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Clinical-epidemiological studies on cutaneous malignant melanoma: A register approach
Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center for Health and Developmental Care, Regional Cancer Center South East Sweden.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The incidence of cutaneous malignant melanoma (CMM) is steadily increasing. Most of the patients have thin CMM with a good prognosis and a 5-year survival of about 90%. The prognosis is highly related to tumour thickness and clinical stage at diagnosis. Effective systemic treatment for patients with metastatic disease has only recently been available. This thesis aims to increase knowledge of trends in tumour thickness, prognostic factors, socioeconomic differences and medical costs in patients with CMM.

The population-based Swedish melanoma register is the main source of data in all papers in the thesis. Papers I-III include patients from all of Sweden while paper IV is delimited to the County of Östergötland. Cox regression and logistic regression are the main multivariable methods used. Paper IV is focused on stage-specific costs of CMM by comparing direct healthcare costs to a general population.

For men, there has been a shift over time towards thinner tumours at diagnosis accompanied by an improved survival. Women are still diagnosed with considerably thinner tumours and they experience a better survival than men. Tumour ulceration, tumour thickness and Clark’s level of invasion all showed significant independent long-term prognostic information in T1 CMMs. By combining these factors, three distinct prognostic subgroups were identified. Lower level of education was associated with reduced CMM-specific survival, which may at least partially be attributed to a more advanced stage at diagnosis. The direct healthcare costs for CMM patients were significantly higher than for the general population, independent of clinical stage. CMM patients diagnosed in clinical stage III-IV were associated with particularly high costs.

Even though the survival among Swedish patients with CMM is among the highest in the world and still seems to improve, the results of this thesis emphasise the need of improved early detection strategies. This may be of particular concern in men, older women, and groups with a low level of education. The results also imply that the costs for the management of CMM patients may be reduced if early detection efforts are successful and lead to a more favourable stage distribution. The finding of a better risk stratification of thin CMMs may help to improve the management of this large patient group.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. , 51 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1428
Keyword [en]
Melanoma, early detection, population-based, registers, time trends, survival, prognostic factors, tumour thickness, stage at diagnosis, level of education, socioeconomic status, healthcare costs
National Category
Dermatology and Venereal Diseases Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-113145DOI: 10.3384/diss.diva-113145ISBN: 978-91-7519-191-1 (print)OAI: oai:DiVA.org:liu-113145DiVA: diva2:779116
Public defence
2015-02-13, Eken, ingång 65, Campus US, Linköpings Universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2015-01-28 Created: 2015-01-12 Last updated: 2016-04-01Bibliographically approved
List of papers
1. Trends in cutaneous malignant melanoma in Sweden 1997-2011: Thinner tumours and improved survival among men
Open this publication in new window or tab >>Trends in cutaneous malignant melanoma in Sweden 1997-2011: Thinner tumours and improved survival among men
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2015 (English)In: British Journal of Dermatology, ISSN 0007-0963, E-ISSN 1365-2133, Vol. 172, no 3, 700-706 p.Article in journal (Refereed) Published
Abstract [en]

Background: Both patient survival and the proportion of patients diagnosed with thin cutaneous malignant melanoma (CMM) have been steadily rising in Sweden as in most western countries, though the rate of improvement in survival appears to have declined in Sweden at the end of last millennium.

Objectives: To analyse the most recent trends in the distribution of tumour thickness (T-category) as well as CMM-specific survival in Swedish patients diagnosed 1997-2011.

Methods: This nationwide population-based study included 30 590 patients registered in the Swedish Melanoma Register (SMR) and diagnosed with a first primary invasive CMM 1997-2011. The patients were followed through 2012 in the national Cause-of-Death Register.

Results: Logistic and Cox regression analyses adjusting for age at diagnosis, tumour site, and health care region were carried out. The odds ratio for being diagnosed with thicker tumours was significantly reduced (P = 0·0008) and the CMM-specific survival significantly improved in men diagnosed 2007-2011 compared to men diagnosed 1997-2001 (hazard ratio=0·81; 95% CI 0·72-0·91, P = 0·0009) while the corresponding differences for women were not significant. Women were diagnosed with significantly thicker tumours during 2002-2006 and a tendency towards decreased survival was observed compared to those diagnosed earlier 1997-2001 and later 2007-2011.

Conclusion: In Sweden, the CMMs of men are detected earlier over time and this seems to be followed by an improved CMM-specific survival for men. Women are still diagnosed with considerably thinner tumours and they experience a better survival than men.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2015
Keyword
malignant melanoma, time trend, survival, tumour thickness, population based
National Category
Dermatology and Venereal Diseases
Identifiers
urn:nbn:se:liu:diva-113143 (URN)10.1111/bjd.13483 (DOI)000351400500029 ()25323770 (PubMedID)
Available from: 2015-01-12 Created: 2015-01-12 Last updated: 2017-12-05Bibliographically approved
2. Prognostic subclassifications of T1 cutaneous melanomas based on ulceration, tumour thickness and Clark’s level of invasion: results of a population-based study from the Swedish Melanoma Register
Open this publication in new window or tab >>Prognostic subclassifications of T1 cutaneous melanomas based on ulceration, tumour thickness and Clark’s level of invasion: results of a population-based study from the Swedish Melanoma Register
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2013 (English)In: British Journal of Dermatology, ISSN 0007-0963, E-ISSN 1365-2133, Vol. 168, no 4, 779-786 p.Article in journal (Refereed) Published
Abstract [en]

Background  Survival and prognostic factors for thin melanomas have been studied relatively little in population-based settings. This patient group accounts for the majority of melanomas diagnosed in western countries today, and better prognostic information is needed.

Objectives  The aim of this study was to use established prognostic factors such as ulceration, tumour thickness and Clark’s level of invasion for risk stratification of T1 cutaneous melanoma.

Methods  From 1990 to 2008, the Swedish Melanoma Register included 97% of all melanomas diagnosed in Sweden. Altogether, 13 026 patients with T1 melanomas in clinical stage I were used for estimating melanoma-specific 10- and 15-year mortality rates. The Cox regression model was used for further survival analysis on 11 165 patients with complete data.

Results  Ulceration, tumour thickness and Clark’s level of invasion all showed significant, independent, long-term prognostic information. By combining these factors the patients could be subdivided into three risk groups: a low-risk group (67·9% of T1 cases) with a 10-year melanoma-specific mortality rate of 1·5% (1·2–1·9%); an intermediate-risk group (28·6% of T1 cases) with a 10-year mortality rate of 6·1% (5·0–7·3%); and a high-risk group (3·5% of T1 cases) with a 10-year mortality rate of 15·6% (11·2–21·4%). The high- and intermediate-risk groups accounted for 66% of melanoma deaths within T1.

Conclusions  Using a population-based melanoma register, and combining ulceration, tumour thickness and Clark’s level of invasion, three distinct prognostic subgroups were identified.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2013
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-92611 (URN)10.1111/bjd.12095 (DOI)000317016100030 ()23066913 (PubMedID)
Note

Funding Agencies|regional cancer centre Southeast in Linkoping||

Available from: 2013-05-16 Created: 2013-05-14 Last updated: 2017-12-06
3. Low level of education is associated with later stage at diagnosis and reduced survival in cutaneous malignant melanoma: A nationwide population-based study in Sweden
Open this publication in new window or tab >>Low level of education is associated with later stage at diagnosis and reduced survival in cutaneous malignant melanoma: A nationwide population-based study in Sweden
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2013 (English)In: European Journal of Cancer, ISSN 0959-8049, E-ISSN 1879-0852, Vol. 49, no 12, 2705-2716 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

A worse outcome has been reported for cutaneous malignant melanoma (CMM) patients with low socioeconomic status. We have investigated the association between level of education, clinical stage at diagnosis (stage at diagnosis) and CMM-specific survival in Sweden.

METHODS:

We identified 27,235 patients from the Swedish Melanoma Register diagnosed with a primary invasive CMM between 1990 and 2007 and linked data to nationwide, population-based, health and census registers with a follow-up to 2010.

RESULTS:

The odds ratio (OR) of higher disease stage at diagnosis was significantly increased in lower education groups (OR stage II versus I=1.6; 95% confidence interval (CI)=1.5-1.7. OR stage III-IV versus I=2.3; 95% CI=1.8-2.9). The risk of dying of CMM, was significantly increased in patients with low (hazard ratio (HR) low versus high=2.02; 95% CI=1.80-2.26; p<0.0001) and intermediate (HR intermediate versus high=1.35; 95% CI=1.20-1.51; p<0.0001) level of education. After adjustment for age, gender, stage at diagnosis and other known prognostic factors, the HRs remained significant for low versus high (HR=1.13; 95% CI=1.01-1.27; p=0.04) but not for intermediate versus high (HR=1.11; 95% CI=0.99-1.24; p=0.08) education. The HR associated with low level of education was significantly higher among female patients, patients <55years, patients with truncal tumours and during the first 5years after diagnosis.

CONCLUSION:

Lower level of education is associated with reduced CMM-specific survival, which may at least partially be attributed to a more advanced stage at diagnosis. These results emphasise the need for improved early detection strategies.

Place, publisher, year, edition, pages
Elsevier, 2013
Keyword
Melanoma, Survival, Socioeconomic status, Level of education, Stage at diagnosis, Population-based
National Category
Medical and Health Sciences Social Sciences
Identifiers
urn:nbn:se:liu:diva-95938 (URN)10.1016/j.ejca.2013.03.013 (DOI)000321336800010 ()23583439 (PubMedID)
Note

Funding Agencies|Swedish Cancer Society||Radiumhemmet Research Funds||Sigurd and Elsa Goljes Memorial Foundation||Stockholm County Council||

Available from: 2013-08-19 Created: 2013-08-12 Last updated: 2017-12-06Bibliographically approved
4. Stage-specific direct healthcare costs in patients with cutaneous malignant melanoma
Open this publication in new window or tab >>Stage-specific direct healthcare costs in patients with cutaneous malignant melanoma
2016 (English)In: Journal of the European Academy of Dermatology and Venereology, ISSN 0926-9959, E-ISSN 1468-3083, Vol. 30, no 5, 789-793 p.Article in journal (Refereed) Published
Abstract [en]

Background Clinical stage at diagnosis is a strong prognostic factor for death in cutaneous malignant melanoma (CMM), with worse prognosis at higher stages. However, few studies have investigated how direct healthcare cost per patient varies with clinical stage.

Objective The aim of this study was to determine the stage-specific direct healthcare costs for CMM patients compared to the healthcare costs in the general population in the County of Östergötland, Sweden.

Methods CMM patients in the County of Östergötland diagnosed 2005-2012 were identified from the Swedish cancer registry. Information on clinical stage was collected from the Swedish Melanoma Register (SMR) and cost data from the Cost per Patient database (CPP) for 1 075 CMM patients in Östergötland. CPP contains costs associated with all healthcare contacts per patient including inpatient, outpatient, and primary care. The CMM-related costs were defined as the difference in mean healthcare costs between CMM patients and general population.

Results The first year after CMM diagnosis, the average healthcare costs for CMM patients was 2.8 times higher than in the general population. The healthcare cost ratio varied from 2.0 (stage I) to 10.1 (stage IV) and the CMM-related costs per patient-year varied from €2 670 (stage I) to €29 291 (stage IV). The mean healthcare costs decreased over time but remained significantly higher than in the general population for all clinical stages. During the first year after diagnosis, patients in clinical stage III-IV (7% of CMM patients) accounted for 27% of the total CMM-related healthcare costs.

Conclusions The direct healthcare costs for CMM patients were significantly higher than in the general population independent of clinical stage. CMM patients diagnosed in clinical stage III-IV were associated with particularly high costs and the healthcare system may save resources by finding CMM patients in earlier stages.

National Category
Dermatology and Venereal Diseases
Identifiers
urn:nbn:se:liu:diva-113144 (URN)10.1111/jdv.13110 (DOI)000374554200007 ()
Note

Funding agencies:Regional cancer center South East in Linkoping

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Available from: 2015-01-12 Created: 2015-01-12 Last updated: 2017-05-03

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