Skin Surveillance Research Articles

Sun protection and sunbathing practices among at-risk family members of patients with melanoma

BackgroundDespite the increased level of familial risk, research indicates that family members of patients with melanoma engage in relatively low levels of sun protection and high levels of sun exposure. The goal of this study was to evaluate a broad range of demographic, medical, psychological, knowledge, and social influence correlates of sun protection and sunbathing practices among first-degree relatives (FDRs) of melanoma patients and to determine if correlates of sun protection and sunbathing were unique.MethodsWe evaluated correlates of sun protection and sunbathing among FDRs of melanoma patients who were at increased disease risk due to low compliance with sun protection and skin surveillance behaviors. Participants (N = 545) completed a phone survey.ResultsFDRs who reported higher sun protection had a higher education level, lower benefits of sunbathing, greater sunscreen self-efficacy, greater concerns about photo-aging and greater sun protection norms. FDRs who reported higher sunbathing were younger, more likely to be female, endorsed fewer sunscreen barriers, perceived more benefits of sunbathing, had lower image norms for tanness, and endorsed higher sunbathing norms.ConclusionInterventions for family members at risk for melanoma might benefit from improving sun protection self-efficacy, reducing perceived sunbathing benefits, and targeting normative influences to sunbathe.

Diversity and Clinical Impact of Acinetobacter baumannii Colonization and Infection at a Military Medical Center

The epidemiology of Acinetobacter baumannii emerging in combat casualties is poorly understood. We analyzed 65 (54 nonreplicate) Acinetobacter isolates from 48 patients (46 hospitalized and 2 outpatient trainees entering the military) from October 2004 to October 2005 for genotypic similarities, time-space relatedness, and antibiotic susceptibility. Clinical and surveillance cultures were compared by amplified fragment length polymorphism (AFLP) genomic fingerprinting to each other and to strains of a reference database. Antibiotic susceptibility was determined, and multiplex PCR was performed for OXA-23-like, -24-like, -51-like, and -58-like carbapenemases. Records were reviewed for overlapping hospital stays of the most frequent genotypes, and risk ratios were calculated for any association of genotype with severity of Acute Physiology and Chronic Health Evaluation II (APACHE II) score or injury severity score (ISS) and previous antibiotic use. Nineteen genotypes were identified; two predominated, one consistent with an emerging novel international clone and the other unique to our database. Both predominant genotypes were carbapenem resistant, were present at another hospital before patients' admission to our facility, and were associated with higher APACHE II scores, higher ISSs, and previous carbapenem antibiotics in comparison with other genotypes. One predominated in wound and respiratory isolates, and the other predominated in wound and skin surveillance samples. Several other genotypes were identified as European clones I to III. Acinetobacter genotypes from recruits upon entry to the military, unlike those in hospitalized patients, did not include carbapenem-resistant genotypes. Acinetobacter species isolated from battlefield casualties are diverse, including genotypes belonging to European clones I to III. Two carbapenem-resistant genotypes were epidemic, one of which appeared to belong to a novel international clone.

Capecitabine for skin cancer prevention in solid organ transplant recipients

Skin cancers are the most common malignancies in solid organ transplant recipients (SOTR). A case-observational, retrospective study was performed to determine the efficacy of low-dose capecitabine in the secondary prevention of skin cancers in SOTRs treated at a single institution. SOTRs with recurrent squamous cell carcinoma (SCC) and/or basal cell carcinoma (BCC) were given low-dose capecitabine 1 g/m(2) daily, days 1-14 of a 21-d treatment cycle. Skin surveillance was performed by dermatologists every 1-3 months. Cumulative incidence rates of SCC, BCC, and actinic keratosis (AK) before and after treatment were scored and statistically compared for each patient using a non-parametric Wilcoxon signed rank test. Fifteen patients (13 men and two women) with a median age of 57 yr (range 40-73) were treated. Incidence rates as measured by mean number of events per month declined by 0.33 for SCC, 0.04 for BCC, and 2.45 for AK (p < 0.05). The most common grade 3 and 4 toxicities included fatigue (40.0%), hand-foot syndrome (20.0%), and diarrhea (20.0%). The discontinuation rate at one yr was approximately 33.3%. We conclude that oral capecitabine significantly decreases the incidence rates of recurrent SCC, BCC, and AK in SOTRs and is associated with manageable toxicity.

Skin cancer screening behaviours among individuals with a strong family history of malignant melanoma.

Background:This study examined the prevalence and correlates of skin cancer screening behaviours among individuals at high risk of developing melanoma due to strong family history.Methods:A total of 120 individuals with a known family-specific CDKN2A mutation (72% response rate) completed a self-report questionnaire assessing annual frequency of skin self-examination (SSE), clinical skin examination (CSE) and a variety of potential demographic, clinical and psychosocial correlates.Results:In the past 12 months, 50% of participants reported engaging in SSE at least four times, and 43% of participants had undergone at least one CSE. Engagement in SSE was associated with doctor recommendation (β=1.77, P=0.001), confidence in one's ability to perform SSE (β=1.44, P<0.0001), positive beliefs about melanoma treatment (β=0.77, P=0.002) and intention to perform SSE in the future (β=1.69, P<0.0001). These variables accounted for 59% of the variance in SSE behaviour. Further, information-seeking style moderated the relationship between anxiety and SSE (β=1.02, P=0.004). Annual uptake of CSE was associated with doctor recommendation (β=2.21, P<0.0001) and intention to undergo CSE in the future (β=1.19, P=0.001).Conclusion:In comparison with clinical guidelines, it appears that individuals at high risk of developing melanoma engage in suboptimal levels of skin surveillance. Improved doctor–patient communication, as well as psycho-education and behavioural support, may be viable means of improving early skin cancer detection behaviours in this high-risk population.

Skin surveillance attitudes and behaviors in relation to skin checks for early signs of skin cancer in a sample of secondary school students and teachers in Palermo, Western Sicily

Background: Malignant melanoma (MM) can be readily treated in its earliest stages: survival rate, whendetected early, is up to 95,0%. This justifies investigations on contributive factors and measures forprecocious detection of skin tumors to improve early detection and to increase survival rates. The purpose ofthis survey was to collect information about knowledge, attitudes and behaviors on prevention in relation toskin checks for early signs of skin cancer on a sample of secondary school students and teachers.Methods: A sample of secondary school students and teachers from Palermo, was recruited using the clustersampling method. A self-administered questionnaire, consisting of twenty four multiple choice questions wasused as the survey instrument. Statistical analysis of data obtained was performed using Openstat software.Results: The research showed a good level of awareness about skin cancer risk factors, which seemed to bestrictly correlated with age. On the contrary, practice of skin self-examination (SSE) is not as widespread, andonly 4,8% regularly checked the parts of their bodies most exposed to the risk of developing skin cancer. Bothstudents and teachers indicated that school-based health education programs are the best way to promotethe importance of prevention.Conclusions: In many countries mortality is not increasing at the same rate as incidence for MM. The practiceof SSE may play a vital role in improving early detection and survival rates. Therefore, school interventions topromote knowledge of the benefits of regular SSE should be implemented.

Treating Recurrent Cases of Squamous Cell Carcinoma with Radiotherapy

Patients with chronic lymphocytic leukemia (CLL) are at a significantly increased risk of developing cutaneous squamous cell carcinoma (SCC), in part because of their impaired immunosurveillance. Here, we report the cases of 4 patients with CLL who had locally aggressive cutaneous scc managed with radiotherapy for local recurrence following surgical excision. All tumours were located in the head-and-neck region. All patients initially achieved complete regression of disease; however, 2 had local recurrence a mean of 8 months after treatment completion. One patient died from progressive SCC. Our findings agree with the high rates reported in literature of multiple tumours, local recurrence, metastases, and mortality from scc in patients with cll. Radiotherapy plays an important role in patient management, and it is the recommended treatment modality when complete surgical excision of disease would result in anatomic and functional defects. Radiotherapy is often used in the case of local recurrence after one or more attempts at surgical excision. Dose escalation through intensity-modulated radiotherapy, hyperfractionation, or novel treatment techniques such as high-intensity focused ultrasound may be explored to improve local control of scc lesions. To optimize patient outcomes, cutaneous SCC arising in patients with a history of cll should be managed and followed in a multidisciplinary clinic, with regular skin surveillance and prompt treatment.

Genetic Testing for Melanoma Predisposition

A complex interaction of genetic, host, and environmental factors results in cutaneous malignant melanoma, the fifth most common cancer among men and the sixth among women in the United States. Mortality rates for cutaneous malignant melanoma depend on stage at diagnosis; thus, efforts are aimed at early detection and identification of risk factors for melanoma to distinguish those individuals requiring close surveillance. Melanoma susceptibility genes CDKN2A and CDK4 play a role in the development of melanoma, especially among some familial melanoma kindreds. The functions of CDKN2A and CDK4 in melanoma development, however, are currently incompletely understood. Therefore, at this time, predictive genetic testing for CDKN2A mutations outside of defined research protocols is not recommended because of the low likelihood of detecting mutations even in high-risk groups, the present inadequacy of interpreting a test result due to variations in penetrance and unclear associations with other cancers, and the minimal influence knowledge of mutation status currently has on medical management. Oncology nurses have an important role in identifying individuals at high risk for melanoma regardless of CDKN2A mutation status, encouraging enrollment in skin surveillance programs, and providing patient education regarding sun protection, prevention and early detection of melanoma.

Keratotic Skin Lesions and Other Risk Factors Are Associated with Skin Cancer in Organ-Transplant Recipients: A Case–Control Study in The Netherlands, United Kingdom, Germany, France, and Italy

This study examines the association of keratotic skin lesions with the development of skin cancer in 915 solid organ-transplant recipients in five European countries. In a hospital-based case-control study, cases with squamous- and basal-cell carcinoma were compared with controls without skin cancer. Questionnaires, scrutiny of medical charts, and skin examination were delivered according to a standardized protocol. Keratotic skin lesions and viral warts were counted on different body sites. Keratotic skin lesions were strongly associated with an increased risk of squamous-cell carcinoma, with adjusted odds ratios of 4.1 (2.4;7.0) and 12.1 (6.1;24) for 1-49 and 50 and more keratotic skin lesions compared with no lesions, respectively. Keratotic skin lesions were also associated with basal-cell carcinoma with adjusted odds ratios of 2.9 (1.7;4.9) and 4.0 (1.7;9.2) for 1-49 and 50 and more lesions, respectively. Lighter skin types and painful sunburns were also significantly associated with an increased risk of squamous- and basal-cell carcinoma. Keratotic skin lesions are strongly associated with skin cancer and are, thus, an important clinical criterion for identifying those organ-transplant recipients at an increased risk of skin cancers who should be offered more intensive skin surveillance.

Monitoring of Kindreds With Hereditary Predisposition for Cutaneous Melanoma and Dysplastic Nevus Syndrome: Results of a Swedish Preventive Program

To evaluate a program initiated in 1987 by the Swedish Melanoma Study Group aiming to provide preventive surveillance to kindreds with hereditary cutaneous melanoma and dysplastic nevus syndrome. Overall, 2,080 individuals belonging to 280 melanoma families were followed for 14 years between 1987 and 2001 at 12 participating centers. Data were registered in a central database. Among 1,912 skin lesions excised during follow-up, 41 melanomas were removed in 32 individuals. Of these, 15 (37%) were in situ melanomas and 26 (63%) invasive melanomas. The median tumor thickness of invasive melanomas was 0.5 mm. Ulceration was absent in 24 of 26 invasive melanomas (92%) and 12 (46%) lacked vertical growth phase. Compared with melanomas in the general Swedish population, the melanomas identified in these kindreds during follow-up had better prognostic characteristics. All melanomas except one were diagnosed in families with two or more first-degree relatives with melanoma. Diagnosis of melanoma occurred in three of eight kindreds with germline CDKN2A mutations, supporting that families with such mutations are at increased risk for melanoma development. Of the 32 individuals who developed melanoma during follow-up, 21 (66%) had had at least one previously diagnosed melanoma. This study shows that a coordinated program aimed at detecting and offering skin surveillance in kindreds with hereditary cutaneous melanoma results in a low incidence of melanomas during the follow-up period and that the tumors that do arise have favorable prognostic characteristics.

Occupational dermatitis related to chromium and cobalt: experience of dermatologists (EPIDERM) and occupational physicians (OPRA) in the U.K. over an 11-year period (1993?2004)

Chromium and cobalt (and their compounds) are well recognized as being important causes of occupational contact dermatitis (OCD), particularly of the hands, although their exact contribution to occupational hand dermatitis varies between different studies. In some European studies, cases of chromium-related dermatitis have decreased following the addition of ferrous sulphate to cement to reduce the amount of available chromium. To examine, using data from the U.K. occupational skin surveillance schemes, the proportionate reported incidence and changing trends in OCD considered to be related to chromium and cobalt for the 11-year period from February 1993 to December 2004. Surveillance data collected by the two British occupational health surveillance schemes, EPIDERM and OPRA, from February 1993 to December 2004 were studied. These are occupational health surveillance schemes in the U.K. to which physicians voluntarily and anonymously report new cases of skin disease suspected to be work related. Over the 11-year period, dermatologists reported 22 184 cases of OCD, comprising 77% of all types of occupational skin diseases that were disclosed. Chromium was recorded as being thought to play a role in 1226 (6%) of these, with cobalt identified as being likely to be implicated in 823 (4%). The numbers fluctuated on a year-on-year basis but there were no overall trends during the period of study. The male/female ratio was 5 : 1 for chromium and 1 : 1 for cobalt. Overall, the male/female ratio for OCD was 1.4 : 1. The rates of dermatitis believed to be related to both metals generally increased with age. In women, the highest rate for chromium was seen in the > 60 years age group, whereas conversely, for cobalt the rate decreased with age. For chromium-related OCD the most common occupations were builders and building contractors, bricklayers, construction workers and plasterers. For cobalt-related OCD, the commonest occupations were hairdressers/barbers, builders/building contractors, retail cash/checkout operators, machine operatives and domestic cleaners. Occupational physicians reported 15 016 cases of OCD (82% of all occupational skin diseases reported by them) for the period May 1994-December 2004. Of these, only 38 cases were thought to be related to chromium and 30 to cobalt (25 of the latter were processing labourers). In this series, chromium was reported by dermatologists as potentially being involved in 6% of all cases of OCD in the U.K., and cobalt in 4%. Our data support the view that chromium-related dermatitis has an onset in later working life and often affects those in the building trades, whereas cobalt-related dermatitis seems to have an earlier onset and may affect a wide range of employments.

Prevalence and Correlates of Sun Protection and Skin Self-Examination Practices Among Cutaneous Malignant Melanoma Survivors

Little is known about the level of engagement and correlates of sun protection and skin self-exam among individuals diagnosed with melanoma. Participants (N = 229) completed measures of skin self-exam and sun protection practice and knowledge and attitudes. Approximately eighty-four percent of patients reported engaging in skin self-examination at least once in the past year. Engagement in sun protection practices was moderate. Self-exam practice was associated with gender, physician recommendation about self-exam, and perceived benefits and barriers of self-exam. Sun protection was associated with gender, age, medical status and health care access, physician recommendation, knowledge, and a number of psychological factors. Behavioral interventions to improve skin surveillance and sun protection may benefit from an emphasis on physician education regarding self-exam and sun protection, education regarding the efficacy of sunscreen and the risks associated with sunbathing, reducing perceived barriers to self-exam and sun protection, and reducing reliance on social influences on sun protection practices.

Review of Patients with Basal Cell Nevus Syndrome

To review patients with basal cell nevus syndrome (BCNS), documenting presentation, referrals, treatment patterns, and associated morbidity. Cross-sectional review and retrospective data collection of 39 patients with BCNS. Patients from the BCNS support group were invited to be examined. Demographics, presenting features, associated pathologies, and treatment modalities were recorded. Demographic data, age at presentation, age at diagnosis, spectrum of ophthalmic and periocular disease, treatment modalities used, and periocular deformities developed were reviewed. Thirty-nine patients were included with age range of 5 to 72 years. Presenting clinical features included odontogenic keratocyst in 17 patients and basal cell carcinoma in 13 patients; less common presentations were with congenital malformations (n = 2), with ophthalmic associations (n = 3), and at genetic counseling (n = 4). Seventeen of the 39 patients confirmed a parental diagnosis of BCNS. Basal cell carcinoma developed in 18 of the 28 patients before the age of 30, confirming the reported early age of onset. Periocular basal cell carcinoma was reported in 24 of 39 patients (61%), with recurrent disease reported in 17 of these 24 (71%), despite a variety of treatment modalities used. Associated ophthalmic features were multiple eyelid cysts (15 patients), strabismus (9 patients), myopia (5 patients), hyperopia (7 patients), cataracts (5 patients), myelinated nerve fibers (3 patients), amblyopia (3 patients), and nystagmus and iris transillumination defects (2 patients each). All patients were involved in multidisciplinary medical care. Patients with BCNS frequently have ophthalmic manifestations, particularly periocular basal cell carcinoma. Multidisciplinary care is essential in the care of the patient with BCNS. Early diagnosis of BCNS may allow for skin protection and surveillance at an earlier age.

Predicting Risk for the Appearance of Melanoma

Predicting Risk for the Appearance of Melanoma

New strains of community-acquired methicillin-resistant Staphylococcus aureus with Panton–Valentine leukocidin causing an outbreak of severe soft tissue infection in a football team

A new category of methicillin-resistant Staphylococcus aureus (MRSA), designated community-acquired MRSA (CA-MRSA), has been noted increasingly in the community in the past 14 years [1]. CA-MRSA strains have different genetic backgrounds than hospital-acquired MRSA, as evidenced by pulsed-field gel electrophoresis (PFGE) patterns, and thus do not descend from nosocomial strains. They also carry a novel staphylococcal cassette chromosome (SCC) mec type IV element, which is differentiated from the hospital-acquired MRSA SCCmec types I-III by its smaller size and the absence of non-s-lactam genetic resistance determinants. In addition, CA-MRSA strains replicate more rapidly than hospital-acquired MRSA strains, they have a better ability to colonize humans, and they possess genes for different toxins [2]. Major risk factors for CA-MRSA colonization, as recognized by Ellis et al. [3], are treatment with systemic antibiotics and skin trauma. The strains producing Panton–Valentine leukocidin cause furunculosis and severe necrotic hemorrhagic pneumonia in otherwise healthy individuals [3, 4]. Outbreaks have been described in day-care and athletic settings. Sport teams are especially vulnerable to infections with these strains because of frequent skin trauma and close contact of team members [4]. In order to detect outbreaks of new CAMRSA, molecular typing [5–8] should be performed and virulence genes detected [9]. Reported here is an outbreak of severe soft tissue infection affecting a football team, which was caused by a new strain of community-acquired methicillin-resistant Staphylococcus aureus carrying the Panton–Valentine leukocidin gene. From July to October 2004, a football team consisting of 26 members (24 players, a coach and a masseur, all male) was affected by a severe, highly transmissible CA-MRSA soft tissue infection. In order to diagnose the infection and investigate the genetic background and virulence of the involved strains, we studied 246 specimens obtained from the team members’ furuncles, skin and nasal surveillance cultures and postoperative wounds. Specimens were plated onto blood agar and oxacillin resistance screening agar base (ORSAB) medium. Isolates were identified as S. aureus by their growth as yellow colonies, with or without hemolysis on blood agar and by the results of Gram staining, catalase, DNase test and tube coagulase test. Blue-colored colonies that appeared after 2 or 3 days of incubation on ORSABmedium were suspected of being possible MRSA. Susceptibility testing was performed using the Kirby–Bauer disk diffusion method, as recommended by the Clinical and Laboratory Standards Institute (formerly NCCLS) [10]. Methicillin resistance was determined using the 1 μg oxacillin disk method and confirmed by oxacillin plate (Mueller–Hinton agar containing 4% NaCl and 6 μg/ml oxacillin), cefoxitin disk and Etest methods. Susceptibility to penicillin, erythromycin, clindamycin, trimethoprim/sulfamethoxazole, vancomycin, rifampin, gentamicin, ciprofloxacin, teicoplanin, linezolid, mupirocin and fusidic acid was determined. Oxacillin resistance was confirmed by the simultaneous detection of M. Muller-Premru (*) . K. Seme . N. S. Kucina . V. Spik . M. Gubina Institute of Microbiology and Immunology, Medical Faculty, Zaloska 4, Ljubljana, Slovenia e-mail: manica.mueller-premru@mf.uni-lj.si Tel.: +386-1-5437425 Fax: +386-1-5437401

Risk of melanoma following adulthood cancer: A case-control study

Melanoma is a severe skin cancer related to sun exposure. Whether this malignancy is linked to exposure to ionising radiation during adulthood is still controversial. This case-control study examined the risk of melanoma following treatment for an adulthood first malignant neoplasm (FMN). Cases were patients who presented with cutaneous melanoma after a first cancer in adulthood. Controls (3 per case) were patients free of melanoma, matched for age, duration of follow-up since the FMN, type of FMN, and followed in the same institution. A total of 57 cases and 171 controls were included. In the final multivariate analysis, no risk of melanoma was associated with radiotherapy (odds ratio (OR) for 1 Gy = 1.01, 95% confidence interval (95%CI) 0.96–1.07) nor hormonotherapy, whereas chemotherapy use (OR = 2.3, 95%CI 0.93–5.6) and having a history of familial cancer (OR = 2.8, 95%CI 1.3–5.9) exhibited a nearly significant risk. In conclusion, unlike the evidence for risk of exposure to ionising radiation during childhood, we did not substantiate a risk for association of melanoma with exposure to ionising radiation during adulthood. The risk associated with chemotherapy should justify the implementation of skin surveillance for early detection of melanoma in these patients.

The incidence of work-related illness in the UK health and social work sector: The Health and Occupation Reporting network 2002–2003

In the United Kingdom, The Health and Occupation Reporting network (THOR) collects incidence data on work-related illness. THOR data show that the health and social work sector generates a high proportion of case reports. This study analyses the most recent data for the health and social work sector, from 2002 to 2003. Cases returned to the Occupational Physicians Reporting Activity (OPRA) scheme and three other specialist schemes (Surveillance of Occupational Stress and Mental Illness, Musculoskeletal Occupational Surveillance Scheme and occupational skin surveillance) were analysed. Estimates of incidence rates for stress-related illness, musculoskeletal disorders and skin disease were calculated using two denominators. In this period, 23% (11,016/47,437) of all estimated cases in THOR were in health and social work sector employees. In OPRA, in the health and social work sector, annual average incidence rates per 100,000 calculated using Labour Force Survey (LFS) data as the denominator were 51.2 for mental illness, 35.9 for musculoskeletal disorders and 10.4 for skin disease; using McDonald's data as the denominator the corresponding rates were 119.5, 83.7 and 24.3. In the specialist THOR schemes, annual average incidence rates per 100,000 using LFS data as the denominator were 18.4 (mental illness), 6.1 (musculoskeletal disorders) and 15.3 (skin disease). Our results highlight the importance of collecting information on incident cases and denominators, to allow calculation of occupational disease rates. The higher incidence of mental illness (compared with musculoskeletal and skin disorders) in this employment sector merits further investigation.

A skin-selective homing mechanism for human immune surveillance T cells.

Effective immune surveillance is essential for maintaining protection and homeostasis of peripheral tissues. However, mechanisms controlling memory T cell migration to peripheral tissues such as the skin are poorly understood. Here, we show that the majority of human T cells in healthy skin express the chemokine receptor CCR8 and respond to its selective ligand I-309/CCL1. These CCR8+ T cells are absent in small intestine and colon tissue, and are extremely rare in peripheral blood, suggesting healthy skin as their physiological target site. Cutaneous CCR8+ T cells are preactivated and secrete proinflammatory cytokines such as tumor necrosis factor–α and interferon-γ, but lack markers of cytolytic T cells. Secretion of interleukin (IL)-4, IL-10, and transforming growth factor–β was low to undetectable, arguing against a strict association of CCR8 expression with either T helper cell 2 or regulatory T cell subsets. Potential precursors of skin surveillance T cells in peripheral blood may correspond to the minor subset of CCR8+CD25− T cells. Importantly, CCL1 is constitutively expressed at strategic cutaneous locations, including dermal microvessels and epidermal antigen-presenting cells. For the first time, these findings define a chemokine system for homeostatic T cell traffic in normal human skin.

Sun protection and skin surveillance practices among relatives of patients with malignant melanoma: prevalence and predictors

Background. Little is known about acceptance of skin cancer risk-reduction practices and attitudes among individuals with a family history of melanoma. The purpose of this study was to examine engagement in and correlates of sun protection, total cutaneous examination (TCE), and skin self-examination (SSE) among first-degree relatives (FDR) of individuals diagnosed with malignant melanoma (MM). Method. First degree relatives ( N = 229) completed measures of engagement in TCE, SSE, and habitual sun protection, as well as measures of knowledge and attitudes about all three behaviors. Results. Slightly more than 50% of family members reported having TCE, and engagement in habitual sun protection was relatively low. Engagement in SSE was higher. Regression analyses revealed that physician recommendation and perceived barriers were consistent correlates of all three risk-reduction behaviors. Self-efficacy and normative influences were also associated with sun protection. Conclusions. Engagement in skin cancer risk-reduction practices among individuals with a family history of melanoma is relatively low. Interventions to improve acceptance would benefit from targeting both nonpsychological and psychological factors, particularly physician influence and perceived barriers.

Is there a role for genetic testing in patients with melanoma?

Autosomal dominant inheritance of mutations in the locus or the gene may confer a high risk of cutaneous melanoma development. The penetrance of mutations is influenced by UV exposure. Inherited variants in the melanocortin-1 receptor also confer increased risk of cutaneous melanoma. Features associated with increased genetic susceptibility to cutaneous melanoma include the presence of multiple affected first-degree relatives on one side of the family, multiple primary melanomas in the same individual, earlier age of onset, and the presence of multiple atypical nevi, but none of these factors reliably predicts for the presence of mutations. It is currently premature to offer predictive DNA testing for melanoma outside of defined research protocols. This is because of (1). the low likelihood of finding mutations in known melanoma susceptibility genes, even in more than 60% of melanoma-prone kindreds; (2). the broad confidence limits on current estimates of lifetime penetrance of mutations and the wide variation in this penetrance with locality; (3). a high "background" incidence of melanoma in non-mutation carriers in melanoma-prone families; (4). current uncertainties about the factors determining the functionality and phenotypic expression of the trait among carriers of these mutations (penetrance), even if found; and (5). the lack of proved efficacy of melanoma prevention and surveillance strategies, even for mutation carriers. Rather than singling out those deemed to be at high risk because of family history, all patients carrying risk factors for cutaneous melanoma should be subject to stringent programs of sun protection and skin surveillance.

Blood is thicker than water: Genetic testing as citizenship through familial obligation and the management of risk

Genetic testing for late onset disease constitutes one aspect of a shift in the organization of public health according to a logic of risk that is based on the surveillance and regulation of normal populations. Using governmentality as a theoretical framework, this paper situates genetic testing as a neoliberal technique of governance that operates by invoking the power of individuals to make informed decisions about their health. Interview data are presented to illustrate how individuals are recruited, and construct themselves, simultaneously as self-regulating agents of health, and as 'carriers' of health risk information. Interviews with study participants who accepted or deferred genetic testing for skin cancer (melanoma) risk revealed that participants felt a responsibility not only to acquire genetic risk information and to manage their genetic risk by modifying their skin surveillance strategies, but also to communicate this information to family members so that they too could refine their risk management strategies to prevent melanoma. It is argued that by fulfilling these duties--to know genetic risk, to manage genetic risk and to carry information about genetic risk--individuals construct themselves as healthy and responsible citizens who collect and deploy genetic risk information in order to protect themselves and their families from disease onset. This paper concludes by considering how 'the carrier' and 'the family' are constituted as objects of, and vehicles for, knowledge concerning genetic risk within neoliberal programmes of governance.