Judith Fine

THE IMPACT OF CO-MORBIDITY ON LIFE EXPECTANCY AMONG MEN WITH LOCALIZED PROSTATE CANCER

PURPOSE We evaluated 3 indexes used to assess patient co-morbidities to determine whether they could predict mortality among men with clinically localized prostate cancer. MATERIALS AND METHODS We measured the impact of co-morbidity classifications on all cause mortality using a parametric proportional hazards model based on a retrospective cohort analysis. RESULTS Each index tested is a highly significant predictor of mortality for patients dying of nonprostate cancer related causes after adjusting for age and Gleason score. CONCLUSIONS Each co-morbidity index provides significant, independent predictive information concerning patient mortality beyond that provided by age, Gleason score and clinical stage alone.

The importance of mitotic rate as a prognostic factor for localized cutaneous melanoma

Background:  Tumor ulceration (TU) is considered the second most important prognostic factor after Breslow thickness for localized cutaneous malignant melanoma (CMM). However, many studies have not included mitotic rate (MR) with TU in these analyses. When both TU and MR are included in the same analysis, MR appears to be the more important than TU and TU loses its significance as an independent prognostic factor.

Patient Knowledge, Awareness, and Delay in Seeking Medical Attention for Malignant Melanoma

We investigated the relationship between patient knowledge, awareness, and delay in seeking medical attention for melanoma. The study population was comprised of 255 cases with cutaneous melanoma newly diagnosed during January 15, 1987 to May 15, 1989, who were part of a population-based case control study. Personal interviews were conducted to obtain information on patients knowledge of melanoma signs and symptoms, skin awareness, delay in seeking medical attention, and related covariates. The adjusted odds ratio for the association between skin awareness and delay was 0.30 (95% confidence interval 0.12-0.71). Odds ratios ranged from 0.43 to 0.81 for knowledge and delay. Awareness of skin changes was associated with a reduced Breslow depth for stage I melanomas. Individuals who are aware of skin changes and abnormalities appear to be less likely to delay seeking medical attention for melanoma. Knowledge of melanoma signs and symptoms may also contribute to a decreased delay in melanoma diagnosis.

Complete follow-up and evaluation of a skin cancer screening in Connecticut

On May 21, 1988, 251 persons were screened for skin cancer in New Haven, Connecticut. A total body skin examination was performed on 98% of the participants. On the basis of follow-up of 93% of persons with positive screens for basal cell carcinoma, squamous cell carcinoma, or Bowens disease, positive predictive values were 43% for basal cell carcinoma, 14% for squamous cell carcinoma, and 50% for Bowens disease. In the group with atypical nevi, a person with two or more clinically atypical nevi was 16 times more likely to have histologic confirmation than a person with a single clinically atypical nevus (p = 0.003). Eighty persons were screened by both a dermatologist and a dermatology nurse; the crude agreement rate for actinic keratoses was 0.62; for atypical nevi, 0.53; and for BCC, 0.88. Both nurses and physicians overdiagnosed in the screening setting, the nurses more so than the physicians. Of the 128 persons screened who were advised to seek medical follow-up, 16 did not do so despite several reminders; their reasons are discussed.

Outcomes Following Active Surveillance of Men With Localized Prostate Cancer Diagnosed in the Prostate Specific Antigen Era

PURPOSE We gained insights concerning outcomes associated with men who elect active surveillance for the management of localized prostate cancer. MATERIALS AND METHODS This is a retrospective case series analysis of 40 patients diagnosed with localized prostate cancer since 1990 who elected active surveillance. RESULTS A total of 31 patients remained on active surveillance for a median of 48 months (range 12 to 168). The 5-year probability of remaining on active surveillance was 74%. Most patients who abandoned this strategy did so within 33 months of diagnosis (range 12 to 84). An increasing prostate specific antigen and anxiety were the 2 most common reasons. A delay in treatment did not appear to compromise subsequent outcomes. CONCLUSIONS Men with low grade prostate cancer can elect active surveillance and have excellent long-term results.

An analysis of interobserver recognition of the histopathologic features of dysplastic nevi from a mixed group of nevomelanocytic lesions

BACKGROUND The diagnostic criteria for the histopathologic recognition of the dysplastic nevus are defined, but difficult to apply in practice. However, the use of skin biopsy is on the increase to search for this nevus because of a possible role in melanomagenesis. OBJECTIVE The aim was to determine the degree of observer reproducibility in the detection of histologic nevomelanocytic dysplasia as measured across multiple observers and to test whether each observer was precise over a wide sample population. A second aim was to gain some measure of the threshold a person has for such lesions. METHODS Histologic specimens from 50 coded nevomelanocytic tumors, which included a group of dysplastic nevi, were independently read by five observers in a blinded fashion. At study completion, the same 50 cases were read again by a melanoma reference pathologist and results analyzed by Cohens kappa to assess agreement and interobserver variation. RESULTS Corrected rates of agreement for dysplastic nevi ranged from 0.32 to 0.71. CONCLUSION Continued study and experience are required for precision and reproducibility in the histologic recognition of dysplastic nevi.

Histologic evaluation of pigmented lesions in Connecticut and its influence on the reporting of melanoma

BACKGROUND Underreporting of melanoma to state tumor registries has been identified as a problem in gathering accurate statistics on melanoma incidence. OBJECTIVE Our purpose was to examine two factors that could influence the reporting of melanoma to the Connecticut Tumor Registry: histologic diagnosis of melanoma in the private offices of dermatologists and histologic diagnosis of melanoma in out-of-state laboratories. METHODS From December 1990 to April 1991, questionnaires were sent to all known practicing dermatologists in the state of Connecticut (N = 149). Of the 127 dermatologists who were eligible, 124 (97.6%) completed the survey. RESULTS The estimated number of melanomas diagnosed in private offices during 1990 was 9 to 18; this was based on the number of dermatologists who officially read their own slides (n = 19), the estimated number of melanomas diagnosed by these 19 dermatologists (n = 91), and the percentage of melanomas and uncertain pigmented lesion cases sent for consultation (80% to 90%). According to the estimates of Connecticut dermatologists, out-of-state laboratories diagnosed 84 of 523 melanomas (16%) in Connecticut residents. CONCLUSION The diagnosis of melanoma in private offices did not appear to be a significant factor in underreporting whereas the diagnosis of melanoma in out-of-state laboratories did appear to be more significant. However, the possibility exists that some of these latter melanomas would eventually be reported at the time of reexcision.

Signs and symptoms of melanoma in older populations.

We conducted a descriptive study to assess the relationship between increasing age and the reporting of melanoma signs/symptoms in 634 hospital-based and 624 population-based incident cases of melanoma. Multivariate logistic regression was used to evaluate the relationship between older age (> or = 50 years) and the reporting of melanoma signs/symptoms. Older patients were less likely to report itching and change in elevation of their lesions (P < 0.05). Change in color was also less likely to be reported by older patients, although not statistically significant. Ulceration of the lesion was reported significantly more by older patients (P < 0.05). Older individuals may be less likely to report itching and change in elevation/color of their lesions, but more likely to report ulceration, a symptom associated with advanced disease and poor prognosis. Further research is necessary to provide a better understanding of the development of melanoma in older populations so that new strategies can be explored to improve early detection in this age group.

The role of the nurse in skin cancer prevention, screening, and early detection

T HE NURSE’S ROLE in skin cancer prevention, screening, and early detection is currently at a crossroads, in much the same way as the nursing profession itself is. There have been substantial changes in the role of the nurse during the past two decades,’ and it is clear that the nurse is now in a unique position to make contributions to the prevention and early diagnosis of skin cancer. use of sunscreens during the first 18 years of life would reduce nonmelanoma skin cancer by 78% and possibly reduce the incidence of melanoma. Behaviors such as avoidance of skin contact with chemicals and other forms of ionizing radiation also play a role in skin cancer prevention. This article focuses on methods of screening and early detection issues of importance to the nurse.

Skin self-examination and long-term melanoma survival.

To evaluate the effect of skin self-examination (SSE) on melanoma mortality, we estimated the survival for individuals performing SSE compared with those who did not. Participants were from a previously carried out case–control study, who were newly diagnosed melanoma cases in 1987–1989. A 20-year survival analysis was carried out using death (event) and other causes of death (competing). Cumulative incidence functions were evaluated using Gray’s test and proportional subdistribution hazards regression models were fitted to study the effect of SSE and other covariates on melanoma survival. Forty-five percent of patients died, with 48.4% melanoma deaths. Individuals who did not perform SSE experienced a continuous increase in the risk of melanoma death trending toward significance for nearly 20 years after diagnosis, whereas melanoma deaths in skin self-examiners plateaued before 10 years after diagnosis (P=0.32). Univariate analyses suggested a 25% lower risk of melanoma death for those who performed SSE [hazard ratio (HR)=0.75, 95% confidence interval (CI)=0.43–1.32, P=0.32]. After adjusting for competing risks, the multivariate risk estimate was above one (HR=1.12, 95% CI=0.61–2.06, P=0.71). Skin awareness (HR=0.46, 95% CI=0.28–0.75, P⩽0.01) was associated independently with a decreased risk of melanoma death. Although we did not find a significant association between melanoma mortality and SSE when adjusting for competing mortality and other covariates, we extended previous findings that increased skin awareness and tumor thickness are strongly inversely related to survival. Research is needed to continue developing best practices for melanoma screening and to further explore the components of SSE and long-term melanoma survival.