Biomedical subjects
Publications and source records attributed to M A Weinstock.
Study of the epidemiology of mycosis fungoides has been hampered by methodologic issues. Mycosis fungoides does appear to be increasing in frequency more rapidly than lymphoma in general. There is substantial geographic variation, as well as variation by race and gender. Analytic studies have not demonstrated additional risk factors.
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BACKGROUND: The epidemiology of anorectal melanoma has not been well studied despite its potential relevance to the cutaneous melanoma epidemic, and prognostic studies have generally been based on referred cases. METHODS: Data reported to nine population-based registries in the United States during 1973 through 1987 were analyzed. RESULTS: Fifty-five cases were reported (0.017 x 10(-5)/year). The incidence among blacks was higher but not significantly higher than among whites [relative risk (RR), 1.7; 95% confidence interval (CI), 0.7-3.9]. Registries north of 40 degrees latitude reported higher incidence than registries south of 38 degrees (RR, 3.2; 95% CI, 1.5-7.1). Incidence was higher in women than men (RR, 2.3; 95% CI, 1.2-4.3) and increased steadily with age but did not change over time. Of the 46 (84%) cases with known stage at diagnosis, 37% were confined to the anorectum, 41% had regional spread, and 22% metastasized to distant sites. One and 5-year survivals (+/- SE) were 50% +/- 7% and 15% +/- 6%, respectively. One-year survival for local, regional, and distant disease was 75% +/- 11%, 39% +/- 12%, and 33% +/- 16%, respectively. Prognosis improved over the 15 years of surveillance. Age, sex, race, and registry area were not associated with survival. CONCLUSIONS: Anorectal melanoma differs markedly from cutaneous melanoma in etiology (indeed, sun exposure may be protective) and has a very poor, although improving prognosis.
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BACKGROUND AND DESIGN: Nonmelanoma skin cancer is the most common malignancy in the United States. Despite its importance, patterns of mortality from this cause are poorly documented. Recent insights into sources of misclassification allow for more accurate estimation of these patterns. This investigation describes nonmelanoma skin cancer mortality in the United States during 1969 through 1988 on the basis of routine death certification and adjusts reported mortality data for two major sources of misclassification. RESULTS: Nonmelanoma skin cancer mortality rates decreased by approximately 20% to 30% for both men and women and for both whites and blacks, although the decline among blacks was less consistent than among whites. Mortality was greater among men than among women and greater among whites than among blacks, although the most pronounced difference was between white men and the other three racial/gender groups studied. Approximately 1200 deaths per year are attributable to nonmelanoma skin cancer. CONCLUSIONS: Nonmelanoma skin cancer mortality is diminishing despite increasing incidence. Mortality rates among blacks are extraordinarily high in comparison with their incidence rates. More careful attention to misclassification in mortality statistics is crucial for an accurate assessment of the public health burden of nonmelanoma skin cancer.
Sun sensitivity is a major risk factor for melanoma, basal cell carcinoma, and squamous cell carcinoma of the skin. Several variables have been used in epidemiologic studies to measure sun sensitivity. The present study assesses their validity and combines them to form a prediction rule for an objective measure of sun sensitivity, the minimal erythema dose of ultraviolet B radiation required to produce visibility reddened skin (MED). Participants were 116 patients with psoriasis presenting for phototherapy who completed a sun sensitivity questionnaire. Of the 14 questionnaire items evaluated, 10 were associated with the MED beyond expectation based on chance. The closest association was with the skin type (of Fitzpatrick), a 4-point scale based on historical ability to tan and susceptibility to sunburn. Color of untanned skin and hair were also independent predictors, and were included in the final prediction rule, which correlated 0.55 with MED. Combining items yields a more accurate predictor of sun sensitivity than any one or two individual response variables, and hence may be preferable for epidemiologic studies.
The rapid increase in melanoma incidence and mortality has given rise to nationwide and international campaigns that encourage the public to protect themselves from solar radiation with clothing, sunscreens, and other measures. The basis of these campaigns has been challenged by proponents of the theory that vitamin D, which is generated in the skin by ultraviolet B radiation, inhibits the development of melanoma. The present investigation tests this theory by examining the relation between dietary vitamin D and melanoma risk in a case-control study. Vitamin D intake was assessed by a food-frequency questionnaire in 165 melanoma patients and 209 controls. After controlling for age, hair color, and family history of melanoma, there was no association of melanoma risk with total vitamin D intake, calorie-adjusted vitamin D intake, vitamin D intake from foods, or consumption of milk or vitamin D supplements. We find no evidence to suggest that vitamin D protects against melanoma, and therefore continue to support the ongoing public health campaigns aimed at reducing sun exposure for the prevention of melanoma.
Nonmelanoma skin cancer is the most common cancer site in the United States, yet mortality from this cause is poorly understood. We sought medical records of the 16 reported deaths during 1979 through 1987 from this cause (International Classification of Diseases, 9th version [ICD-9], code 173) among Rhode Island residents to evaluate the accuracy of the reported cause of death. Of the 110 cases for which the cause of death could be classified as correct or incorrect, 59 (54%) were misclassified, 49 (83%) of which were mucous-membrane, squamous-cell carcinomas of the head and neck. For most of these, the written death certificate diagnosis was squamous-cell carcinoma of the head and neck, which was coded 173.4. Other problematic diagnoses were cancer of the head and neck and malignant fibrous histiocytoma. In response to a mailed survey, most health departments replied that squamous-cell carcinoma of the head and neck was coded under rubric 173 and malignant fibrous histiocytoma was coded under rubric 171, but there was no unanimity. The misclassification of other causes of death to ICD-9 rubric 173 is substantial. The vast majority were coded to rubric 173.4 and were due to a small number of diagnoses that are recognizable on examination of the death certificate.
We report a case of auricular calcification in an elderly man with a history of frostbite and normal serum calcium levels. The causes of calcification of the cartilage of the external ear are discussed.
The authors examined the relation between sun exposure and melanoma risk and tested the previously published site-specific association of bikini use and melanoma of the trunk in a study of 130 cases incident between 1976 and 1984 and 300 controls nested within the Nurses' Health Study. A summary variable derived from four measures of sun sensitivity was more closely associated with melanoma than any component measure. There was no association of bikini use at ages 15-20 years with trunk melanoma risk (relative risk (RR) = 0.8, p = 0.7), and the 95% confidence interval (CI) (0.3-2.6) excludes the previously published estimate. High frequency of swimsuit use outdoors at ages 15-20 years was associated with increased melanoma risk among sun-sensitive women (RR = 6.4, 95% CI 1.7-23.8, p = 0.006), but appeared to be protective among sun-resistant women (RR = 0.3, 95% CI 0.1-1.0, p = 0.06). These findings suggest that the risk of trunk melanoma associated with bikini use is at most modest and that sun-sensitive women may increase their risk of melanoma with frequent sun exposures, but that sun-resistant women do not, presumably because they develop a photoprotective tan.
Sun-induced freckles are a risk factor for epidermal and melanocytic neoplasia. Whereas sun-induced freckles in children and older adults may be clinically indistinguishable, and sun-induced freckles in older adults usually consist of increased numbers of intraepidermal melanocytes, the histology of sun-induced freckles in children remains unsettled. Using L-3,4 dihydroxyphenylalanine (DOPA)-paraffin sections, the authors examined six sun-induced freckles and adjacent nonpigmented skin (ANP) in as many white male subjects, ages 10 to 23 years. Melanocyte frequency was expressed as the ratio of DOPA-reactive melanocytes to total epidermal basal unit cells. For each case, melanocyte frequencies in freckles were significantly greater than in ANP. Cellular atypia of melanocytes was noticed in four of six freckles. Reactivity of melanocytes for HMB-45 was noticed in two freckles studied, compared with no reactivity in three specimens of ANP studied. The authors conclude the sun-induced freckles in the young may consist of a hyperplasia of melanocytes (i.e., similar to solar lentigines in the elderly), sometimes with cellular atypia, and that these findings may be relevant to melanocytic neoplasia.
The dysplastic nevus (DN) is the most important risk factor and precursor for malignant melanoma. The authors compared the responses of 132 consecutive cases of DN, 186 consecutive cases of cutaneous melanoma, and 239 controls attending the same subspecialty clinic to questions regarding sun sensitivity, sun exposure, and other possible risk factors. Dysplastic nevus cases were younger than controls and were of a higher social class, as indicated by more years of formal education. Sun sensitivity (assessed by reported depth of tan after multiple exposures) was associated with both DN risk and melanoma risk after controlling for age and education in logistic regression analysis (P = 0.009 and 0.03, respectively), but for DN risk this association was nonlinear: the relative risks (versus deep tan) were 2.3 for average tanners, 2.8 for light tanners, and 1.6 for those who reported practically no tan. Sun exposure measures were not associated with DN risk after controlling for age and education, whether or not depth of tan was controlled in the analysis. These observations suggest a role for either sunlight or a trait linked with sun sensitivity in the development of dysplastic nevi.
In a case-control study nested in the Nurses' Health Study cohort, the authors assessed recall bias in the ascertainment of two risk factors for melanoma: hair color and ability to tan. Participants reported on these risk factors in a 1982 questionnaire and in a subsequent case-control questionnaire or telephone interview. The test-retest reliability among controls was high for both questions (Spearman's r = 0.76). Among women diagnosed with melanoma after the first questionnaire and before the second, there was a substantial shift toward reporting a reduced ability to tan when participants were questioned after the diagnosis of melanoma (p = 0.035). No shift was noted for the hair color question (p = 0.8). The authors conclude that recall bias was observed among female nurses with cutaneous melanoma in the assessment of tanning ability, a major risk factor for melanoma.
The etiology of mycosis fungoides is unknown. Two possible causes (an unknown retrovirus with increased prevalence among never-married men, and prior malignancies) were investigated to determine whether they are associated with the incidence of mycosis fungoides. During 1973 to 1986, 953 case patients with mycosis fungoides or Sézary syndrome were registered by the Surveillance, Epidemiology, and End Results program. Each was matched by 5-year age group, sex, ethnicity, and geographic area to four control subjects, one each with cancer of the pancreas, brain, and stomach, and non-Hodgkin's lymphoma. For never-versus ever-married men, none of the relative risks differed significantly from those for women (odd ratios, .8-1.0). For any prior malignancy, the relative risks (and 95% confidence intervals) were 1.3 (.9-2.0), 1.2 (.8-1.8), 1.0 (.7-1.5), and 1.1 (.7-1.6). These data reject the previous relative risk estimate of 3.3 with greater than 99% power, and are consistent with only a small risk, if any, attributable to prior malignancy.
To estimate the magnitude of nonmelanoma skin cancer mortality and describe its parameters, we reviewed the medical records of all deaths certified as due to this cause among Rhode Island residents from 1979 through 1987. After excluding acquired immunodeficiency syndrome-associated Kaposi's sarcoma, we confirmed that nonmelanoma skin cancer was the cause of death for 51 individuals, a quarter of the number of melanoma deaths reported. The age-adjusted nonmelanoma skin cancer mortality rate was 0.44/10(5) per year. Fifty-nine percent were due to squamous cell carcinoma, and 20% were due to basal cell carcinoma. Most appeared actinically induced. Among deaths from squamous cell carcinoma, the mean age was 73 years. At least 80% of the squamous cell carcinomas metastasized, and 47% arose on the ear. None appeared due to refusal of treatment. Among deaths from basal cell carcinoma, the mean age was 85 years, and refusal of surgical intervention was documented in 40%. Study of nonmelanoma skin cancer mortality provides for estimation of the magnitude of this problem, complements other studies of prognosis, and helps guide prevention, early detection, and treatment.
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