Risk factors and outcomes of cutaneous melanoma in women less than 50 years of age

Published:January 20, 2016DOI:https://doi.org/10.1016/j.jaad.2015.11.014

      Background

      Melanoma is the fifth most common cancer in the United States, with recent reports indicating increasing incidence among young women.

      Objective

      This study sought to investigate histopathology, staging, risk factors, and outcomes of cutaneous melanoma in women younger than 50 years.

      Methods

      All female patients aged up to 49 years with biopsy-proven diagnosis of melanoma between 1988 and 2012 were included. Patients with a follow-up of less than 2 years were excluded.

      Results

      A total of 462 patients were identified, with mean age of 34.7 years. Invasive melanoma was less common in women 19 years of age or younger ( P < .0008). Positive sentinel node status ( P < .008), recurrence rates, metastatic disease ( P < .001), and death rates ( P < .008) were higher for women ages 40 to 49 years. The 41 patients with a pregnancy-associated melanoma had a significantly worse prognosis in comparison with a control group of nonpregnant patients, with a 9-fold increase in recurrence ( P < .001), 7-fold increase in metastasis ( P = .03) and 5-fold increase in mortality ( P = .06).

      Limitations

      This was a retrospective study.

      Conclusion

      The increasing incidence of melanoma for women younger than 50 years suggests that regular skin checks and self-examinations are warranted. In addition, in women given the diagnosis of melanoma during or within 1 year after childbirth, regular follow-up and monitoring for recurrence are recommended.

      Key words

      Abbreviations used:

      AJCC ( American Joint Committee on Cancer), MM ( malignant melanoma), PAMM ( pregnancy-associated malignant melanoma)
      To read this article in full you will need to make a payment
      AAD Member Login
      AAD Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Mayer J.E.
        • Swetter S.M.
        • Fu T.
        • Geller A.C.
        Screening, early detection, education, and trends for melanoma: current status (2007-2013) and future directions: part I, epidemiology, high-risk groups, clinical strategies, and diagnostic technology.
        J Am Acad Dermatol. 2014; 71 (quiz 610, 599.e12): 599.e1-599.e12
      1. Howlader N. Noone A.M. Krapcho M. SEER cancer statistics review, 1975-2012. National Cancer Institute, Bethesda, MDApril 2015 (http://seer.cancer.gov/csr/1975_2012/, based on November 2014 SEER data submission, posted to the SEER web site)
        • Purdue M.P.
        • Freeman L.E.
        • Anderson W.F.
        • Tucker M.A.
        Recent trends in incidence of cutaneous melanoma among US Caucasian young adults.
        J Invest Dermatol. 2008; 128: 2905-2908
      2. Bleyer A. O'Leary M. Barr R. Ries L.A.G Cancer epidemiology in older adolescents and young adults 15 to 29 years of age, including SEER incidence and survival: 1975-2000. National Cancer Institute, NIH Pub. No. 06-5767, Bethesda, MD2006
        • Andersson T.M.
        • Johansson A.L.
        • Fredriksson I.
        • Lambe M.
        Cancer during pregnancy and the postpartum period: a population-based study.
        Cancer. 2015; 121: 2072-2077
        • Balch C.M.
        • Gershenwald J.E.
        • Soong S.J.
        Final version of 2009 AJCC melanoma staging and classification.
        J Clin Oncol. 2009; 27: 6199-6206
        • Byrom L.
        • Olsen C.
        • Knight L.
        • Khosrotehrani K.
        • Green A.C.
        Increased mortality for pregnancy-associated melanoma: systematic review and meta-analysis.
        J Eur Acad Dermatol Venereol. 2015; 29: 1457-1466
        • Daryanani D.
        • Plukker J.T.
        • De Hullu J.A.
        • Kuiper H.
        • Nap R.E.
        • Hoekstra H.J.
        Pregnancy and early-stage melanoma.
        Cancer. 2003; 97: 2248-2253
        • Houghton A.N.
        • Flannery J.
        • Viola M.V.
        Malignant melanoma of the skin occurring during pregnancy.
        Cancer. 1981; 48: 407-410
        • Johansson A.L.
        • Andersson T.M.
        • Plym A.
        • Ullenhag G.J.
        • Moller H.
        • Lambe M.
        Mortality in women with pregnancy-associated malignant melanoma.
        J Am Acad Dermatol. 2014; 71: 1093-1101
        • Lens M.B.
        • Rosdahl I.
        • Ahlbom A.
        • et al.
        Effect of pregnancy on survival in women with cutaneous malignant melanoma.
        J Clin Oncol. 2004; 22: 4369-4375
        • MacKie R.M.
        • Bufalino R.
        • Morabito A.
        • Sutherland C.
        • Cascinelli N.
        Lack of effect of pregnancy on outcome of melanoma for the World Health Organization melanoma program.
        Lancet. 1991; 337: 653-655
        • McManamny D.S.
        • Moss A.L.
        • Pocock P.V.
        • Briggs J.C.
        Melanoma and pregnancy: a long-term follow-up.
        Br J Obstet Gynaecol. 1989; 96: 1419-1423
        • Moller H.
        • Purushotham A.
        • Linklater K.M.
        • et al.
        Recent childbirth is an adverse prognostic factor in breast cancer and melanoma, but not in Hodgkin lymphoma.
        Eur J Cancer. 2013; 49: 3686-3693
        • O'Meara A.T.
        • Cress R.
        • Xing G.
        • Danielsen B.
        • Smith L.H.
        Malignant melanoma in pregnancy: a population-based evaluation.
        Cancer. 2005; 103: 1217-1226
        • Pack G.T.
        • Scharnagel I.M.
        The prognosis for malignant melanoma in the pregnant woman.
        Cancer. 1951; 4: 324-334
        • Reintgen D.S.
        • McCarty Jr., K.S.
        • Vollmer R.
        • Cox E.
        • Seigler H.F.
        Malignant melanoma and pregnancy.
        Cancer. 1985; 55: 1340-1344
        • Shiu M.H.
        • Schottenfeld D.
        • Maclean B.
        • Fortner J.G.
        Adverse effect of pregnancy on melanoma: a reappraisal.
        Cancer. 1976; 37: 181-187
        • Slingluff Jr., C.L.
        • Reintgen D.S.
        • Vollmer R.T.
        • Seigler H.F.
        Malignant melanoma arising during pregnancy. A study of 100 patients.
        Ann Surg. 1990; 211: 552-559
        • Silipo V.
        • De Simone P.
        • Mariani G.
        • Buccini P.
        • Ferrari A.
        • Catricala C.
        Malignant melanoma and pregnancy.
        Melanoma Res. 2006; 16: 497-500
        • Stensheim H.
        • Moller B.
        • van Dijk T.
        • Fossa S.D.
        Cause-specific survival for women diagnosed with cancer during pregnancy or lactation: a registry-based cohort study.
        J Clin Oncol. 2009; 27: 45-51
        • Travers R.L.
        • Sober A.J.
        • Berwick M.
        • Mihm Jr., M.C.
        • Barnhill R.L.
        • Duncan L.M.
        Increased thickness of pregnancy-associated melanoma.
        Br J Dermatol. 1995; 132: 876-883
        • Vihinen P.
        • Vainio-Kaila M.
        • Talve L.
        • Koskivuo I.
        • Syrjanen K.
        • Pyrhonen S.
        Previous pregnancy is a favorable prognostic factor in women with localized cutaneous melanoma.
        Acta Oncol. 2012; 51: 662-668
        • Wong J.H.
        • Sterns E.E.
        • Kopald K.H.
        • Nizze J.A.
        • Morton D.L.
        Prognostic significance of pregnancy in stage I melanoma.
        Arch Surg. 1989; 124: 1227-1231
        • Sutherland C.M.
        • Loutfi A.
        • Mather F.J.
        • et al.
        Effect of pregnancy upon malignant melanoma.
        Surg Gynecol Obstet. 1983; 157: 443-446
        • Driscoll M.S.
        • Grant-Kels J.M.
        Hormones, nevi, and melanoma: an approach to the patient.
        J Am Acad Dermatol. 2007; 57 (quiz 932-936): 919-931
        • Izquierdo J.N.
        • Schoenbach V.J.
        The potential and limitations of data from population-based state cancer registries.
        Am J Public Health. 2000; 90: 695-698
        • Beguerie J.R.
        • Xingzhong J.
        • Valdez R.P.
        Tamoxifen vs. non-tamoxifen treatment for advanced melanoma: a meta-analysis.
        Int J Dermatol. 2010; 49: 1194-1202
        • Lens M.B.
        • Reiman T.
        • Husain A.F.
        Use of tamoxifen in the treatment of malignant melanoma.
        Cancer. 2003; 98: 1355-1361
        • Hannibal C.G.
        • Jensen A.
        • Sharif H.
        • Kjaer S.K.
        Malignant melanoma risk after exposure to fertility drugs: results from a large Danish cohort study.
        Cancer Causes Control. 2008; 19: 759-765
        • Reigstad M.M.
        • Larsen I.K.
        • Myklebust T.A.
        • et al.
        Cancer risk among parous women following assisted reproductive technology.
        Hum Reprod. 2015; 30: 1952-1963
        • Rossing M.A.
        • Daling J.R.
        • Weiss N.S.
        • Moore D.E.
        • Self S.G.
        Risk of cutaneous melanoma in a cohort of infertile women.
        Melanoma Res. 1995; 5: 123-127
        • Stewart L.M.
        • Holman C.D.
        • Finn J.C.
        • Preen D.B.
        • Hart R.
        Association between in-vitro fertilization, birth and melanoma.
        Melanoma Res. 2013; 23: 489-495
        • Mauti L.A.
        • Le Bitoux M.A.
        • Baumer K.
        • et al.
        Myeloid-derived suppressor cells are implicated in regulating permissiveness for tumor metastasis during mouse gestation.
        J Clin Invest. 2011; 121: 2794-2807
        • Brewer J.D.
        • Christenson L.J.
        • Weaver A.L.
        • et al.
        Malignant melanoma in solid transplant recipients: collection of database cases and comparison with Surveillance, Epidemiology, and End Results data for outcome analysis.
        Arch Dermatol. 2011; 147: 790-796
        • Frankenthaler A.
        • Sullivan R.J.
        • Wang W.
        • et al.
        Impact of concomitant immunosuppression on the presentation and prognosis of patients with melanoma.
        Melanoma Res. 2010; 20: 496-500
        • Khosrotehrani K.
        • Nguyen Huu S.
        • Prignon A.
        • et al.
        Pregnancy promotes melanoma metastasis through enhanced lymphangiogenesis.
        Am J Pathol. 2011; 178: 1870-1880
        • Dadras S.S.
        • Lange-Asschenfeldt B.
        • Velasco P.
        • et al.
        Tumor lymphangiogenesis predicts melanoma metastasis to sentinel lymph nodes.
        Mod Pathol. 2005; 18: 1232-1242
        • Rodero M.P.
        • Prignon A.
        • Avril M.F.
        • Boitier F.
        • Aractingi S.
        • Khosrotehrani K.
        Increase lymphangiogenesis in melanoma during pregnancy: correlation with the prolactin signaling pathway.
        J Eur Acad Dermatol Venereol. 2013; 27: e144-e145
        • Johansson A.L.
        • Andersson T.M.
        • Hsieh C.C.
        • Cnattingius S.
        • Lambe M.
        Increased mortality in women with breast cancer detected during pregnancy and different periods postpartum.
        Cancer Epidemiol Biomarkers Prev. 2011; 20: 1865-1872
        • Fabian M.
        • Toth V.
        • Somlai B.
        • et al.
        Retrospective analysis of clinicopathological characteristics of pregnancy associated melanoma.
        Pathol Oncol Res. 2015; 21: 1265-1271
        • Fang S.
        • Wang Y.
        • Sui D.
        • et al.
        C-reactive protein as a marker of melanoma progression.
        J Clin Oncol. 2015; 33: 1389-1396
      3. The Skin Cancer Foundation. Early detection and self exams. Available from: URL: http://www.skincancer.org/skin-cancer-information/early-detection. Accessed October 29, 2015.

      Linked Article

      • Pregnancy-associated melanoma (PAMM): Is there truly a worse prognosis? Would not sound alarm bells just yet…
        Journal of the American Academy of DermatologyVol. 75Issue 2
        • In Brief
          To the Editor: We read with interest the article by Tellez and colleagues1 who report an increased risk of mortality, recurrence, and metastasis in pregnancy-associated melanoma (PAMM). We believe their conclusions should not overturn the bulk of evidence demonstrating that localized PAMM is not associated with worse prognosis than melanomas that occur in nonpregnant women with similar prognostic factors.2-4
        • Full-Text
        • PDF
      • Estrogen receptor (ER)β expression and worse outcome from melanoma in pregnant and perimenopausal women
        Journal of the American Academy of DermatologyVol. 75Issue 3
        • In Brief
          To the Editor: Tellez et al1 are to be congratulated for their recently reported retrospective analysis of 420 women under 50 years of age. This study investigated the histopathology, staging, risk factors, and outcomes of cutaneous melanoma in this young subset of female patients. The authors extrapolated 2 important, emerging conclusions from their work. First, pregnant women had a higher incidence of melanoma mortality, recurrence, and metastasis compared with nonpregnant control subjects. Second, women presenting at 40 to 49 years of age showed higher rates of melanoma-related death and positive sentinel nodes.
        • Full-Text
        • PDF
      • Melanoma during pregnancy: Level of evidence and principles of precaution
        Journal of the American Academy of DermatologyVol. 76Issue 1
        • In Brief
          To the Editor: For many years, the outcome of melanoma during pregnancy has been subject to debate. This is an ever-increasing medical issue as melanoma ranks first among malignancies discovered during pregnancy and postpartum in many parts of the world.1,2 A major discussion point has been whether analysis of the association with mortality should be adjusted for tumor thickness, a major prognostic factor, because some large population cohorts observed that melanomas during pregnancy and the first year postpartum are significantly thicker.
        • Full-Text
        • PDF