Melanoma

The benefits and harms of visual screen cancer screening exams for asymptomatic adults can’t be adequately assessed with current evidence, according to a new recommendation from the U.S. Preventive Services Task Force.

“Evidence is inadequate to reliably conclude that early detection of skin cancer through visual skin examination by a clinician reduces morbidity or mortality,” according to the statement published online July 26 in JAMA (2016;316[4]:429-435. doi:10.1001/jama.2016.8465).

©Wavebreakmedia Ltd/Thinkstock

Approximately 76,400 adults in the United States will develop melanoma, and more than 10,000 will die from it, according to the USPSTF. However, more than 98% of skin cancer cases in the United States are basal and squamous cell carcinoma, which have much lower morbidity and mortality rates, noted the USPSTF researchers, led by Kirsten Bibbins-Domingo, MD, PhD, of the University of California, San Francisco.

The current statement updates the USPSTF’s 2009 recommendation, which also found insufficient evidence to assess the harms and benefits of visual skin cancer screening in asymptomatic adults with no history of premalignant or malignant skin lesions. However, the current recommendation eliminates a statement about patients’ skin self-exams.

According to the USPSTF, evidence is “adequate” that a clinician’s visual skin exam has “modest sensitivity and specificity for detecting melanoma,” but evidence is inconsistent to support the ability of a visual skin exam to detect nonmelanoma skin cancer.

The USPSTF commissioned an evidence review that included 11 studies previously reviewed and 2 additional studies conducted since 2009. The two new studies included one that evaluated skin cancer screening performed by dermatologists or plastic surgeons and one that evaluated skin cancer screening performed by primary care physicians. Sensitivity and specificity in the two studies ranged from 40% to 70% and from 86% to 98%, respectively.

“None of the studies could draw reliable conclusions as to whether screening performed by any of the clinical specialties differed in diagnostic accuracy,” the researchers noted. In addition, “no [randomized controlled trial] has directly evaluated the effectiveness of the clinical visual skin examination for reducing skin cancer morbidity and mortality,” they wrote.

The recommendation was accompanied by several editorials published online July 26 in JAMA journals.

In JAMA, Hensin Tsao, MD, PhD, of Massachusetts General Hospital, Boston, and Martin Weinstock, MD, PhD, of Brown University, Providence, R.I., noted that the USPSTF considered the possibility of including information from high-quality case-control studies in lieu of randomized controlled trials, which have been difficult to conduct in skin cancer screening. “The evidentiary standard needs to be further refined to be appropriate to the modest magnitude of potential harms of a properly performed skin cancer screening,” they wrote (JAMA. 2016;316:398-400). Dr. Tsao disclosed an honorarium from Lubax.

In JAMA Dermatology, Susan Swetter, MD, of the Veterans Affairs Palo Alto (Calif.) Health Care System; Alan C. Geller, MPH, of Harvard School of Public Health, Boston; and Allan C. Halpern, MD, of Memorial Sloan Kettering Cancer Center, New York, wrote about ways to promote broader uptake of skin cancer screening. “Alternative models should be explored to bundle skin screening with other preventive services (e.g., blood pressure measurements or flu shots) and to engage advanced practice providers (e.g., nurse practitioners and physician assistants) to promote screening among individuals with less access to dermatologists,” they wrote (JAMA Dermatol. 2016. doi: 10.1001/jamadermatol.2016.2606).

In JAMA Oncology, Vinayak K. Nahar, MD, of the University of Mississippi Medical Center, Jackson; Jonathan E. Mayer, MD, of Johns Hopkins University, Baltimore; and Jane M. Grant-Kels, MD, of the University of Connecticut, Farmington, addressed concerns over performing more biopsies. “The USPSTF also raises concern over the number needed to biopsy to detect 1 case of melanoma. In weighing these data, one must also consider that many of the nonmelanomas biopsied were likely severely atypical nevi that have their own risk of malignant transformation. Although difficult to quantify, there is some benefit to removing a severely atypical nevus, both for risk of transformation and for a patient’s peace of mind,” they wrote (JAMA Oncol. 2016. doi: 10.1001/jamaoncol.2016.2440).

In JAMA Internal Medicine, Eleni Linos, MD, of the University of California, San Francisco; Kenneth A. Katz, MD, of Kaiser Permanente, San Francisco; and Graham A. Colditz, MD, of Washington University, St. Louis, cautioned that the USPSTF recommendations shouldn’t be interpreted as minimizing the importance of skin cancer. “Instead, the report should motivate us to improve the evidence base for identifying groups of people in whom the benefits of screening might outweigh risks,” they wrote. “Meanwhile, we should also fully implement skin cancer primary prevention by eliminating indoor tanning exposure, especially among youths, and increasing the use of sun-protection strategies that work” (JAMA Intern. Med. 2016. doi: 10.1001/jamaintermed.2016.5008).

The recommendations are not an official position of the U.S. Department of Health and Human Services or the Agency for Healthcare Research and Quality.

The benefits and harms of visual screen cancer screening exams for asymptomatic adults can’t be adequately assessed with current evidence, according to a new recommendation from the U.S. Preventive Services Task Force.

“Evidence is inadequate to reliably conclude that early detection of skin cancer through visual skin examination by a clinician reduces morbidity or mortality,” according to the statement published online July 26 in JAMA (2016;316[4]:429-435. doi:10.1001/jama.2016.8465).

©Wavebreakmedia Ltd/Thinkstock

Approximately 76,400 adults in the United States will develop melanoma, and more than 10,000 will die from it, according to the USPSTF. However, more than 98% of skin cancer cases in the United States are basal and squamous cell carcinoma, which have much lower morbidity and mortality rates, noted the USPSTF researchers, led by Kirsten Bibbins-Domingo, MD, PhD, of the University of California, San Francisco.

The current statement updates the USPSTF’s 2009 recommendation, which also found insufficient evidence to assess the harms and benefits of visual skin cancer screening in asymptomatic adults with no history of premalignant or malignant skin lesions. However, the current recommendation eliminates a statement about patients’ skin self-exams.

According to the USPSTF, evidence is “adequate” that a clinician’s visual skin exam has “modest sensitivity and specificity for detecting melanoma,” but evidence is inconsistent to support the ability of a visual skin exam to detect nonmelanoma skin cancer.

The USPSTF commissioned an evidence review that included 11 studies previously reviewed and 2 additional studies conducted since 2009. The two new studies included one that evaluated skin cancer screening performed by dermatologists or plastic surgeons and one that evaluated skin cancer screening performed by primary care physicians. Sensitivity and specificity in the two studies ranged from 40% to 70% and from 86% to 98%, respectively.

“None of the studies could draw reliable conclusions as to whether screening performed by any of the clinical specialties differed in diagnostic accuracy,” the researchers noted. In addition, “no [randomized controlled trial] has directly evaluated the effectiveness of the clinical visual skin examination for reducing skin cancer morbidity and mortality,” they wrote.

The recommendation was accompanied by several editorials published online July 26 in JAMA journals.

In JAMA, Hensin Tsao, MD, PhD, of Massachusetts General Hospital, Boston, and Martin Weinstock, MD, PhD, of Brown University, Providence, R.I., noted that the USPSTF considered the possibility of including information from high-quality case-control studies in lieu of randomized controlled trials, which have been difficult to conduct in skin cancer screening. “The evidentiary standard needs to be further refined to be appropriate to the modest magnitude of potential harms of a properly performed skin cancer screening,” they wrote (JAMA. 2016;316:398-400). Dr. Tsao disclosed an honorarium from Lubax.

In JAMA Dermatology, Susan Swetter, MD, of the Veterans Affairs Palo Alto (Calif.) Health Care System; Alan C. Geller, MPH, of Harvard School of Public Health, Boston; and Allan C. Halpern, MD, of Memorial Sloan Kettering Cancer Center, New York, wrote about ways to promote broader uptake of skin cancer screening. “Alternative models should be explored to bundle skin screening with other preventive services (e.g., blood pressure measurements or flu shots) and to engage advanced practice providers (e.g., nurse practitioners and physician assistants) to promote screening among individuals with less access to dermatologists,” they wrote (JAMA Dermatol. 2016. doi: 10.1001/jamadermatol.2016.2606).

In JAMA Oncology, Vinayak K. Nahar, MD, of the University of Mississippi Medical Center, Jackson; Jonathan E. Mayer, MD, of Johns Hopkins University, Baltimore; and Jane M. Grant-Kels, MD, of the University of Connecticut, Farmington, addressed concerns over performing more biopsies. “The USPSTF also raises concern over the number needed to biopsy to detect 1 case of melanoma. In weighing these data, one must also consider that many of the nonmelanomas biopsied were likely severely atypical nevi that have their own risk of malignant transformation. Although difficult to quantify, there is some benefit to removing a severely atypical nevus, both for risk of transformation and for a patient’s peace of mind,” they wrote (JAMA Oncol. 2016. doi: 10.1001/jamaoncol.2016.2440).

In JAMA Internal Medicine, Eleni Linos, MD, of the University of California, San Francisco; Kenneth A. Katz, MD, of Kaiser Permanente, San Francisco; and Graham A. Colditz, MD, of Washington University, St. Louis, cautioned that the USPSTF recommendations shouldn’t be interpreted as minimizing the importance of skin cancer. “Instead, the report should motivate us to improve the evidence base for identifying groups of people in whom the benefits of screening might outweigh risks,” they wrote. “Meanwhile, we should also fully implement skin cancer primary prevention by eliminating indoor tanning exposure, especially among youths, and increasing the use of sun-protection strategies that work” (JAMA Intern. Med. 2016. doi: 10.1001/jamaintermed.2016.5008).

The recommendations are not an official position of the U.S. Department of Health and Human Services or the Agency for Healthcare Research and Quality.

The benefits and harms of visual screen cancer screening exams for asymptomatic adults can’t be adequately assessed with current evidence, according to a new recommendation from the U.S. Preventive Services Task Force.

“Evidence is inadequate to reliably conclude that early detection of skin cancer through visual skin examination by a clinician reduces morbidity or mortality,” according to the statement published online July 26 in JAMA (2016;316[4]:429-435. doi:10.1001/jama.2016.8465).

©Wavebreakmedia Ltd/Thinkstock

Approximately 76,400 adults in the United States will develop melanoma, and more than 10,000 will die from it, according to the USPSTF. However, more than 98% of skin cancer cases in the United States are basal and squamous cell carcinoma, which have much lower morbidity and mortality rates, noted the USPSTF researchers, led by Kirsten Bibbins-Domingo, MD, PhD, of the University of California, San Francisco.

The current statement updates the USPSTF’s 2009 recommendation, which also found insufficient evidence to assess the harms and benefits of visual skin cancer screening in asymptomatic adults with no history of premalignant or malignant skin lesions. However, the current recommendation eliminates a statement about patients’ skin self-exams.

According to the USPSTF, evidence is “adequate” that a clinician’s visual skin exam has “modest sensitivity and specificity for detecting melanoma,” but evidence is inconsistent to support the ability of a visual skin exam to detect nonmelanoma skin cancer.

The USPSTF commissioned an evidence review that included 11 studies previously reviewed and 2 additional studies conducted since 2009. The two new studies included one that evaluated skin cancer screening performed by dermatologists or plastic surgeons and one that evaluated skin cancer screening performed by primary care physicians. Sensitivity and specificity in the two studies ranged from 40% to 70% and from 86% to 98%, respectively.

“None of the studies could draw reliable conclusions as to whether screening performed by any of the clinical specialties differed in diagnostic accuracy,” the researchers noted. In addition, “no [randomized controlled trial] has directly evaluated the effectiveness of the clinical visual skin examination for reducing skin cancer morbidity and mortality,” they wrote.

The recommendation was accompanied by several editorials published online July 26 in JAMA journals.

In JAMA, Hensin Tsao, MD, PhD, of Massachusetts General Hospital, Boston, and Martin Weinstock, MD, PhD, of Brown University, Providence, R.I., noted that the USPSTF considered the possibility of including information from high-quality case-control studies in lieu of randomized controlled trials, which have been difficult to conduct in skin cancer screening. “The evidentiary standard needs to be further refined to be appropriate to the modest magnitude of potential harms of a properly performed skin cancer screening,” they wrote (JAMA. 2016;316:398-400). Dr. Tsao disclosed an honorarium from Lubax.

In JAMA Dermatology, Susan Swetter, MD, of the Veterans Affairs Palo Alto (Calif.) Health Care System; Alan C. Geller, MPH, of Harvard School of Public Health, Boston; and Allan C. Halpern, MD, of Memorial Sloan Kettering Cancer Center, New York, wrote about ways to promote broader uptake of skin cancer screening. “Alternative models should be explored to bundle skin screening with other preventive services (e.g., blood pressure measurements or flu shots) and to engage advanced practice providers (e.g., nurse practitioners and physician assistants) to promote screening among individuals with less access to dermatologists,” they wrote (JAMA Dermatol. 2016. doi: 10.1001/jamadermatol.2016.2606).

In JAMA Oncology, Vinayak K. Nahar, MD, of the University of Mississippi Medical Center, Jackson; Jonathan E. Mayer, MD, of Johns Hopkins University, Baltimore; and Jane M. Grant-Kels, MD, of the University of Connecticut, Farmington, addressed concerns over performing more biopsies. “The USPSTF also raises concern over the number needed to biopsy to detect 1 case of melanoma. In weighing these data, one must also consider that many of the nonmelanomas biopsied were likely severely atypical nevi that have their own risk of malignant transformation. Although difficult to quantify, there is some benefit to removing a severely atypical nevus, both for risk of transformation and for a patient’s peace of mind,” they wrote (JAMA Oncol. 2016. doi: 10.1001/jamaoncol.2016.2440).

In JAMA Internal Medicine, Eleni Linos, MD, of the University of California, San Francisco; Kenneth A. Katz, MD, of Kaiser Permanente, San Francisco; and Graham A. Colditz, MD, of Washington University, St. Louis, cautioned that the USPSTF recommendations shouldn’t be interpreted as minimizing the importance of skin cancer. “Instead, the report should motivate us to improve the evidence base for identifying groups of people in whom the benefits of screening might outweigh risks,” they wrote. “Meanwhile, we should also fully implement skin cancer primary prevention by eliminating indoor tanning exposure, especially among youths, and increasing the use of sun-protection strategies that work” (JAMA Intern. Med. 2016. doi: 10.1001/jamaintermed.2016.5008).

The recommendations are not an official position of the U.S. Department of Health and Human Services or the Agency for Healthcare Research and Quality.

MINNEAPOLIS, MINN. – Indoor tanning is a significant contributor to the U.S. skin cancer epidemic and represents a 100% preventable source of exposure to these cancers. Understanding exactly who is using indoor tanning – and why – can provide insight and leverage to help change behavior, according to Cindy Firkins Smith, MD, adjunct professor of dermatology at the University of Minnesota, Minneapolis.

Dr. Smith noted that the typical indoor tanning bed user is female and between 17 and 30 years old. Other aspects of her lifestyle may be unhealthy; for example, she may smoke cigarettes, have an unhealthy pattern of alcohol consumption, and make unhealthy food choices (Cancer Causes Control 2006 June. doi:10.1007/s10552-005-0453-9). She also is likely to watch beauty-focused reality TV shows (J Am Acad Dermatol 2013 May. doi:10.1016/j.jaad.2012.09.055) and is likely to objectify her own body, seeing it as something to be viewed and judged (Arch Dermatol 2009 Sep 1. doi:10.1001/archdermatol.2009.190).

©Vidmantas Goldbergas/Thinkstock

Tanning is a behavior that provides relaxation and positive emotions, and she receives support for this behavior from family and friends. “Tanning often starts with mom, which is one reason that parental permission legislation doesn’t work,” she said at the annual meeting of the Society for Pediatric Dermatology.

Dr. Smith said that up to 30 million people tan indoors every year. Rates of tanning for teenage girls are very high: up to 40% of American teenagers use indoor tanning, and 20%-30% of all 18- to 29-year-olds have used a tanning bed in the previous year (Jama Dermatol 2014 April doi: 10.1001/jamadermatol.2013.6896).

The ubiquity of tanning salons contributes to the problem, said Dr. Smith. “More is not better; in the largest U.S. cities, tanning salons outnumber [both] Starbucks and McDonald’s,” she said, noting that studies have shown that both proximity to tanning salons and the low cost of tanning encourage their use (Am J Prev Med. 2009 Mar 36[3]:243-6).

A 2015 study surveyed 125 colleges, finding that 48% had indoor tanning facilities in their campus or off-campus housing. College cash cards were acceptable payment at 14.4% of colleges, and 96% of off-campus housing facilities that offered tanning provided it as a free “perk” to residents (JAMA Dermatol 2015 Jan. doi: 10.1001/jamadermatol.2014.3590).

Further, some data suggest that tanning really can be addictive for some patients. Ultraviolet light exposure has been shown to “light up” pleasure centers in PET-CT studies, and some frequent tanners report relaxation and pleasure from tanning as well as craving and feelings of withdrawal when they miss sessions. Dr. Smith said she does not hesitate to refer teen patients to mental health providers if there are concerns about mood and depression.

Having an understanding of patient motivations to tan can help in getting patients to take steps toward change, said Dr. Smith. “What can we do? We can actually do a lot. We have a lot more influence than we think we do.”

At the level of the individual patient, just opening up a conversation can make a big difference. “We assume we know why teenagers go to a tanning booth. But do we? When you notice a young woman who’s been to a tanning booth, ask why,” using a nonjudgmental approach to begin a dialogue about the near-term and long-term dangers of tanning. A positive approach is key, noted Dr. Smith. “Focusing on the benefits of avoiding UV tanning is more effective than a heavy reliance on scare tactics,” she said. Also, “multiple interventions work better.”

Before-and-after photos of celebrities whose appearance has been affected by photoaging can be effective. Another tactic with a more positive spin is to share images of celebrities who have chosen not to tan and who celebrate their fair skin. These conversations are particularly important at prom time, peak tanning season for many young women, said Dr. Smith. She has a portfolio of photos showing fair-skinned women wearing high-contrast gowns, which she says are more flattering for pale skin than white or nude colors.

For patients who still want that tan look, “Tanning for reasons of appearance can be satisfied with sunless tanners,” said Dr. Smith. The most common ingredient in sunless tanners is dihydroxyacetone (DHA), which was approved in the 1970s for topical use. However, the Food and Drug Administration issued a warning in 2011 about spray tanning, noting that the “industry has not provided safety data to FDA in order for the agency to consider approving it for … ‘misting’ from tanning booths.” The FDA’s specific concern had to do with the unknown safety of ingestion, inhalation, and mucous membrane exposure that can result from spray tanning.

Moving to the legislative and policy level, change can be achieved when stakeholders band together to “ban the tan,” said Dr. Smith. “The best way to do it is with a village. It really takes a lot of people to do this.”

There are solid epidemiologic and economic reasons to focus on the skin cancer epidemic, said Dr. Smith. Skin cancer is now the most common cancer in the United States, and more new cases “are diagnosed each year than breast, prostate, lung, and colon cancers combined,” she said. Of nonmelanoma skin cancers, 90% are thought to be UV-related, and “the vast majority of mutations found in melanoma are caused by UV radiation.”

Skin cancers cost the United States over $8 billion annually, and although promising new immunotherapies are extending the lives of those with melanoma, these treatments cost hundreds of thousands of dollars a year. “This type of treatment is unaffordable for our system,” said Dr. Smith.

Progress is being made, she said, despite industry opposition. Individual states have regulated or banned tanning for minors, and at the federal level, tanning beds are now considered by the FDA to be Class II (moderate-risk) medical devices, a step up from their previous classification as the lowest-risk Class I devices, “The same as a tongue blade,” she said.

Dr. Smith had no relevant financial disclosures.

[email protected]

On Twitter @karioakes

MINNEAPOLIS, MINN. – Indoor tanning is a significant contributor to the U.S. skin cancer epidemic and represents a 100% preventable source of exposure to these cancers. Understanding exactly who is using indoor tanning – and why – can provide insight and leverage to help change behavior, according to Cindy Firkins Smith, MD, adjunct professor of dermatology at the University of Minnesota, Minneapolis.

Dr. Smith noted that the typical indoor tanning bed user is female and between 17 and 30 years old. Other aspects of her lifestyle may be unhealthy; for example, she may smoke cigarettes, have an unhealthy pattern of alcohol consumption, and make unhealthy food choices (Cancer Causes Control 2006 June. doi:10.1007/s10552-005-0453-9). She also is likely to watch beauty-focused reality TV shows (J Am Acad Dermatol 2013 May. doi:10.1016/j.jaad.2012.09.055) and is likely to objectify her own body, seeing it as something to be viewed and judged (Arch Dermatol 2009 Sep 1. doi:10.1001/archdermatol.2009.190).

©Vidmantas Goldbergas/Thinkstock

Tanning is a behavior that provides relaxation and positive emotions, and she receives support for this behavior from family and friends. “Tanning often starts with mom, which is one reason that parental permission legislation doesn’t work,” she said at the annual meeting of the Society for Pediatric Dermatology.

Dr. Smith said that up to 30 million people tan indoors every year. Rates of tanning for teenage girls are very high: up to 40% of American teenagers use indoor tanning, and 20%-30% of all 18- to 29-year-olds have used a tanning bed in the previous year (Jama Dermatol 2014 April doi: 10.1001/jamadermatol.2013.6896).

The ubiquity of tanning salons contributes to the problem, said Dr. Smith. “More is not better; in the largest U.S. cities, tanning salons outnumber [both] Starbucks and McDonald’s,” she said, noting that studies have shown that both proximity to tanning salons and the low cost of tanning encourage their use (Am J Prev Med. 2009 Mar 36[3]:243-6).

A 2015 study surveyed 125 colleges, finding that 48% had indoor tanning facilities in their campus or off-campus housing. College cash cards were acceptable payment at 14.4% of colleges, and 96% of off-campus housing facilities that offered tanning provided it as a free “perk” to residents (JAMA Dermatol 2015 Jan. doi: 10.1001/jamadermatol.2014.3590).

Further, some data suggest that tanning really can be addictive for some patients. Ultraviolet light exposure has been shown to “light up” pleasure centers in PET-CT studies, and some frequent tanners report relaxation and pleasure from tanning as well as craving and feelings of withdrawal when they miss sessions. Dr. Smith said she does not hesitate to refer teen patients to mental health providers if there are concerns about mood and depression.

Having an understanding of patient motivations to tan can help in getting patients to take steps toward change, said Dr. Smith. “What can we do? We can actually do a lot. We have a lot more influence than we think we do.”

At the level of the individual patient, just opening up a conversation can make a big difference. “We assume we know why teenagers go to a tanning booth. But do we? When you notice a young woman who’s been to a tanning booth, ask why,” using a nonjudgmental approach to begin a dialogue about the near-term and long-term dangers of tanning. A positive approach is key, noted Dr. Smith. “Focusing on the benefits of avoiding UV tanning is more effective than a heavy reliance on scare tactics,” she said. Also, “multiple interventions work better.”

Before-and-after photos of celebrities whose appearance has been affected by photoaging can be effective. Another tactic with a more positive spin is to share images of celebrities who have chosen not to tan and who celebrate their fair skin. These conversations are particularly important at prom time, peak tanning season for many young women, said Dr. Smith. She has a portfolio of photos showing fair-skinned women wearing high-contrast gowns, which she says are more flattering for pale skin than white or nude colors.

For patients who still want that tan look, “Tanning for reasons of appearance can be satisfied with sunless tanners,” said Dr. Smith. The most common ingredient in sunless tanners is dihydroxyacetone (DHA), which was approved in the 1970s for topical use. However, the Food and Drug Administration issued a warning in 2011 about spray tanning, noting that the “industry has not provided safety data to FDA in order for the agency to consider approving it for … ‘misting’ from tanning booths.” The FDA’s specific concern had to do with the unknown safety of ingestion, inhalation, and mucous membrane exposure that can result from spray tanning.

Moving to the legislative and policy level, change can be achieved when stakeholders band together to “ban the tan,” said Dr. Smith. “The best way to do it is with a village. It really takes a lot of people to do this.”

There are solid epidemiologic and economic reasons to focus on the skin cancer epidemic, said Dr. Smith. Skin cancer is now the most common cancer in the United States, and more new cases “are diagnosed each year than breast, prostate, lung, and colon cancers combined,” she said. Of nonmelanoma skin cancers, 90% are thought to be UV-related, and “the vast majority of mutations found in melanoma are caused by UV radiation.”

Skin cancers cost the United States over $8 billion annually, and although promising new immunotherapies are extending the lives of those with melanoma, these treatments cost hundreds of thousands of dollars a year. “This type of treatment is unaffordable for our system,” said Dr. Smith.

Progress is being made, she said, despite industry opposition. Individual states have regulated or banned tanning for minors, and at the federal level, tanning beds are now considered by the FDA to be Class II (moderate-risk) medical devices, a step up from their previous classification as the lowest-risk Class I devices, “The same as a tongue blade,” she said.

Dr. Smith had no relevant financial disclosures.

[email protected]

On Twitter @karioakes

MINNEAPOLIS, MINN. – Indoor tanning is a significant contributor to the U.S. skin cancer epidemic and represents a 100% preventable source of exposure to these cancers. Understanding exactly who is using indoor tanning – and why – can provide insight and leverage to help change behavior, according to Cindy Firkins Smith, MD, adjunct professor of dermatology at the University of Minnesota, Minneapolis.

Dr. Smith noted that the typical indoor tanning bed user is female and between 17 and 30 years old. Other aspects of her lifestyle may be unhealthy; for example, she may smoke cigarettes, have an unhealthy pattern of alcohol consumption, and make unhealthy food choices (Cancer Causes Control 2006 June. doi:10.1007/s10552-005-0453-9). She also is likely to watch beauty-focused reality TV shows (J Am Acad Dermatol 2013 May. doi:10.1016/j.jaad.2012.09.055) and is likely to objectify her own body, seeing it as something to be viewed and judged (Arch Dermatol 2009 Sep 1. doi:10.1001/archdermatol.2009.190).

©Vidmantas Goldbergas/Thinkstock

Tanning is a behavior that provides relaxation and positive emotions, and she receives support for this behavior from family and friends. “Tanning often starts with mom, which is one reason that parental permission legislation doesn’t work,” she said at the annual meeting of the Society for Pediatric Dermatology.

Dr. Smith said that up to 30 million people tan indoors every year. Rates of tanning for teenage girls are very high: up to 40% of American teenagers use indoor tanning, and 20%-30% of all 18- to 29-year-olds have used a tanning bed in the previous year (Jama Dermatol 2014 April doi: 10.1001/jamadermatol.2013.6896).

The ubiquity of tanning salons contributes to the problem, said Dr. Smith. “More is not better; in the largest U.S. cities, tanning salons outnumber [both] Starbucks and McDonald’s,” she said, noting that studies have shown that both proximity to tanning salons and the low cost of tanning encourage their use (Am J Prev Med. 2009 Mar 36[3]:243-6).

A 2015 study surveyed 125 colleges, finding that 48% had indoor tanning facilities in their campus or off-campus housing. College cash cards were acceptable payment at 14.4% of colleges, and 96% of off-campus housing facilities that offered tanning provided it as a free “perk” to residents (JAMA Dermatol 2015 Jan. doi: 10.1001/jamadermatol.2014.3590).

Further, some data suggest that tanning really can be addictive for some patients. Ultraviolet light exposure has been shown to “light up” pleasure centers in PET-CT studies, and some frequent tanners report relaxation and pleasure from tanning as well as craving and feelings of withdrawal when they miss sessions. Dr. Smith said she does not hesitate to refer teen patients to mental health providers if there are concerns about mood and depression.

Having an understanding of patient motivations to tan can help in getting patients to take steps toward change, said Dr. Smith. “What can we do? We can actually do a lot. We have a lot more influence than we think we do.”

At the level of the individual patient, just opening up a conversation can make a big difference. “We assume we know why teenagers go to a tanning booth. But do we? When you notice a young woman who’s been to a tanning booth, ask why,” using a nonjudgmental approach to begin a dialogue about the near-term and long-term dangers of tanning. A positive approach is key, noted Dr. Smith. “Focusing on the benefits of avoiding UV tanning is more effective than a heavy reliance on scare tactics,” she said. Also, “multiple interventions work better.”

Before-and-after photos of celebrities whose appearance has been affected by photoaging can be effective. Another tactic with a more positive spin is to share images of celebrities who have chosen not to tan and who celebrate their fair skin. These conversations are particularly important at prom time, peak tanning season for many young women, said Dr. Smith. She has a portfolio of photos showing fair-skinned women wearing high-contrast gowns, which she says are more flattering for pale skin than white or nude colors.

For patients who still want that tan look, “Tanning for reasons of appearance can be satisfied with sunless tanners,” said Dr. Smith. The most common ingredient in sunless tanners is dihydroxyacetone (DHA), which was approved in the 1970s for topical use. However, the Food and Drug Administration issued a warning in 2011 about spray tanning, noting that the “industry has not provided safety data to FDA in order for the agency to consider approving it for … ‘misting’ from tanning booths.” The FDA’s specific concern had to do with the unknown safety of ingestion, inhalation, and mucous membrane exposure that can result from spray tanning.

Moving to the legislative and policy level, change can be achieved when stakeholders band together to “ban the tan,” said Dr. Smith. “The best way to do it is with a village. It really takes a lot of people to do this.”

There are solid epidemiologic and economic reasons to focus on the skin cancer epidemic, said Dr. Smith. Skin cancer is now the most common cancer in the United States, and more new cases “are diagnosed each year than breast, prostate, lung, and colon cancers combined,” she said. Of nonmelanoma skin cancers, 90% are thought to be UV-related, and “the vast majority of mutations found in melanoma are caused by UV radiation.”

Skin cancers cost the United States over $8 billion annually, and although promising new immunotherapies are extending the lives of those with melanoma, these treatments cost hundreds of thousands of dollars a year. “This type of treatment is unaffordable for our system,” said Dr. Smith.

Progress is being made, she said, despite industry opposition. Individual states have regulated or banned tanning for minors, and at the federal level, tanning beds are now considered by the FDA to be Class II (moderate-risk) medical devices, a step up from their previous classification as the lowest-risk Class I devices, “The same as a tongue blade,” she said.

Dr. Smith had no relevant financial disclosures.

[email protected]

On Twitter @karioakes

CHICAGO – The combination of pembrolizumab, an antibody to the human cell surface receptor programmed death-1 (PD-1), and ipilimumab, an antibody to the human T-cell receptor cytotoxic T-lymphocyte-associated antigen 4 (CTLA4), is highly active against advanced melanoma and has acceptable safety, finds the KEYNOTE 029 trial’s expansion cohort.

The 153 patients in the cohort received a standard dose of pembrolizumab (2 mg/kg every 3 weeks) with a reduced dose of ipilimumab (1 mg/kg every 3 weeks for four doses) on the basis of earlier data showing substantial toxicity when a standard dose of ipilimumab was combined with other immune checkpoint inhibitors.

Results reported at the annual meeting of the American Society of Clinical Oncology showed that the overall response rate was 57%, and the disease control rate was 78%. Although 42% of patients experienced grade 3 or 4 treatment-related adverse events, most of these events resolved, and there were no treatment-related deaths.

“Pembrolizumab 2 mg/kg in combination with four doses of ipilimumab 1 mg/kg has a manageable toxicity profile and provides robust antitumor activity in patients with advanced melanoma,” concluded the investigators, who were led by Georgina Long, PhD, MBBS, chair of Melanoma Medical Oncology and Translational Research at the Melanoma Institute Australia and Royal North Shore Hospital, University of Sydney.

The response rate seen in KEYNOTE 029 was almost identical to that seen in the CheckMate 067 trial with the combination of nivolumab and standard-dose ipilimumab (3 mg/kg every 3 weeks for four doses), noted invited discussant Marc S. Ernstoff, MD, professor and chair of the department of medicine at the Roswell Park Cancer Institute in Buffalo, N.Y. It was also “remarkably comparable” to the 69% seen in the COMBI-d melanoma trial with the combination of dabrafenib (a BRAF inhibitor) and trametinib (an inhibitor of MEK MAPK/ERK kinase).

“There is a significant amount of grade 3 and 4 toxicity, but the dose of ipilimumab appeared to decrease this in the pembrolizumab-ipilimumab study compared to the nivolumab-ipilimumab study,” he noted. “There was a high percent of low-grade toxicities reported in all of these studies, and I would argue that as we are seeing patients survive longer, these low-grade toxicities are going to become more of an issue for us as oncologists to be able to deal with in terms of quality of life for patients surviving.”

There is good rationale for combining CTLA4 blockade and PD1 (or PD-L1) blockade in melanoma, Dr. Long maintained when introducing the research. “We know that CTLA inhibition at the priming phase in the periphery, at antigen presentation, is effective, as is PD-1 or PD-L1 [inhibition] at the effector phase down in the tumor bed,” she elaborated.

The patients with advanced melanoma enrolled in the expansion cohort could have received any number of prior therapies other than immune checkpoint inhibitors. However, in 87%, the study regimen was their first therapy.

At the time of data cutoff, 72% of patients had received all four planned doses of ipilimumab (Yervoy), and 56% were continuing on pembrolizumab (Keytruda).

The rates of any-grade and grade 3 or 4 treatment-related adverse events were 95% and 42%, respectively. The corresponding rates of immune-mediated adverse events were 58% and 25%.

The most common grade 3 or 4 treatment-related adverse events were lipase elevation (14%) and rash (3%). The former was asymptomatic and had no sequelae in the majority of cases, Dr. Long reported.

Hepatitis, colitis, and skin reactions were the most common grade 3 or 4 immune-mediated adverse events. The majority of immune-mediated adverse events were managed with systemic treatment, usually corticosteroids, and resolved.

When it came to efficacy, the overall response rate with the combination was similar across subgroups of patients stratified by PD-L1 status in the tumor and adjacent immune tissue, treatment history, baseline lactate dehydrogenase level, and BRAF mutational status.

Responses were ongoing in 98% of patients at data cutoff, with the duration of response ranging from about 6 weeks to 43 weeks, Dr. Long said. The disease control rate was 78%.

With a median follow-up of 10.0 months, median progression-free survival and overall survival were not yet reached. However, the 6-month rates of these outcomes were 70% and 93%, respectively.

Dr. Long disclosed that she is a consultant/adviser to Amgen, Bristol-Myers Squibb, Merck, Novartis, Provectus, and Roche, and that she has received honoraria from Bristol-Myers Squibb, Merck, and Novartis. The trial was supported by Merck.

CHICAGO – The combination of pembrolizumab, an antibody to the human cell surface receptor programmed death-1 (PD-1), and ipilimumab, an antibody to the human T-cell receptor cytotoxic T-lymphocyte-associated antigen 4 (CTLA4), is highly active against advanced melanoma and has acceptable safety, finds the KEYNOTE 029 trial’s expansion cohort.

The 153 patients in the cohort received a standard dose of pembrolizumab (2 mg/kg every 3 weeks) with a reduced dose of ipilimumab (1 mg/kg every 3 weeks for four doses) on the basis of earlier data showing substantial toxicity when a standard dose of ipilimumab was combined with other immune checkpoint inhibitors.

Results reported at the annual meeting of the American Society of Clinical Oncology showed that the overall response rate was 57%, and the disease control rate was 78%. Although 42% of patients experienced grade 3 or 4 treatment-related adverse events, most of these events resolved, and there were no treatment-related deaths.

“Pembrolizumab 2 mg/kg in combination with four doses of ipilimumab 1 mg/kg has a manageable toxicity profile and provides robust antitumor activity in patients with advanced melanoma,” concluded the investigators, who were led by Georgina Long, PhD, MBBS, chair of Melanoma Medical Oncology and Translational Research at the Melanoma Institute Australia and Royal North Shore Hospital, University of Sydney.

The response rate seen in KEYNOTE 029 was almost identical to that seen in the CheckMate 067 trial with the combination of nivolumab and standard-dose ipilimumab (3 mg/kg every 3 weeks for four doses), noted invited discussant Marc S. Ernstoff, MD, professor and chair of the department of medicine at the Roswell Park Cancer Institute in Buffalo, N.Y. It was also “remarkably comparable” to the 69% seen in the COMBI-d melanoma trial with the combination of dabrafenib (a BRAF inhibitor) and trametinib (an inhibitor of MEK MAPK/ERK kinase).

“There is a significant amount of grade 3 and 4 toxicity, but the dose of ipilimumab appeared to decrease this in the pembrolizumab-ipilimumab study compared to the nivolumab-ipilimumab study,” he noted. “There was a high percent of low-grade toxicities reported in all of these studies, and I would argue that as we are seeing patients survive longer, these low-grade toxicities are going to become more of an issue for us as oncologists to be able to deal with in terms of quality of life for patients surviving.”

There is good rationale for combining CTLA4 blockade and PD1 (or PD-L1) blockade in melanoma, Dr. Long maintained when introducing the research. “We know that CTLA inhibition at the priming phase in the periphery, at antigen presentation, is effective, as is PD-1 or PD-L1 [inhibition] at the effector phase down in the tumor bed,” she elaborated.

The patients with advanced melanoma enrolled in the expansion cohort could have received any number of prior therapies other than immune checkpoint inhibitors. However, in 87%, the study regimen was their first therapy.

At the time of data cutoff, 72% of patients had received all four planned doses of ipilimumab (Yervoy), and 56% were continuing on pembrolizumab (Keytruda).

The rates of any-grade and grade 3 or 4 treatment-related adverse events were 95% and 42%, respectively. The corresponding rates of immune-mediated adverse events were 58% and 25%.

The most common grade 3 or 4 treatment-related adverse events were lipase elevation (14%) and rash (3%). The former was asymptomatic and had no sequelae in the majority of cases, Dr. Long reported.

Hepatitis, colitis, and skin reactions were the most common grade 3 or 4 immune-mediated adverse events. The majority of immune-mediated adverse events were managed with systemic treatment, usually corticosteroids, and resolved.

When it came to efficacy, the overall response rate with the combination was similar across subgroups of patients stratified by PD-L1 status in the tumor and adjacent immune tissue, treatment history, baseline lactate dehydrogenase level, and BRAF mutational status.

Responses were ongoing in 98% of patients at data cutoff, with the duration of response ranging from about 6 weeks to 43 weeks, Dr. Long said. The disease control rate was 78%.

With a median follow-up of 10.0 months, median progression-free survival and overall survival were not yet reached. However, the 6-month rates of these outcomes were 70% and 93%, respectively.

Dr. Long disclosed that she is a consultant/adviser to Amgen, Bristol-Myers Squibb, Merck, Novartis, Provectus, and Roche, and that she has received honoraria from Bristol-Myers Squibb, Merck, and Novartis. The trial was supported by Merck.

CHICAGO – The combination of pembrolizumab, an antibody to the human cell surface receptor programmed death-1 (PD-1), and ipilimumab, an antibody to the human T-cell receptor cytotoxic T-lymphocyte-associated antigen 4 (CTLA4), is highly active against advanced melanoma and has acceptable safety, finds the KEYNOTE 029 trial’s expansion cohort.

The 153 patients in the cohort received a standard dose of pembrolizumab (2 mg/kg every 3 weeks) with a reduced dose of ipilimumab (1 mg/kg every 3 weeks for four doses) on the basis of earlier data showing substantial toxicity when a standard dose of ipilimumab was combined with other immune checkpoint inhibitors.

Results reported at the annual meeting of the American Society of Clinical Oncology showed that the overall response rate was 57%, and the disease control rate was 78%. Although 42% of patients experienced grade 3 or 4 treatment-related adverse events, most of these events resolved, and there were no treatment-related deaths.

“Pembrolizumab 2 mg/kg in combination with four doses of ipilimumab 1 mg/kg has a manageable toxicity profile and provides robust antitumor activity in patients with advanced melanoma,” concluded the investigators, who were led by Georgina Long, PhD, MBBS, chair of Melanoma Medical Oncology and Translational Research at the Melanoma Institute Australia and Royal North Shore Hospital, University of Sydney.

The response rate seen in KEYNOTE 029 was almost identical to that seen in the CheckMate 067 trial with the combination of nivolumab and standard-dose ipilimumab (3 mg/kg every 3 weeks for four doses), noted invited discussant Marc S. Ernstoff, MD, professor and chair of the department of medicine at the Roswell Park Cancer Institute in Buffalo, N.Y. It was also “remarkably comparable” to the 69% seen in the COMBI-d melanoma trial with the combination of dabrafenib (a BRAF inhibitor) and trametinib (an inhibitor of MEK MAPK/ERK kinase).

“There is a significant amount of grade 3 and 4 toxicity, but the dose of ipilimumab appeared to decrease this in the pembrolizumab-ipilimumab study compared to the nivolumab-ipilimumab study,” he noted. “There was a high percent of low-grade toxicities reported in all of these studies, and I would argue that as we are seeing patients survive longer, these low-grade toxicities are going to become more of an issue for us as oncologists to be able to deal with in terms of quality of life for patients surviving.”

There is good rationale for combining CTLA4 blockade and PD1 (or PD-L1) blockade in melanoma, Dr. Long maintained when introducing the research. “We know that CTLA inhibition at the priming phase in the periphery, at antigen presentation, is effective, as is PD-1 or PD-L1 [inhibition] at the effector phase down in the tumor bed,” she elaborated.

The patients with advanced melanoma enrolled in the expansion cohort could have received any number of prior therapies other than immune checkpoint inhibitors. However, in 87%, the study regimen was their first therapy.

At the time of data cutoff, 72% of patients had received all four planned doses of ipilimumab (Yervoy), and 56% were continuing on pembrolizumab (Keytruda).

The rates of any-grade and grade 3 or 4 treatment-related adverse events were 95% and 42%, respectively. The corresponding rates of immune-mediated adverse events were 58% and 25%.

The most common grade 3 or 4 treatment-related adverse events were lipase elevation (14%) and rash (3%). The former was asymptomatic and had no sequelae in the majority of cases, Dr. Long reported.

Hepatitis, colitis, and skin reactions were the most common grade 3 or 4 immune-mediated adverse events. The majority of immune-mediated adverse events were managed with systemic treatment, usually corticosteroids, and resolved.

When it came to efficacy, the overall response rate with the combination was similar across subgroups of patients stratified by PD-L1 status in the tumor and adjacent immune tissue, treatment history, baseline lactate dehydrogenase level, and BRAF mutational status.

Responses were ongoing in 98% of patients at data cutoff, with the duration of response ranging from about 6 weeks to 43 weeks, Dr. Long said. The disease control rate was 78%.

With a median follow-up of 10.0 months, median progression-free survival and overall survival were not yet reached. However, the 6-month rates of these outcomes were 70% and 93%, respectively.

Dr. Long disclosed that she is a consultant/adviser to Amgen, Bristol-Myers Squibb, Merck, Novartis, Provectus, and Roche, and that she has received honoraria from Bristol-Myers Squibb, Merck, and Novartis. The trial was supported by Merck.

Stand Up To Cancer is calling for proposals to investigate additional uses for nivolumab, ipilimumab, elotuzumab, and urelumab, as part of a new researcher-industry collaborative program.

As many as four projects will be funded by Bristol-Myers Squibb, maker of the four agents, in the range of $1 million to $3 million each, according to a written statement from the American Association for Cancer Research (AACR).

The company will provide access to the three drugs already approved for the treatement of various cancers –nivolumab, ipilimumab, and elotuzumab– and to urelumab, an investigational agent that is currently in early clinical trials.

Proposals can include the study of one or more of the products, alone or in combination with other treatments, and may include products from other companies, as well as explore potential new uses for the drug(s), AACR said in the statement.

Nivolumab (Opdivo) is currently approved to treat advanced melanoma, non-small cell lung cancer, renal cell carcinoma, and classical Hodgkin lymphoma; Ipilimumab (Yervoy) is approved to treat melanoma; and elotuzumab (Empliciti) is approved to treat multiple myeloma, in conjunction with other drugs. Urelumab is being evaluated as a treatment for a range of cancers, including some hematological cancers, advanced colorectal cancer, and head and neck cancers.

The Stand Up To Cancer (SU2C) Catalyst program was launched in April to “use funding and materials from the pharmaceutical, biotechnology, diagnostic, and medical devices industries to accelerate research on cancer prevention, detection, and treatment,” according to a written statement from SU2C. Founding collaborators in addition to Bristol-Myers Squibb include Merck and Genentech.

The Catalyst projects must follow the SU2C model be carried out by a collaborative team, and be designed to accelerate the clinical use of therapeutic agents within the 3-year term of the grant, and to deliver near-term patient benefit.

The Request for Proposal for the Bristol-Myers Squibb agents is available at proposalCENTRAL, with proposals due by noon ET Monday, Aug. 15.

[email protected]

On Twitter @NikolaidesLaura

Stand Up To Cancer is calling for proposals to investigate additional uses for nivolumab, ipilimumab, elotuzumab, and urelumab, as part of a new researcher-industry collaborative program.

As many as four projects will be funded by Bristol-Myers Squibb, maker of the four agents, in the range of $1 million to $3 million each, according to a written statement from the American Association for Cancer Research (AACR).

The company will provide access to the three drugs already approved for the treatement of various cancers –nivolumab, ipilimumab, and elotuzumab– and to urelumab, an investigational agent that is currently in early clinical trials.

Proposals can include the study of one or more of the products, alone or in combination with other treatments, and may include products from other companies, as well as explore potential new uses for the drug(s), AACR said in the statement.

Nivolumab (Opdivo) is currently approved to treat advanced melanoma, non-small cell lung cancer, renal cell carcinoma, and classical Hodgkin lymphoma; Ipilimumab (Yervoy) is approved to treat melanoma; and elotuzumab (Empliciti) is approved to treat multiple myeloma, in conjunction with other drugs. Urelumab is being evaluated as a treatment for a range of cancers, including some hematological cancers, advanced colorectal cancer, and head and neck cancers.

The Stand Up To Cancer (SU2C) Catalyst program was launched in April to “use funding and materials from the pharmaceutical, biotechnology, diagnostic, and medical devices industries to accelerate research on cancer prevention, detection, and treatment,” according to a written statement from SU2C. Founding collaborators in addition to Bristol-Myers Squibb include Merck and Genentech.

The Catalyst projects must follow the SU2C model be carried out by a collaborative team, and be designed to accelerate the clinical use of therapeutic agents within the 3-year term of the grant, and to deliver near-term patient benefit.

The Request for Proposal for the Bristol-Myers Squibb agents is available at proposalCENTRAL, with proposals due by noon ET Monday, Aug. 15.

[email protected]

On Twitter @NikolaidesLaura

Stand Up To Cancer is calling for proposals to investigate additional uses for nivolumab, ipilimumab, elotuzumab, and urelumab, as part of a new researcher-industry collaborative program.

As many as four projects will be funded by Bristol-Myers Squibb, maker of the four agents, in the range of $1 million to $3 million each, according to a written statement from the American Association for Cancer Research (AACR).

The company will provide access to the three drugs already approved for the treatement of various cancers –nivolumab, ipilimumab, and elotuzumab– and to urelumab, an investigational agent that is currently in early clinical trials.

Proposals can include the study of one or more of the products, alone or in combination with other treatments, and may include products from other companies, as well as explore potential new uses for the drug(s), AACR said in the statement.

Nivolumab (Opdivo) is currently approved to treat advanced melanoma, non-small cell lung cancer, renal cell carcinoma, and classical Hodgkin lymphoma; Ipilimumab (Yervoy) is approved to treat melanoma; and elotuzumab (Empliciti) is approved to treat multiple myeloma, in conjunction with other drugs. Urelumab is being evaluated as a treatment for a range of cancers, including some hematological cancers, advanced colorectal cancer, and head and neck cancers.

The Stand Up To Cancer (SU2C) Catalyst program was launched in April to “use funding and materials from the pharmaceutical, biotechnology, diagnostic, and medical devices industries to accelerate research on cancer prevention, detection, and treatment,” according to a written statement from SU2C. Founding collaborators in addition to Bristol-Myers Squibb include Merck and Genentech.

The Catalyst projects must follow the SU2C model be carried out by a collaborative team, and be designed to accelerate the clinical use of therapeutic agents within the 3-year term of the grant, and to deliver near-term patient benefit.

The Request for Proposal for the Bristol-Myers Squibb agents is available at proposalCENTRAL, with proposals due by noon ET Monday, Aug. 15.

[email protected]

On Twitter @NikolaidesLaura

New data from Consumer Reports indicate that 48% of all sunscreens tested (N=104) over 4 years did not provide the sun protection factor (SPF) promised on product labels, leaving consumers with insufficient sun protection, which could lead to long-term sun damage including wrinkles or skin cancer. Furthermore, 42% of chemical sunscreens (n=85) and 74% of mineral sunscreens (n=19) did not meet their SPF claims.

The study also reveals that more than one-third (35%) of sunscreens registered below SPF 30, which is the minimum recommended by the American Academy of Dermatology (AAD). Although product labels featured claims of water resistance, nearly half of the sunscreens tested failed to meet their SPF claim following water immersion.

Dermatologists can educate patients about correct sunscreen use and product labels to ensure the highest level of protection against melanoma and other skin cancers. According to a 2016 AAD survey, only 32% of respondents knew that an SPF 30 sunscreen does not provide twice as much protection as an SPF 15 sunscreen. Furthermore, only 45% of respondents knew that a higher-SPF sunscreen does not protect skin from sun exposure longer than a lower-SPF sunscreen.

The AAD has issued a list of talking points highlighting key messages that dermatologists can share with patients and/or the media when asked about sun-protection techniques and the recent sunscreen data released by Consumer Reports.

New data from Consumer Reports indicate that 48% of all sunscreens tested (N=104) over 4 years did not provide the sun protection factor (SPF) promised on product labels, leaving consumers with insufficient sun protection, which could lead to long-term sun damage including wrinkles or skin cancer. Furthermore, 42% of chemical sunscreens (n=85) and 74% of mineral sunscreens (n=19) did not meet their SPF claims.

The study also reveals that more than one-third (35%) of sunscreens registered below SPF 30, which is the minimum recommended by the American Academy of Dermatology (AAD). Although product labels featured claims of water resistance, nearly half of the sunscreens tested failed to meet their SPF claim following water immersion.

Dermatologists can educate patients about correct sunscreen use and product labels to ensure the highest level of protection against melanoma and other skin cancers. According to a 2016 AAD survey, only 32% of respondents knew that an SPF 30 sunscreen does not provide twice as much protection as an SPF 15 sunscreen. Furthermore, only 45% of respondents knew that a higher-SPF sunscreen does not protect skin from sun exposure longer than a lower-SPF sunscreen.

The AAD has issued a list of talking points highlighting key messages that dermatologists can share with patients and/or the media when asked about sun-protection techniques and the recent sunscreen data released by Consumer Reports.

New data from Consumer Reports indicate that 48% of all sunscreens tested (N=104) over 4 years did not provide the sun protection factor (SPF) promised on product labels, leaving consumers with insufficient sun protection, which could lead to long-term sun damage including wrinkles or skin cancer. Furthermore, 42% of chemical sunscreens (n=85) and 74% of mineral sunscreens (n=19) did not meet their SPF claims.

The study also reveals that more than one-third (35%) of sunscreens registered below SPF 30, which is the minimum recommended by the American Academy of Dermatology (AAD). Although product labels featured claims of water resistance, nearly half of the sunscreens tested failed to meet their SPF claim following water immersion.

Dermatologists can educate patients about correct sunscreen use and product labels to ensure the highest level of protection against melanoma and other skin cancers. According to a 2016 AAD survey, only 32% of respondents knew that an SPF 30 sunscreen does not provide twice as much protection as an SPF 15 sunscreen. Furthermore, only 45% of respondents knew that a higher-SPF sunscreen does not protect skin from sun exposure longer than a lower-SPF sunscreen.

The AAD has issued a list of talking points highlighting key messages that dermatologists can share with patients and/or the media when asked about sun-protection techniques and the recent sunscreen data released by Consumer Reports.

Customer satisfaction ratings of sunscreens do not always reflect the products’ effectiveness, as 40% of the 65 top-rated sunscreens available on Amazon.com did not adhere to all three of the American Academy of Dermatology’s recommended criteria.

The AAD recommends the following for all sunscreens: sun protection factor (SPF) of 30 more, broad-spectrum protection, and water and/or sweat resistance. Of those criteria, water/sweat resistance was missing in 19 (29%), compared with SPF less than 30 in 7 (11%) products and lack of broad-spectrum protection in 4 (6%). Some products missed more than one criterion, said Shuai Xu, MD, of Northwestern University, Chicago, and his associates (JAMA Dermatolol. 2016 Jul 6. doi: 10.1001/jamadermatol.2016.2344).

Of the qualities besides performance that were analyzed, “cosmetic elegance,” which the investigators “defined as any feature associated with skin sensation on application, color, or scent,” was the positive feature most often mentioned in the customer reviews. On the other hand, they noted, “dermatologist recommendations were not a significantly cited positive feature.”

The sunscreens in the analysis represented the top 1 percentile by customer rating of the 6,500 products categorized as sunscreens on Amazon as of December 2015. The 65 products included in the study had more than 24,400 customer reviews and a median rating of 4.5 out of 5 stars, Dr. Xu and his associates said.

The investigators did not report any conflicts of interest.

[email protected]

Customer satisfaction ratings of sunscreens do not always reflect the products’ effectiveness, as 40% of the 65 top-rated sunscreens available on Amazon.com did not adhere to all three of the American Academy of Dermatology’s recommended criteria.

The AAD recommends the following for all sunscreens: sun protection factor (SPF) of 30 more, broad-spectrum protection, and water and/or sweat resistance. Of those criteria, water/sweat resistance was missing in 19 (29%), compared with SPF less than 30 in 7 (11%) products and lack of broad-spectrum protection in 4 (6%). Some products missed more than one criterion, said Shuai Xu, MD, of Northwestern University, Chicago, and his associates (JAMA Dermatolol. 2016 Jul 6. doi: 10.1001/jamadermatol.2016.2344).

Of the qualities besides performance that were analyzed, “cosmetic elegance,” which the investigators “defined as any feature associated with skin sensation on application, color, or scent,” was the positive feature most often mentioned in the customer reviews. On the other hand, they noted, “dermatologist recommendations were not a significantly cited positive feature.”

The sunscreens in the analysis represented the top 1 percentile by customer rating of the 6,500 products categorized as sunscreens on Amazon as of December 2015. The 65 products included in the study had more than 24,400 customer reviews and a median rating of 4.5 out of 5 stars, Dr. Xu and his associates said.

The investigators did not report any conflicts of interest.

[email protected]

Customer satisfaction ratings of sunscreens do not always reflect the products’ effectiveness, as 40% of the 65 top-rated sunscreens available on Amazon.com did not adhere to all three of the American Academy of Dermatology’s recommended criteria.

The AAD recommends the following for all sunscreens: sun protection factor (SPF) of 30 more, broad-spectrum protection, and water and/or sweat resistance. Of those criteria, water/sweat resistance was missing in 19 (29%), compared with SPF less than 30 in 7 (11%) products and lack of broad-spectrum protection in 4 (6%). Some products missed more than one criterion, said Shuai Xu, MD, of Northwestern University, Chicago, and his associates (JAMA Dermatolol. 2016 Jul 6. doi: 10.1001/jamadermatol.2016.2344).

Of the qualities besides performance that were analyzed, “cosmetic elegance,” which the investigators “defined as any feature associated with skin sensation on application, color, or scent,” was the positive feature most often mentioned in the customer reviews. On the other hand, they noted, “dermatologist recommendations were not a significantly cited positive feature.”

The sunscreens in the analysis represented the top 1 percentile by customer rating of the 6,500 products categorized as sunscreens on Amazon as of December 2015. The 65 products included in the study had more than 24,400 customer reviews and a median rating of 4.5 out of 5 stars, Dr. Xu and his associates said.

The investigators did not report any conflicts of interest.

[email protected]

SCOTTSDALE, ARIZ. – Distant metastatic sites of Merkel cell carcinoma most often involved the supraclavicular, retroperitoneal, and iliac lymph nodes, in a single center retrospective study of 305 patients.

Merkel cell carcinoma metastases “clearly favored distant nodes, but the distribution of other metastatic sites was distinct from other cancers, such as melanoma,” Jamiluddin Qazi, an undergraduate student at the University of Washington, Seattle, said at the annual meeting of the Society for Investigative Dermatology. The findings could help guide imaging and other surveillance of patients after they develop a primary Merkel cell tumor, he added.

Wikimedia Commons/Ed Uthman/CC BY-SA 2.0

About 2,000 individuals in the United States are diagnosed with Merkel cell carcinoma every year. About 40% of these patients develop metastatic disease, which has a 5-year survival rate of less than 25%, Mr. Qazi noted. Indeed, median survival after diagnosis of metastatic Merkel cell carcinoma was only 9.5 months in one recent study (J Cutan Pathol. 2010;37:20-7). Programmed death 1 (PD-1) blockade with pembrolizumab (Keytruda) can potentially improve survival (N Engl J Med. 2016; 374:2542-52), “but there is no consensus regarding follow-up for Merkel cell carcinoma. The 2016 National Comprehensive Cancer Network (NCCN) guidelines recommend ‘follow up as clinically indicated,’ and a lack of data has led to ambiguity,” Mr. Qazi said.

Working with oncologists and radiologists at the Seattle Cancer Care Alliance, he analyzed a tissue and clinical database of 442 initial distant Merkel cell carcinoma metastases among 305 patients. Initial distant metastases were defined as the first lesions detected beyond the regional lymph nodes of the primary tumor. A total of 69% of patients had one initial distant metastasis, 19% had two concurrently identified lesions, 9% had three lesions, and 4% had at least four lesions, Mr. Qazi reported.

“Merkel cell carcinoma seemed to metastasize to unusual places, but clearly preferred the distant lymph nodes. In all, 26% of metastases localized there, most commonly to the supraclavicular, retroperitoneal, and iliac nodes,” he said. The next most common site of distant metastasis was the liver (15% of lesions), followed by the skin and bone (13% of lesions each), lung (6%), and pancreas (5%). Less common sites included the heart, spleen, abdominal muscle, brain, kidneys, adrenal glands, gonad, chest wall, and stomach.

Comparing these findings with a similar study in melanoma (J Oncol 2012. doi: 10.1155/2012/647684) showed that both cancers have about the same chances of metastasizing to the liver, bone, kidneys, adrenal glands, and stomach, Mr. Qazi said. However, Merkel cell carcinoma was less likely to metastasize to the brain (3% of lesions, vs. 12% for melanoma) and lung (6% vs. 14%), and was more likely to metastasize to the pancreas (5% vs. 1%).

Now the investigators are working to link metastatic sites with factors such as the location of the primary tumor, the presence or absence of lymphovascular invasion, and the status of the immune system and Merkel polyomavirus infection, said Mr. Qazi. They also are analyzing time from diagnosis or treatment to metastasis to help guide decisions about when to order follow-up imaging. Ultimately, they hope to create an online tool that enables clinicians to describe a primary Merkel cell carcinoma and rapidly receive automated information about the most likely timing and location of metastasis.

The National Institutes of Health supported the study. Mr. Qazi had no conflicts of interest.

SCOTTSDALE, ARIZ. – Distant metastatic sites of Merkel cell carcinoma most often involved the supraclavicular, retroperitoneal, and iliac lymph nodes, in a single center retrospective study of 305 patients.

Merkel cell carcinoma metastases “clearly favored distant nodes, but the distribution of other metastatic sites was distinct from other cancers, such as melanoma,” Jamiluddin Qazi, an undergraduate student at the University of Washington, Seattle, said at the annual meeting of the Society for Investigative Dermatology. The findings could help guide imaging and other surveillance of patients after they develop a primary Merkel cell tumor, he added.

Wikimedia Commons/Ed Uthman/CC BY-SA 2.0

About 2,000 individuals in the United States are diagnosed with Merkel cell carcinoma every year. About 40% of these patients develop metastatic disease, which has a 5-year survival rate of less than 25%, Mr. Qazi noted. Indeed, median survival after diagnosis of metastatic Merkel cell carcinoma was only 9.5 months in one recent study (J Cutan Pathol. 2010;37:20-7). Programmed death 1 (PD-1) blockade with pembrolizumab (Keytruda) can potentially improve survival (N Engl J Med. 2016; 374:2542-52), “but there is no consensus regarding follow-up for Merkel cell carcinoma. The 2016 National Comprehensive Cancer Network (NCCN) guidelines recommend ‘follow up as clinically indicated,’ and a lack of data has led to ambiguity,” Mr. Qazi said.

Working with oncologists and radiologists at the Seattle Cancer Care Alliance, he analyzed a tissue and clinical database of 442 initial distant Merkel cell carcinoma metastases among 305 patients. Initial distant metastases were defined as the first lesions detected beyond the regional lymph nodes of the primary tumor. A total of 69% of patients had one initial distant metastasis, 19% had two concurrently identified lesions, 9% had three lesions, and 4% had at least four lesions, Mr. Qazi reported.

“Merkel cell carcinoma seemed to metastasize to unusual places, but clearly preferred the distant lymph nodes. In all, 26% of metastases localized there, most commonly to the supraclavicular, retroperitoneal, and iliac nodes,” he said. The next most common site of distant metastasis was the liver (15% of lesions), followed by the skin and bone (13% of lesions each), lung (6%), and pancreas (5%). Less common sites included the heart, spleen, abdominal muscle, brain, kidneys, adrenal glands, gonad, chest wall, and stomach.

Comparing these findings with a similar study in melanoma (J Oncol 2012. doi: 10.1155/2012/647684) showed that both cancers have about the same chances of metastasizing to the liver, bone, kidneys, adrenal glands, and stomach, Mr. Qazi said. However, Merkel cell carcinoma was less likely to metastasize to the brain (3% of lesions, vs. 12% for melanoma) and lung (6% vs. 14%), and was more likely to metastasize to the pancreas (5% vs. 1%).

Now the investigators are working to link metastatic sites with factors such as the location of the primary tumor, the presence or absence of lymphovascular invasion, and the status of the immune system and Merkel polyomavirus infection, said Mr. Qazi. They also are analyzing time from diagnosis or treatment to metastasis to help guide decisions about when to order follow-up imaging. Ultimately, they hope to create an online tool that enables clinicians to describe a primary Merkel cell carcinoma and rapidly receive automated information about the most likely timing and location of metastasis.

The National Institutes of Health supported the study. Mr. Qazi had no conflicts of interest.

SCOTTSDALE, ARIZ. – Distant metastatic sites of Merkel cell carcinoma most often involved the supraclavicular, retroperitoneal, and iliac lymph nodes, in a single center retrospective study of 305 patients.

Merkel cell carcinoma metastases “clearly favored distant nodes, but the distribution of other metastatic sites was distinct from other cancers, such as melanoma,” Jamiluddin Qazi, an undergraduate student at the University of Washington, Seattle, said at the annual meeting of the Society for Investigative Dermatology. The findings could help guide imaging and other surveillance of patients after they develop a primary Merkel cell tumor, he added.

Wikimedia Commons/Ed Uthman/CC BY-SA 2.0

About 2,000 individuals in the United States are diagnosed with Merkel cell carcinoma every year. About 40% of these patients develop metastatic disease, which has a 5-year survival rate of less than 25%, Mr. Qazi noted. Indeed, median survival after diagnosis of metastatic Merkel cell carcinoma was only 9.5 months in one recent study (J Cutan Pathol. 2010;37:20-7). Programmed death 1 (PD-1) blockade with pembrolizumab (Keytruda) can potentially improve survival (N Engl J Med. 2016; 374:2542-52), “but there is no consensus regarding follow-up for Merkel cell carcinoma. The 2016 National Comprehensive Cancer Network (NCCN) guidelines recommend ‘follow up as clinically indicated,’ and a lack of data has led to ambiguity,” Mr. Qazi said.

Working with oncologists and radiologists at the Seattle Cancer Care Alliance, he analyzed a tissue and clinical database of 442 initial distant Merkel cell carcinoma metastases among 305 patients. Initial distant metastases were defined as the first lesions detected beyond the regional lymph nodes of the primary tumor. A total of 69% of patients had one initial distant metastasis, 19% had two concurrently identified lesions, 9% had three lesions, and 4% had at least four lesions, Mr. Qazi reported.

“Merkel cell carcinoma seemed to metastasize to unusual places, but clearly preferred the distant lymph nodes. In all, 26% of metastases localized there, most commonly to the supraclavicular, retroperitoneal, and iliac nodes,” he said. The next most common site of distant metastasis was the liver (15% of lesions), followed by the skin and bone (13% of lesions each), lung (6%), and pancreas (5%). Less common sites included the heart, spleen, abdominal muscle, brain, kidneys, adrenal glands, gonad, chest wall, and stomach.

Comparing these findings with a similar study in melanoma (J Oncol 2012. doi: 10.1155/2012/647684) showed that both cancers have about the same chances of metastasizing to the liver, bone, kidneys, adrenal glands, and stomach, Mr. Qazi said. However, Merkel cell carcinoma was less likely to metastasize to the brain (3% of lesions, vs. 12% for melanoma) and lung (6% vs. 14%), and was more likely to metastasize to the pancreas (5% vs. 1%).

Now the investigators are working to link metastatic sites with factors such as the location of the primary tumor, the presence or absence of lymphovascular invasion, and the status of the immune system and Merkel polyomavirus infection, said Mr. Qazi. They also are analyzing time from diagnosis or treatment to metastasis to help guide decisions about when to order follow-up imaging. Ultimately, they hope to create an online tool that enables clinicians to describe a primary Merkel cell carcinoma and rapidly receive automated information about the most likely timing and location of metastasis.

The National Institutes of Health supported the study. Mr. Qazi had no conflicts of interest.

SCOTTSDALE, ARIZ. – Distant metastatic sites of Merkel cell carcinoma most often involved the supraclavicular, retroperitoneal, and iliac lymph nodes, in a single center retrospective study of 305 patients.

Merkel cell carcinoma metastases “clearly favored distant nodes, but the distribution of other metastatic sites was distinct from other cancers, such as melanoma,” Jamiluddin Qazi, an undergraduate student at the University of Washington, Seattle, said at the annual meeting of the Society for Investigative Dermatology. The findings could help guide imaging and other surveillance of patients after they develop a primary Merkel cell tumor, he added.

Wikimedia Commons/Ed Uthman/CC BY-SA 2.0

About 2,000 individuals in the United States are diagnosed with Merkel cell carcinoma every year. About 40% of these patients develop metastatic disease, which has a 5-year survival rate of less than 25%, Mr. Qazi noted. Indeed, median survival after diagnosis of metastatic Merkel cell carcinoma was only 9.5 months in one recent study (J Cutan Pathol. 2010;37:20-7). Programmed death 1 (PD-1) blockade with pembrolizumab (Keytruda) can potentially improve survival (N Engl J Med. 2016; 374:2542-52), “but there is no consensus regarding follow-up for Merkel cell carcinoma. The 2016 National Comprehensive Cancer Network (NCCN) guidelines recommend ‘follow up as clinically indicated,’ and a lack of data has led to ambiguity,” Mr. Qazi said.

Working with oncologists and radiologists at the Seattle Cancer Care Alliance, he analyzed a tissue and clinical database of 442 initial distant Merkel cell carcinoma metastases among 305 patients. Initial distant metastases were defined as the first lesions detected beyond the regional lymph nodes of the primary tumor. A total of 69% of patients had one initial distant metastasis, 19% had two concurrently identified lesions, 9% had three lesions, and 4% had at least four lesions, Mr. Qazi reported.

“Merkel cell carcinoma seemed to metastasize to unusual places, but clearly preferred the distant lymph nodes. In all, 26% of metastases localized there, most commonly to the supraclavicular, retroperitoneal, and iliac nodes,” he said. The next most common site of distant metastasis was the liver (15% of lesions), followed by the skin and bone (13% of lesions each), lung (6%), and pancreas (5%). Less common sites included the heart, spleen, abdominal muscle, brain, kidneys, adrenal glands, gonad, chest wall, and stomach.

Comparing these findings with a similar study in melanoma (J Oncol 2012. doi: 10.1155/2012/647684) showed that both cancers have about the same chances of metastasizing to the liver, bone, kidneys, adrenal glands, and stomach, Mr. Qazi said. However, Merkel cell carcinoma was less likely to metastasize to the brain (3% of lesions, vs. 12% for melanoma) and lung (6% vs. 14%), and was more likely to metastasize to the pancreas (5% vs. 1%).

Now the investigators are working to link metastatic sites with factors such as the location of the primary tumor, the presence or absence of lymphovascular invasion, and the status of the immune system and Merkel polyomavirus infection, said Mr. Qazi. They also are analyzing time from diagnosis or treatment to metastasis to help guide decisions about when to order follow-up imaging. Ultimately, they hope to create an online tool that enables clinicians to describe a primary Merkel cell carcinoma and rapidly receive automated information about the most likely timing and location of metastasis.

The National Institutes of Health supported the study. Mr. Qazi had no conflicts of interest.

SCOTTSDALE, ARIZ. – Distant metastatic sites of Merkel cell carcinoma most often involved the supraclavicular, retroperitoneal, and iliac lymph nodes, in a single center retrospective study of 305 patients.

Merkel cell carcinoma metastases “clearly favored distant nodes, but the distribution of other metastatic sites was distinct from other cancers, such as melanoma,” Jamiluddin Qazi, an undergraduate student at the University of Washington, Seattle, said at the annual meeting of the Society for Investigative Dermatology. The findings could help guide imaging and other surveillance of patients after they develop a primary Merkel cell tumor, he added.

Wikimedia Commons/Ed Uthman/CC BY-SA 2.0

About 2,000 individuals in the United States are diagnosed with Merkel cell carcinoma every year. About 40% of these patients develop metastatic disease, which has a 5-year survival rate of less than 25%, Mr. Qazi noted. Indeed, median survival after diagnosis of metastatic Merkel cell carcinoma was only 9.5 months in one recent study (J Cutan Pathol. 2010;37:20-7). Programmed death 1 (PD-1) blockade with pembrolizumab (Keytruda) can potentially improve survival (N Engl J Med. 2016; 374:2542-52), “but there is no consensus regarding follow-up for Merkel cell carcinoma. The 2016 National Comprehensive Cancer Network (NCCN) guidelines recommend ‘follow up as clinically indicated,’ and a lack of data has led to ambiguity,” Mr. Qazi said.

Working with oncologists and radiologists at the Seattle Cancer Care Alliance, he analyzed a tissue and clinical database of 442 initial distant Merkel cell carcinoma metastases among 305 patients. Initial distant metastases were defined as the first lesions detected beyond the regional lymph nodes of the primary tumor. A total of 69% of patients had one initial distant metastasis, 19% had two concurrently identified lesions, 9% had three lesions, and 4% had at least four lesions, Mr. Qazi reported.

“Merkel cell carcinoma seemed to metastasize to unusual places, but clearly preferred the distant lymph nodes. In all, 26% of metastases localized there, most commonly to the supraclavicular, retroperitoneal, and iliac nodes,” he said. The next most common site of distant metastasis was the liver (15% of lesions), followed by the skin and bone (13% of lesions each), lung (6%), and pancreas (5%). Less common sites included the heart, spleen, abdominal muscle, brain, kidneys, adrenal glands, gonad, chest wall, and stomach.

Comparing these findings with a similar study in melanoma (J Oncol 2012. doi: 10.1155/2012/647684) showed that both cancers have about the same chances of metastasizing to the liver, bone, kidneys, adrenal glands, and stomach, Mr. Qazi said. However, Merkel cell carcinoma was less likely to metastasize to the brain (3% of lesions, vs. 12% for melanoma) and lung (6% vs. 14%), and was more likely to metastasize to the pancreas (5% vs. 1%).

Now the investigators are working to link metastatic sites with factors such as the location of the primary tumor, the presence or absence of lymphovascular invasion, and the status of the immune system and Merkel polyomavirus infection, said Mr. Qazi. They also are analyzing time from diagnosis or treatment to metastasis to help guide decisions about when to order follow-up imaging. Ultimately, they hope to create an online tool that enables clinicians to describe a primary Merkel cell carcinoma and rapidly receive automated information about the most likely timing and location of metastasis.

The National Institutes of Health supported the study. Mr. Qazi had no conflicts of interest.

SCOTTSDALE, ARIZ. – Distant metastatic sites of Merkel cell carcinoma most often involved the supraclavicular, retroperitoneal, and iliac lymph nodes, in a single center retrospective study of 305 patients.

Merkel cell carcinoma metastases “clearly favored distant nodes, but the distribution of other metastatic sites was distinct from other cancers, such as melanoma,” Jamiluddin Qazi, an undergraduate student at the University of Washington, Seattle, said at the annual meeting of the Society for Investigative Dermatology. The findings could help guide imaging and other surveillance of patients after they develop a primary Merkel cell tumor, he added.

Wikimedia Commons/Ed Uthman/CC BY-SA 2.0

About 2,000 individuals in the United States are diagnosed with Merkel cell carcinoma every year. About 40% of these patients develop metastatic disease, which has a 5-year survival rate of less than 25%, Mr. Qazi noted. Indeed, median survival after diagnosis of metastatic Merkel cell carcinoma was only 9.5 months in one recent study (J Cutan Pathol. 2010;37:20-7). Programmed death 1 (PD-1) blockade with pembrolizumab (Keytruda) can potentially improve survival (N Engl J Med. 2016; 374:2542-52), “but there is no consensus regarding follow-up for Merkel cell carcinoma. The 2016 National Comprehensive Cancer Network (NCCN) guidelines recommend ‘follow up as clinically indicated,’ and a lack of data has led to ambiguity,” Mr. Qazi said.

Working with oncologists and radiologists at the Seattle Cancer Care Alliance, he analyzed a tissue and clinical database of 442 initial distant Merkel cell carcinoma metastases among 305 patients. Initial distant metastases were defined as the first lesions detected beyond the regional lymph nodes of the primary tumor. A total of 69% of patients had one initial distant metastasis, 19% had two concurrently identified lesions, 9% had three lesions, and 4% had at least four lesions, Mr. Qazi reported.

“Merkel cell carcinoma seemed to metastasize to unusual places, but clearly preferred the distant lymph nodes. In all, 26% of metastases localized there, most commonly to the supraclavicular, retroperitoneal, and iliac nodes,” he said. The next most common site of distant metastasis was the liver (15% of lesions), followed by the skin and bone (13% of lesions each), lung (6%), and pancreas (5%). Less common sites included the heart, spleen, abdominal muscle, brain, kidneys, adrenal glands, gonad, chest wall, and stomach.

Comparing these findings with a similar study in melanoma (J Oncol 2012. doi: 10.1155/2012/647684) showed that both cancers have about the same chances of metastasizing to the liver, bone, kidneys, adrenal glands, and stomach, Mr. Qazi said. However, Merkel cell carcinoma was less likely to metastasize to the brain (3% of lesions, vs. 12% for melanoma) and lung (6% vs. 14%), and was more likely to metastasize to the pancreas (5% vs. 1%).

Now the investigators are working to link metastatic sites with factors such as the location of the primary tumor, the presence or absence of lymphovascular invasion, and the status of the immune system and Merkel polyomavirus infection, said Mr. Qazi. They also are analyzing time from diagnosis or treatment to metastasis to help guide decisions about when to order follow-up imaging. Ultimately, they hope to create an online tool that enables clinicians to describe a primary Merkel cell carcinoma and rapidly receive automated information about the most likely timing and location of metastasis.

The National Institutes of Health supported the study. Mr. Qazi had no conflicts of interest.

CHICAGO – Immune checkpoint blockade, especially with a combination of agents having complementary mechanisms of action, has durable efficacy when used as initial therapy for advanced melanoma, according to an update of the CheckMate 067 trial.

The trial randomized 945 treatment-naive patients with unresectable stage III or IV melanoma evenly to double-blind treatment with nivolumab, an antibody to the cell surface receptor programmed death 1 (PD-1); ipilimumab, an antibody to the T-cell receptor cytotoxic T-lymphocyte–associated antigen 4 (CTLA4); or the combination.

Initial results, after a median follow-up of about 12.4 months, showed that the risk of progression-free survival events was 58% lower with the combination and 43% lower with nivolumab alone as compared with ipilimumab alone (N Engl J Med. 2015;373[1]:23-34).

The update, now with a median follow-up of 20.7 months, showed that these results held up, with respective 58% and 45% reductions in the risk of events, researchers reported at the annual meeting of the American Society of Clinical Oncology. The combination was also superior to nivolumab alone, netting a 24% lower risk of events. Additionally, no cumulative or new toxicities were seen.

“Based on available evidence, the combination of nivolumab and ipilimumab represents a means to improve outcomes versus nivolumab alone,” said first author Jedd D. Wolchok, MD, PhD, chief of the Melanoma & Immunotherapeutics Service at the Memorial Sloan Kettering Cancer Center in New York. “Additional insights will be gained with the emergence of overall survival data.”

Neither tumor expression of PD-L1, a ligand of PD-1, nor presence of a BRAF mutation was very helpful in identifying patients who would benefit to a greater extent from these therapies.

The findings add to evidence establishing the efficacy of combination immunotherapy in melanoma, according to invited discussant Marc S. Ernstoff, MD, professor and chair of the department of medicine at the Roswell Park Cancer Institute in Buffalo, N.Y. At the same time, the trial left unanswered questions such as what strategy should be used after progression on either or both agents, and what are the appropriate doses and durations of therapy. Also unclear is which type of therapy to use first line in patients with BRAF mutations, he added. “Whether you start with immunotherapy or targeted therapy in BRAF-mutated patients is still in equipoise, and I would encourage everyone here to participate in the ECOG 6134 trial looking at the randomization of immune checkpoint therapy versus targeted therapy in BRAF-mutated patients,” he said. “The biomarker studies are still provocative, and we still need a lot more data to be able to preselect patients who might benefit from either of these therapies.”

“One has to recognize that these agents are costly,” Dr. Ernstoff maintained, with the acquisition cost of the checkpoint inhibitors ranging from roughly $140,000 to $290,000 per year depending on the agent(s) used. This issue will also have to be addressed going forward.

“The future is very bright. There are now 76 trials listed in PDQ [Physician Data Query] of combination PD-1 therapies in melanoma alone,” he concluded. “Immunotherapy continues to capture our imagination.”

The updated intent-to-treat analyses of CheckMate 067 – conducted after all patients had at least 18 months of follow-up – showed that median progression-free survival, one of the trial’s primary endpoints, was now 11.5 months with the combination of nivolumab (Opdivo) and ipilimumab (Yervoy), 6.9 months with nivolumab alone, and 2.9 months with ipilimumab alone, Dr. Wolchok reported at the meeting.

The differences translated to significantly better outcomes with the combination (hazard ratio, 0.42) and with nivolumab (HR, 0.55) as compared with ipilimumab. Moreover, the combination was superior to nivolumab (HR, 0.76).

The overall response rate, the trial’s other primary endpoint, was 57.6% with the combination and 43.7% with nivolumab alone, both of which were superior to the 19.0% with ipilimumab alone.

“While the response rates have not changed, some partial responses have evolved into complete responses over time,” Dr. Wolchok noted.

Findings were similar when patients were stratified by BRAF mutational status. And in exploratory analyses, outcomes were numerically better with the combination than with nivolumab alone regardless of whether tumors had high or low PD-L1 expression.

Safety results were much the same as previously reported. The rate of grade 3 or 4 treatment-related adverse events was 56.5% with the combination, 19.8% with nivolumab monotherapy, and 27.0% with ipilimumab monotherapy. There were no treatment-related deaths with the combination and one with each of the monotherapies.

“There is no common signature adverse event with this combination,” Dr. Wolchok pointed out. “The majority of grade 3 or 4 adverse events resolved in all of the groups with the use of established algorithms. However, as observed in prior studies, most of the endocrine events did not resolve and required hormone replacement.”

About 40% of the combination therapy group stopped treatment because of adverse events. “Interestingly, 68% of these patients who discontinued due to treatment-related adverse events developed a response, and 50% of these responses occurred after treatment had ended,” he reported. “This is very important information for us as we talk to patients and their families about the difficulties of stopping treatment.”

Dr. Wolchok disclosed that he is a consultant for Bristol-Myers Squibb, Genentech, Jounce Therapeutics, Medimmune, Merck, Polaris, Polynoma, Potenza, Tizona, Ziopharm, F-Star, Beigene, Lilly, Advaxis, and Sellas, and that he receives grant/research support from Bristol-Myers Squibb. The trial was sponsored by Bristol-Myers Squibb. Dako collaborated on development of the automated anti–PD-L1 immunohistochemistry assay.

CHICAGO – Immune checkpoint blockade, especially with a combination of agents having complementary mechanisms of action, has durable efficacy when used as initial therapy for advanced melanoma, according to an update of the CheckMate 067 trial.

The trial randomized 945 treatment-naive patients with unresectable stage III or IV melanoma evenly to double-blind treatment with nivolumab, an antibody to the cell surface receptor programmed death 1 (PD-1); ipilimumab, an antibody to the T-cell receptor cytotoxic T-lymphocyte–associated antigen 4 (CTLA4); or the combination.

Initial results, after a median follow-up of about 12.4 months, showed that the risk of progression-free survival events was 58% lower with the combination and 43% lower with nivolumab alone as compared with ipilimumab alone (N Engl J Med. 2015;373[1]:23-34).

The update, now with a median follow-up of 20.7 months, showed that these results held up, with respective 58% and 45% reductions in the risk of events, researchers reported at the annual meeting of the American Society of Clinical Oncology. The combination was also superior to nivolumab alone, netting a 24% lower risk of events. Additionally, no cumulative or new toxicities were seen.

“Based on available evidence, the combination of nivolumab and ipilimumab represents a means to improve outcomes versus nivolumab alone,” said first author Jedd D. Wolchok, MD, PhD, chief of the Melanoma & Immunotherapeutics Service at the Memorial Sloan Kettering Cancer Center in New York. “Additional insights will be gained with the emergence of overall survival data.”

Neither tumor expression of PD-L1, a ligand of PD-1, nor presence of a BRAF mutation was very helpful in identifying patients who would benefit to a greater extent from these therapies.

The findings add to evidence establishing the efficacy of combination immunotherapy in melanoma, according to invited discussant Marc S. Ernstoff, MD, professor and chair of the department of medicine at the Roswell Park Cancer Institute in Buffalo, N.Y. At the same time, the trial left unanswered questions such as what strategy should be used after progression on either or both agents, and what are the appropriate doses and durations of therapy. Also unclear is which type of therapy to use first line in patients with BRAF mutations, he added. “Whether you start with immunotherapy or targeted therapy in BRAF-mutated patients is still in equipoise, and I would encourage everyone here to participate in the ECOG 6134 trial looking at the randomization of immune checkpoint therapy versus targeted therapy in BRAF-mutated patients,” he said. “The biomarker studies are still provocative, and we still need a lot more data to be able to preselect patients who might benefit from either of these therapies.”

“One has to recognize that these agents are costly,” Dr. Ernstoff maintained, with the acquisition cost of the checkpoint inhibitors ranging from roughly $140,000 to $290,000 per year depending on the agent(s) used. This issue will also have to be addressed going forward.

“The future is very bright. There are now 76 trials listed in PDQ [Physician Data Query] of combination PD-1 therapies in melanoma alone,” he concluded. “Immunotherapy continues to capture our imagination.”

The updated intent-to-treat analyses of CheckMate 067 – conducted after all patients had at least 18 months of follow-up – showed that median progression-free survival, one of the trial’s primary endpoints, was now 11.5 months with the combination of nivolumab (Opdivo) and ipilimumab (Yervoy), 6.9 months with nivolumab alone, and 2.9 months with ipilimumab alone, Dr. Wolchok reported at the meeting.

The differences translated to significantly better outcomes with the combination (hazard ratio, 0.42) and with nivolumab (HR, 0.55) as compared with ipilimumab. Moreover, the combination was superior to nivolumab (HR, 0.76).

The overall response rate, the trial’s other primary endpoint, was 57.6% with the combination and 43.7% with nivolumab alone, both of which were superior to the 19.0% with ipilimumab alone.

“While the response rates have not changed, some partial responses have evolved into complete responses over time,” Dr. Wolchok noted.

Findings were similar when patients were stratified by BRAF mutational status. And in exploratory analyses, outcomes were numerically better with the combination than with nivolumab alone regardless of whether tumors had high or low PD-L1 expression.

Safety results were much the same as previously reported. The rate of grade 3 or 4 treatment-related adverse events was 56.5% with the combination, 19.8% with nivolumab monotherapy, and 27.0% with ipilimumab monotherapy. There were no treatment-related deaths with the combination and one with each of the monotherapies.

“There is no common signature adverse event with this combination,” Dr. Wolchok pointed out. “The majority of grade 3 or 4 adverse events resolved in all of the groups with the use of established algorithms. However, as observed in prior studies, most of the endocrine events did not resolve and required hormone replacement.”

About 40% of the combination therapy group stopped treatment because of adverse events. “Interestingly, 68% of these patients who discontinued due to treatment-related adverse events developed a response, and 50% of these responses occurred after treatment had ended,” he reported. “This is very important information for us as we talk to patients and their families about the difficulties of stopping treatment.”

Dr. Wolchok disclosed that he is a consultant for Bristol-Myers Squibb, Genentech, Jounce Therapeutics, Medimmune, Merck, Polaris, Polynoma, Potenza, Tizona, Ziopharm, F-Star, Beigene, Lilly, Advaxis, and Sellas, and that he receives grant/research support from Bristol-Myers Squibb. The trial was sponsored by Bristol-Myers Squibb. Dako collaborated on development of the automated anti–PD-L1 immunohistochemistry assay.

CHICAGO – Immune checkpoint blockade, especially with a combination of agents having complementary mechanisms of action, has durable efficacy when used as initial therapy for advanced melanoma, according to an update of the CheckMate 067 trial.

The trial randomized 945 treatment-naive patients with unresectable stage III or IV melanoma evenly to double-blind treatment with nivolumab, an antibody to the cell surface receptor programmed death 1 (PD-1); ipilimumab, an antibody to the T-cell receptor cytotoxic T-lymphocyte–associated antigen 4 (CTLA4); or the combination.

Initial results, after a median follow-up of about 12.4 months, showed that the risk of progression-free survival events was 58% lower with the combination and 43% lower with nivolumab alone as compared with ipilimumab alone (N Engl J Med. 2015;373[1]:23-34).

The update, now with a median follow-up of 20.7 months, showed that these results held up, with respective 58% and 45% reductions in the risk of events, researchers reported at the annual meeting of the American Society of Clinical Oncology. The combination was also superior to nivolumab alone, netting a 24% lower risk of events. Additionally, no cumulative or new toxicities were seen.

“Based on available evidence, the combination of nivolumab and ipilimumab represents a means to improve outcomes versus nivolumab alone,” said first author Jedd D. Wolchok, MD, PhD, chief of the Melanoma & Immunotherapeutics Service at the Memorial Sloan Kettering Cancer Center in New York. “Additional insights will be gained with the emergence of overall survival data.”

Neither tumor expression of PD-L1, a ligand of PD-1, nor presence of a BRAF mutation was very helpful in identifying patients who would benefit to a greater extent from these therapies.

The findings add to evidence establishing the efficacy of combination immunotherapy in melanoma, according to invited discussant Marc S. Ernstoff, MD, professor and chair of the department of medicine at the Roswell Park Cancer Institute in Buffalo, N.Y. At the same time, the trial left unanswered questions such as what strategy should be used after progression on either or both agents, and what are the appropriate doses and durations of therapy. Also unclear is which type of therapy to use first line in patients with BRAF mutations, he added. “Whether you start with immunotherapy or targeted therapy in BRAF-mutated patients is still in equipoise, and I would encourage everyone here to participate in the ECOG 6134 trial looking at the randomization of immune checkpoint therapy versus targeted therapy in BRAF-mutated patients,” he said. “The biomarker studies are still provocative, and we still need a lot more data to be able to preselect patients who might benefit from either of these therapies.”

“One has to recognize that these agents are costly,” Dr. Ernstoff maintained, with the acquisition cost of the checkpoint inhibitors ranging from roughly $140,000 to $290,000 per year depending on the agent(s) used. This issue will also have to be addressed going forward.

“The future is very bright. There are now 76 trials listed in PDQ [Physician Data Query] of combination PD-1 therapies in melanoma alone,” he concluded. “Immunotherapy continues to capture our imagination.”

The updated intent-to-treat analyses of CheckMate 067 – conducted after all patients had at least 18 months of follow-up – showed that median progression-free survival, one of the trial’s primary endpoints, was now 11.5 months with the combination of nivolumab (Opdivo) and ipilimumab (Yervoy), 6.9 months with nivolumab alone, and 2.9 months with ipilimumab alone, Dr. Wolchok reported at the meeting.

The differences translated to significantly better outcomes with the combination (hazard ratio, 0.42) and with nivolumab (HR, 0.55) as compared with ipilimumab. Moreover, the combination was superior to nivolumab (HR, 0.76).

The overall response rate, the trial’s other primary endpoint, was 57.6% with the combination and 43.7% with nivolumab alone, both of which were superior to the 19.0% with ipilimumab alone.

“While the response rates have not changed, some partial responses have evolved into complete responses over time,” Dr. Wolchok noted.

Findings were similar when patients were stratified by BRAF mutational status. And in exploratory analyses, outcomes were numerically better with the combination than with nivolumab alone regardless of whether tumors had high or low PD-L1 expression.

Safety results were much the same as previously reported. The rate of grade 3 or 4 treatment-related adverse events was 56.5% with the combination, 19.8% with nivolumab monotherapy, and 27.0% with ipilimumab monotherapy. There were no treatment-related deaths with the combination and one with each of the monotherapies.

“There is no common signature adverse event with this combination,” Dr. Wolchok pointed out. “The majority of grade 3 or 4 adverse events resolved in all of the groups with the use of established algorithms. However, as observed in prior studies, most of the endocrine events did not resolve and required hormone replacement.”

About 40% of the combination therapy group stopped treatment because of adverse events. “Interestingly, 68% of these patients who discontinued due to treatment-related adverse events developed a response, and 50% of these responses occurred after treatment had ended,” he reported. “This is very important information for us as we talk to patients and their families about the difficulties of stopping treatment.”

Dr. Wolchok disclosed that he is a consultant for Bristol-Myers Squibb, Genentech, Jounce Therapeutics, Medimmune, Merck, Polaris, Polynoma, Potenza, Tizona, Ziopharm, F-Star, Beigene, Lilly, Advaxis, and Sellas, and that he receives grant/research support from Bristol-Myers Squibb. The trial was sponsored by Bristol-Myers Squibb. Dako collaborated on development of the automated anti–PD-L1 immunohistochemistry assay.

Consider melanoma-associated leukoderma (MAL) as a possible diagnosis in patients presenting with atypical vitiligo-like skin depigmentation that is refractory to standard treatment, advised the authors of a series of seven such cases.

In a research letter published online in the British Journal of Dermatology, Dr. H.E. Teulings and colleagues from the department of dermatology and the Netherlands Institute for Pigment Disorders at the University of Amsterdam, presented a retrospective analysis of seven patients diagnosed with MAL from 2009-2014, who had been initially diagnosed with nonsegmental vitiligo.

The authors defined MAL as “depigmentation that developed within 1 year before the detection of a primary melanoma or within 3 years before the detection of melanoma metastases with an unknown primary tumour.”

The five women and two men were white and were older (aged 45 to 72 years). They had experienced a sudden onset of highly progressive hypo- and depigmentation, which the authors described as often consisting of “round, patchy, confetti-like lesions” measuring 4-5 mm in diameter; most were scattered symmetrically over the trunk, extremities, and/or face (Br J Dermatol. 2016 Jun 7. doi: 10.1111/bjd.14790).

The authors noted that this presentation was unlike typical vitiligo, “which is often bilaterally distributed in an acrofacial pattern, or scattered symmetrically over the entire body with a predilection for extensor surfaces with a relatively early onset in life and a slowly evolving disease course over time.”

The lesions were also generally resistant to topical steroids and UV phototherapy, and six of the seven patients had no family history of vitiligo. The patients were either diagnosed with a primary melanoma at first presentation or were later diagnosed with metastatic melanoma. The majority responded well to immunotherapy, although one patient died.

“In conclusion, although MAL only constitutes a small percentage of patients presenting with vitiligo-like depigmentation, awareness of this phenomenon and correct diagnosis of these patients is crucial to limit further melanoma treatment delay,” the authors wrote. “Many dermatologists are not aware of the diagnosis MAL and may easily diagnose and treat these patients as having nonsegmental vitiligo, thereby overlooking the underlying (metastatic) melanoma,” they added.

Dr. Teulings is supported by a grant from the Dutch Cancer Society. The authors had no conflicts of interest to declare.

Consider melanoma-associated leukoderma (MAL) as a possible diagnosis in patients presenting with atypical vitiligo-like skin depigmentation that is refractory to standard treatment, advised the authors of a series of seven such cases.

In a research letter published online in the British Journal of Dermatology, Dr. H.E. Teulings and colleagues from the department of dermatology and the Netherlands Institute for Pigment Disorders at the University of Amsterdam, presented a retrospective analysis of seven patients diagnosed with MAL from 2009-2014, who had been initially diagnosed with nonsegmental vitiligo.

The authors defined MAL as “depigmentation that developed within 1 year before the detection of a primary melanoma or within 3 years before the detection of melanoma metastases with an unknown primary tumour.”

The five women and two men were white and were older (aged 45 to 72 years). They had experienced a sudden onset of highly progressive hypo- and depigmentation, which the authors described as often consisting of “round, patchy, confetti-like lesions” measuring 4-5 mm in diameter; most were scattered symmetrically over the trunk, extremities, and/or face (Br J Dermatol. 2016 Jun 7. doi: 10.1111/bjd.14790).

The authors noted that this presentation was unlike typical vitiligo, “which is often bilaterally distributed in an acrofacial pattern, or scattered symmetrically over the entire body with a predilection for extensor surfaces with a relatively early onset in life and a slowly evolving disease course over time.”

The lesions were also generally resistant to topical steroids and UV phototherapy, and six of the seven patients had no family history of vitiligo. The patients were either diagnosed with a primary melanoma at first presentation or were later diagnosed with metastatic melanoma. The majority responded well to immunotherapy, although one patient died.

“In conclusion, although MAL only constitutes a small percentage of patients presenting with vitiligo-like depigmentation, awareness of this phenomenon and correct diagnosis of these patients is crucial to limit further melanoma treatment delay,” the authors wrote. “Many dermatologists are not aware of the diagnosis MAL and may easily diagnose and treat these patients as having nonsegmental vitiligo, thereby overlooking the underlying (metastatic) melanoma,” they added.

Dr. Teulings is supported by a grant from the Dutch Cancer Society. The authors had no conflicts of interest to declare.

Consider melanoma-associated leukoderma (MAL) as a possible diagnosis in patients presenting with atypical vitiligo-like skin depigmentation that is refractory to standard treatment, advised the authors of a series of seven such cases.

In a research letter published online in the British Journal of Dermatology, Dr. H.E. Teulings and colleagues from the department of dermatology and the Netherlands Institute for Pigment Disorders at the University of Amsterdam, presented a retrospective analysis of seven patients diagnosed with MAL from 2009-2014, who had been initially diagnosed with nonsegmental vitiligo.

The authors defined MAL as “depigmentation that developed within 1 year before the detection of a primary melanoma or within 3 years before the detection of melanoma metastases with an unknown primary tumour.”

The five women and two men were white and were older (aged 45 to 72 years). They had experienced a sudden onset of highly progressive hypo- and depigmentation, which the authors described as often consisting of “round, patchy, confetti-like lesions” measuring 4-5 mm in diameter; most were scattered symmetrically over the trunk, extremities, and/or face (Br J Dermatol. 2016 Jun 7. doi: 10.1111/bjd.14790).

The authors noted that this presentation was unlike typical vitiligo, “which is often bilaterally distributed in an acrofacial pattern, or scattered symmetrically over the entire body with a predilection for extensor surfaces with a relatively early onset in life and a slowly evolving disease course over time.”

The lesions were also generally resistant to topical steroids and UV phototherapy, and six of the seven patients had no family history of vitiligo. The patients were either diagnosed with a primary melanoma at first presentation or were later diagnosed with metastatic melanoma. The majority responded well to immunotherapy, although one patient died.

“In conclusion, although MAL only constitutes a small percentage of patients presenting with vitiligo-like depigmentation, awareness of this phenomenon and correct diagnosis of these patients is crucial to limit further melanoma treatment delay,” the authors wrote. “Many dermatologists are not aware of the diagnosis MAL and may easily diagnose and treat these patients as having nonsegmental vitiligo, thereby overlooking the underlying (metastatic) melanoma,” they added.

Dr. Teulings is supported by a grant from the Dutch Cancer Society. The authors had no conflicts of interest to declare.