutaneous malignant melanoma: correlation between tumor characteristics and diagnostic delay in Norwegian patients. Eur J Dermatol. 1997;7359- 361

Figures

Place holder to copy figure label and caption
Figure 1.

World-standardized incidence of melanoma in the department of the Bas-Rhin.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

New cases of melanoma diagnosed at the Department for Cutaneous Histopathology, University Hospitals, Strasbourg, France, between 1980 and 1997.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Tumor size as determined by mean and median Breslow index for both men and women.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

New cases of melanoma in women according to histologic subtype. ALM indicates acrolentiginous melanoma; LMM, lentigo maligna melanoma; NOD, nodular melanoma; and SSM, superficial spreading melanoma.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

New cases of melanoma in men according to histologic subtype. ALM indicates acrolentiginous melanoma; LMM, lentigo maligna melanoma; NOD, nodular melanoma; and SSM, superficial spreading melanoma.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

New cases of melanoma in women according to tumor thickness.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

New cases of melanoma in men according to tumor thickness.

Graphic Jump Location

Tables

Table Graphic Jump LocationAnatomic Site Distribution of Melanomas According to Sex

References

Boyle  PMaisonneuve  PDoré  JF Epidemiology of malignant melanoma. Br Med Bull. 1995;51523- 547
MacKie  RMHole  DHunter  JAA  et al.  Cutaneous malignant melanoma in Scotland: incidence, survival, and mortality. 1979-94. BMJ. 1997;3151117- 1121
Link to Article
Herd  RMCooper  EJHunter  JAA  et al.  Cutaneous malignant melanoma: publicity, screening clinics and survival: the Edinburgh experience 1982-90. Br J Dermatol. 1995;132563- 570
Link to Article
MacLennan  RGreen  ACMcLeod  GRMartin  NG Increasing incidence of cutaneous melanoma in Queensland, Australia. J Natl Cancer Inst. 1992;841427- 1432
Link to Article
Laplanche  ABenhamou  E Estimation de l'incidence des cancers en France. Bull Cancer. 1991;78405- 414
Estève  JKricker  AFerlay  JParkin  DM Facts and figures of cancer in the European Community. IARC Monogr Eval Carcinog Risks Hum. 1993;
Thiele  HSchöls  AScuppe  HCJungblut  RMGoerz  G Das maligne melanom: klinische und diagnostische Erfahrungen. Z Hautkr. 1993;68311- 314
Rompel  RWeiss  HZöfel  PPetres  J Epidemiologie des malignen Melanoms in Stadt- und Landbevölkerung. Z Hautkr. 1997;7229- 33
Baccard  MHavard  SSouques  M Prospective study of the incidence of melanoma in the Paris region in 1994. Melanoma Res. 1997;7335- 338
Link to Article
Lipsker  DHeid  EGrosshans  ECribier  B Le mélanome au CHU de Strasbourg: etude sur 30 ans. Ann Dermatol Venereol. 1998;125241- 246
Buzaid  ACRoss  MIBalch  CM  et al.  Critical analysis of the current American Joint Committee on Cancer Staging System for Cutaneous Melanoma and Proposal of a New Staging System. J Clin Oncol. 1997;151039- 1051
Roush  GCBerwick  MKoh  HKMacKie  RM Screening for melanoma. Balch  CMHoughton  ANMilton  GWSober  AJSoong  SJeds.Cutaneous Melanoma. 2nd ed. Philadelphia, Pa Lippincott–Williams & Wilkins1992;70- 81
MacKie  RM Melanoma prevention and early detection. Br Med Bull. 1995;51570- 583
Doherty  VRMacKie  RM Experience of a public education programme on early detection of cutaneous malignant melanoma. BMJ. 1988;287388- 391
Link to Article
MacKie  RMHole  D Audit of public education campaign to encourage earlier detection of malignant melanoma. BMJ. 1992;3041012- 1015
Link to Article
Cristofolini  MBianchi  RSebastiana  B  et al.  Analysis of the cost-effectiveness ratio of the health campaign for the early diagnosis of cutaneous melanoma in Trentino, Italy. Cancer. 1993;71370- 374
Link to Article
Rampen  FHJvan Huystee  BEWLKiemeney  LALM Melanoma/skin cancer screening clinics: experiences in the Netherlands. J Am Acad Dermatol. 1991;25776- 777
Link to Article
Hoffmann  KDirschka  TSchatz  HSegerling  MTiemann  THoffmann  A A local education campaign on early diagnosis of malignant melanoma. Eur J Epidemiol. 1993;9591- 598
Link to Article
Koh  HKNorton  LAGeller  AC  et al.  Evaluation of the American Academy of Dermatology's national skin cancer and early detection and screening program. J Am Acad Dermatol. 1996;34971- 978
Link to Article
Guerry IV  DSynnestvedt  MElder  DESchultz  E Lessons from tumor progression: the invasive radial growth phase of melanoma is common, incapable of metastastis, and indolent. J Invest Dermatol. 1993;100 (suppl) 342S- 345S
Link to Article
Kerbel  RSKobayashi  HGraham  CHLu  C Analysis and significance of the malignant eclipse during the progression of primary cutaneous human melanomas. J Invest Dermatol. 1996;103183- 187
 edFrancis  B  edGreen  M  edPayne  C GLIM 4–The Statistical System for Generalised Linear Interactive Modelling.  Oxford, England Clarendon Press1994;
Van der Esch  EPMuir  CSNectoux  J  et al.  Temporal change in diagnostic criteria as a cause of the increase of malignant melanoma over time is unlikely. Int J Cancer. 1991;47483- 489
Link to Article
Berwick  M Epidemiology: current trends, risk factors, and enviromental concerns. Balch  CMHoughton  ANSober  AJSoong  SJeds.Cutaneous Melanoma. 3rd ed. St Louis, Mo Quality Medical Publishing Inc1998;551- 571
Burton  RCArmstrong  BK Recent incidence trends imply a nonmetastasizing form of invasive melanoma. Melanoma Res. 1994;4107- 113
Link to Article
Swerlick  RAChen  S The melanoma epidemic: is increased surveillance the solution or the problem? Arch Dermatol. 1996;132881- 884
Link to Article
Dunkley  MPMorris  AM Cutaneous malignant melanoma: audit of the diagnostic process. Ann R Coll Surg Engl. 1991;73248- 252
Helsing  PFaye  RLangmark  F Cutaneous malignant melanoma: correlation between tumor characteristics and diagnostic delay in Norwegian patients. Eur J Dermatol. 1997;7359- 361

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 85

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

Users' Guides to the Medical Literature
Melanoma

The Rational Clinical Examination
Make the Diagnosis: Melanoma