Cutaneous melanoma and intervention strategies to reduce tumor‐related mortality: what we know, what we don't know, and what we think we know that isn't so

The care of patients who have cutaneous melanoma (CM) has undergone a dramatic change during the past five decades. In an increasing majority of cases, CM is being discovered in a premetastatic phase of tumor progression. Most patients are being treated in the ambulatory setting with a minimum of inconvenience and economic cost, and modest re‐excision margins have largely replaced the mutilating surgical exonerations that were once standard only four decades ago. Histopathologic assessment of the primary tumor is the most widely used staging procedure to determine who is most likely to develop metastatic disease. For patients who develop distant metastases, there is no therapy currently available, based on large‐scale randomized trials, that will prolong patient survival. Therefore, establishing an early diagnosis in a premetastatic phase of tumor development must be the overriding goal of any intervention strategy that seeks to reduce CM‐related mortality. Unfortunately, as a result of public messages that emphasize the role of ultraviolet radiation (UVR) exposure in tumor development, most general physicians and lay people believe that most if not all cases of CM are the direct result of UVR exposure. In fact, we do not know the case fraction of CM directly attributable to UVR, and the unintended consequences of current messages directly linking UVR exposure and CM development may be thwarting the primary intervention goal of reducing tumor‐related mortality. More likely to have an immediate positive impact on CM‐related mortality are public messages that encourage skin awareness and self‐examination by patients, total skin screening examinations by physicians during routine care, and periodic lifetime surveillance of patients determined to have a high CM risk based on identifiable historic and phenotypic traits.