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Figure 1.
Melanoma Overall by Country
Melanoma Overall by Country

Joinpoint regression for trends in age-adjusted incidence of head and neck melanoma among pediatric, adolescent, and young adult patients in Canada, the United States, and both countries combined from 1995 to 2014. Annual percentage changes (APCs) for both countries combined: 1995-2001, 3.71 (95% CI, 1.70-5.75); 2001-2014, 1.21 (95% CI, 0.66-1.76). APC for Canada: 1995-2014, 2.18 (95% CI, 1.15-3.21). APCs for the United States: 1995-2000, 4.68 (95% CI, 1.65-7.81); 2000-2014, 1.15 (95% CI, 0.59-1.71).

Figure 2.
Melanoma by Country and Sex
Melanoma by Country and Sex

Joinpoint regression for trends in age-adjusted incidence of head and neck melanoma among pediatric, adolescent, and young adult patients in Canada, the United States, and both countries combined from 1995 to 2014 stratified by sex. Annual percentage changes (APCs) for both countries combined: male 1995-2002, 5.03 (95% CI, 2.63-7.48); 2002-2005, −4.15 (95% CI, −18.82 to 13.18); 2005-2014, 2.17 (95% CI, 0.67-3.70); female 1995-2014, 2.03 (95% CI, 1.72-2.34). Canada APCs: male 1995-2014, 2.56 (95% CI, 1.11-4.04); female 1995-2014, 1.56 (95% CI, −0.07 to 3.22). United States APCs: male 1995-2001, 4.47 (95% CI, 0.64-8.45); male 2001-2014, 0.57 (95% CI, −0.49 to 1.64); female 1995-2014, 2.08 (95% CI, 1.69-2.46).

Figure 3.
Melanoma by Country and Age
Melanoma by Country and Age

Joinpoint regression for trends in age-adjusted incidence of head and neck melanoma among pediatric, adolescent, and young adult patients in Canada, the United States, and both countries combined from 1995 to 2014 stratified by age at diagnosis. Country and age groups with dotted lines could not have Joinpoint trends calculated because of a cell size lower than 6 for at least 1 year; the dotted lines represent the age-adjusted incidence rate for all years (1995-2014) for those groups. Annual percentage changes (APCs) for both countries combined: age 0 to 14 1995-2003, 13.33 (95% CI, 6.00-21.16); 2003 to 2014, −1.55 (95% CI, −4.64 to 1.64); age 15 to 39 years 1995-2014, 1.71 (95% CI, 1.33-2.10). Canada APC: age 15-39 years 1995-2014, 2.12 (95% CI, 1.09-3.16). United States APCs: age 0 to 14 years 1995-2003, 13.45 (95% CI, 5.60-21.89); 2003-2014, −1.73 (95% CI, −5.02 to 1.68); age 15 to 39 years 1995-2014, 1.67 (95% CI, 1.24-2.10).

Figure 4.
Melanoma in US by Race/Ethnicity
Melanoma in US by Race/Ethnicity

Joinpoint regression for trends in age-adjusted incidence of head and neck melanoma among pediatric, adolescent, and young adult patients in the United States stratified by race/ethnicity. Racial/ethnic groups with dotted lines could not have Joinpoint trends calculated because of a cell size lower than 6 for at least 1 year; the dotted lines represent the age-adjusted incidence rate for all years (1995-2014) for those groups. Hispanic 1995-2014 annual percentage change (APC),  1.18 (95% CI, −0.15 to 2.52); non-Hispanic white 1995-2000, 6.17 (95% CI, 3.41-9.00); 2000-2014, 2.11 (95% CI, 1.60-2.62). AIAN indicates American Indian or Alaska Native; API, Asian or Pacific Islander.

Table.  
Melanoma Counts, Age-Adjusted Incidence Rates, and Rate Ratios by Country, NAACCR CiNA Public Use Data, 1995-2014
Melanoma Counts, Age-Adjusted Incidence Rates, and Rate Ratios by Country, NAACCR CiNA Public Use Data, 1995-2014
1.
Siegel  RL, Miller  KD, Jemal  A.  Cancer statistics, 2019.  CA Cancer J Clin. 2019;69(1):7-34. doi:10.3322/caac.21551PubMedGoogle ScholarCrossref
2.
Canadian Cancer Society. Canadian cancer statistics: a 2018 special report. http://cancer.ca/Canadian-Cancer-Statistics-2018-EN. Published June 2018. Accessed April 17, 2019.
3.
Pollack  LA, Li  J, Berkowitz  Z,  et al.  Melanoma survival in the United States, 1992 to 2005.  J Am Acad Dermatol. 2011;65(5)(suppl 1):S78-S86. doi:10.1016/j.jaad.2011.05.030PubMedGoogle ScholarCrossref
4.
Pruthi  DK, Guilfoyle  R, Nugent  Z, Wiseman  MC, Demers  AA.  Incidence and anatomic presentation of cutaneous malignant melanoma in central Canada during a 50-year period: 1956 to 2005.  J Am Acad Dermatol. 2009;61(1):44-50. doi:10.1016/j.jaad.2009.01.020PubMedGoogle ScholarCrossref
5.
O’Brien  CJ, Coates  AS, Petersen-Schaefer  K,  et al.  Experience with 998 cutaneous melanomas of the head and neck over 30 years.  Am J Surg. 1991;162(4):310-314. doi:10.1016/0002-9610(91)90138-4PubMedGoogle ScholarCrossref
6.
Golger  A, Young  DS, Ghazarian  D, Neligan  PC.  Epidemiological features and prognostic factors of cutaneous head and neck melanoma: a population-based study.  Arch Otolaryngol Head Neck Surg. 2007;133(5):442-447. doi:10.1001/archotol.133.5.442PubMedGoogle ScholarCrossref
7.
Lachiewicz  AM, Berwick  M, Wiggins  CL, Thomas  NE.  Survival differences between patients with scalp or neck melanoma and those with melanoma of other sites in the Surveillance, Epidemiology, and End Results (SEER) program.  Arch Dermatol. 2008;144(4):515-521. doi:10.1001/archderm.144.4.515PubMedGoogle ScholarCrossref
8.
Richards  MK, Czechowicz  J, Goldin  AB,  et al.  Survival and surgical outcomes for pediatric head and neck melanoma.  JAMA Otolaryngol Head Neck Surg. 2017;143(1):34-40. doi:10.1001/jamaoto.2016.2630PubMedGoogle ScholarCrossref
9.
Wong  JR, Harris  JK, Rodriguez-Galindo  C, Johnson  KJ.  Incidence of childhood and adolescent melanoma in the United States: 1973-2009.  Pediatrics. 2013;131(5):846-854. doi:10.1542/peds.2012-2520PubMedGoogle ScholarCrossref
10.
Barr  RD, Ries  LA, Lewis  DR,  et al; US National Cancer Institute Science of Adolescent and Young Adult Oncology Epidemiology Working Group.  Incidence and incidence trends of the most frequent cancers in adolescent and young adult Americans, including “nonmalignant/noninvasive” tumors.  Cancer. 2016;122(7):1000-1008. doi:10.1002/cncr.29867PubMedGoogle ScholarCrossref
11.
National Cancer Advisory Board. Closing the gap: research and care imperatives for adolescents and young adults with cancer: report of the Adolescent and Young Adult Oncology Progress Review Group. https://deainfo.nci.nih.gov/advisory/ncab/archive/139_0906/presentations/AYAO.pdf. Published September 6, 2006. Accessed July 30, 2019.
12.
Strouse  JJ, Fears  TR, Tucker  MA, Wayne  AS.  Pediatric melanoma: risk factor and survival analysis of the surveillance, epidemiology and end results database.  J Clin Oncol. 2005;23(21):4735-4741. doi:10.1200/JCO.2005.02.899PubMedGoogle ScholarCrossref
13.
McWhirter  JE, Byl  S, Green  A, Sears  W, Papadopoulos  A.  Availability of tanning salons in Ontario relative to indoor tanning policy (2001-2017).  Prev Med Rep. 2018;12:40-45. doi:10.1016/j.pmedr.2018.08.010PubMedGoogle ScholarCrossref
14.
International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer.  The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review.  Int J Cancer. 2007;120(5):1116-1122.PubMedGoogle Scholar
15.
Friedman  RJ, Rigel  DS, Kopf  AW.  Early detection of malignant melanoma: the role of physician examination and self-examination of the skin.  CA Cancer J Clin. 1985;35(3):130-151. doi:10.3322/canjclin.35.3.130PubMedGoogle ScholarCrossref
16.
Centers for Disease Control and Prevention (CDC).  Use of indoor tanning devices by adults—United States, 2010.  MMWR Morb Mortal Wkly Rep. 2012;61(18):323-326.PubMedGoogle Scholar
17.
Austin  MT, Xing  Y, Hayes-Jordan  AA, Lally  KP, Cormier  JN.  Melanoma incidence rises for children and adolescents: an epidemiologic review of pediatric melanoma in the United States.  J Pediatr Surg. 2013;48(11):2207-2213. doi:10.1016/j.jpedsurg.2013.06.002PubMedGoogle ScholarCrossref
18.
NAACCR Incidence—CiNA Public File, 1995-2015 (which includes data from CDC’s National Program of Cancer Registries (NPCR), CCCR’s Provincial and Territorial Registries, and the NCI’s Surveillance, Epidemiology and End Results (SEER) Registries), North American Association of Central Cancer Registries.
19.
Description of CiNA public use dataset. https://www.naaccr.org/wp-content/uploads/2018/09/5-Appendix-A.-CiNA-Public-Use-Dataset.pdf. Accessed August 2, 2018.
20.
National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Site recode ICD-O-3/WHO 2008 definition. https://seer.cancer.gov/siterecode/icdo3_dwhoheme/index.html. Accessed August 3, 2018.
21.
National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Standard populations (millions) for age-adjustment. https://seer.cancer.gov/stdpopulations/. Accessed January 23, 2019.
22.
National Cancer Institute. Surveillance Research Program. Linear or log-linear model. https://surveillance.cancer.gov/help/joinpoint/tech-help/frequently-asked-questions/linear-or-log-linear-model. Accessed August 3, 2018.
23.
National Cancer Institute. Surveillance Research Program. Selecting the final model. https://surveillance.cancer.gov/help/joinpoint/tech-help/frequently-asked-questions/selecting-the-final-model. Accessed August 3, 2018.
24.
Lesage  C, Barbe  C, Le Clainche  A, Lesage  F-X, Bernard  P, Grange  F.  Sex-related location of head and neck melanoma strongly argues for a major role of sun exposure in cars and photoprotection by hair.  J Invest Dermatol. 2013;133(5):1205-1211. doi:10.1038/jid.2012.405PubMedGoogle ScholarCrossref
25.
Green  AC, Kimlin  M, Siskind  V, Whiteman  DC.  Hypothesis: hair cover can protect against invasive melanoma on the head and neck (Australia).  Cancer Causes Control. 2006;17(10):1263-1266. doi:10.1007/s10552-006-0063-1PubMedGoogle ScholarCrossref
26.
Weir  HK, Marrett  LD, Cokkinides  V,  et al.  Melanoma in adolescents and young adults (ages 15-39 years): United States, 1999-2006.  J Am Acad Dermatol. 2011;65(5)(suppl 1):S38-S49. doi:10.1016/j.jaad.2011.04.038PubMedGoogle ScholarCrossref
27.
Brenner  M, Hearing  VJ.  The protective role of melanin against UV damage in human skin.  Photochem Photobiol. 2008;84(3):539-549. doi:10.1111/j.1751-1097.2007.00226.xPubMedGoogle ScholarCrossref
28.
Wu  XC, Eide  MJ, King  J,  et al.  Racial and ethnic variations in incidence and survival of cutaneous melanoma in the United States, 1999-2006.  J Am Acad Dermatol. 2011;65(5)(suppl 1):S26-S37. doi:10.1016/j.jaad.2011.05.034PubMedGoogle ScholarCrossref
29.
Stough  D, Stenn  K, Haber  R,  et al.  Psychological effect, pathophysiology, and management of androgenetic alopecia in men.  Mayo Clin Proc. 2005;80(10):1316-1322. doi:10.4065/80.10.1316PubMedGoogle ScholarCrossref
30.
Li  W-Q, Cho  E, Han  J, Weinstock  MA, Qureshi  AA.  Male pattern baldness and risk of incident skin cancer in a cohort of men.  Int J Cancer. 2016;139(12):2671-2678. doi:10.1002/ijc.30395PubMedGoogle ScholarCrossref
31.
Madigan  LM, Lim  HW.  Tanning beds: impact on health, and recent regulations.  Clin Dermatol. 2016;34(5):640-648. doi:10.1016/j.clindermatol.2016.05.016PubMedGoogle ScholarCrossref
32.
Robinson  JK, Rigel  DS, Amonette  RA.  Trends in sun exposure knowledge, attitudes, and behaviors: 1986 to 1996.  J Am Acad Dermatol. 1997;37(2 Pt 1):179-186. doi:10.1016/S0190-9622(97)80122-3PubMedGoogle ScholarCrossref
33.
Chang  C, Murzaku  EC, Penn  L,  et al.  More skin, more sun, more tan, more melanoma.  Am J Public Health. 2014;104(11):e92-e99. doi:10.2105/AJPH.2014.302185PubMedGoogle ScholarCrossref
34.
National Toxicology Program. Report on Carcinogens, Tenth Edition: Carcinogen Profiles 2002. Research Triangle Park, NC: US Dept. of Health and Human Services, Public Health Service, National Toxicology Program; 2002.
35.
World Health Organization.  Artificial Tanning Sunbeds: Risks and Guidance. Geneva, Switzerland: World Health Organization; 2003.
36.
Nadalin  V, Marrett  LD, Cawley  C, Minaker  LM, Manske  S.  Intentional tanning among adolescents in seven Canadian provinces: provincial comparisons (CRAYS 2015).  Prev Med. 2018;111:225-230. doi:10.1016/j.ypmed.2018.03.004PubMedGoogle ScholarCrossref
37.
Office of Disease Prevention and Health Promotion. Healthy people 2020. https://www.healthypeople.gov/2020/topics-objectives/2020-Topics-and-Objectives-Objectives-A-Z. Accessed August 3, 2018.
38.
Bibbins-Domingo  K, Grossman  DC, Curry  SJ,  et al; US Preventive Services Task Force.  Screening for skin cancer: US Preventive Services Task Force recommendation statement.  JAMA. 2016;316(4):429-435. doi:10.1001/jama.2016.8465PubMedGoogle ScholarCrossref
39.
Tsao  H, Weinstock  MA.  Visual inspection and the US Preventive Services Task Force recommendation on skin cancer screening.  JAMA. 2016;316(4):398-400. doi:10.1001/jama.2016.9850PubMedGoogle ScholarCrossref
40.
Nahar  VK, Mayer  JE, Grant-Kels  JM.  The case for skin cancer screening with total-body skin examinations.  JAMA Oncol. 2016;2(8):999-1001. doi:10.1001/jamaoncol.2016.2440PubMedGoogle ScholarCrossref
41.
Swetter  SM, Geller  AC, Halpern  AC.  What the USPSTF “insufficient” skin cancer screening recommendation means for primary care clinicians and dermatologists.  JAMA Dermatol. 2016;152(9):973-975. doi:10.1001/jamadermatol.2016.2606PubMedGoogle ScholarCrossref
42.
Linos  E, Katz  KA, Colditz  GA.  Skin cancer—the importance of prevention.  JAMA Intern Med. 2016;176(10):1435-1436. doi:10.1001/jamainternmed.2016.5008PubMedGoogle ScholarCrossref
43.
Smith  RA, Brooks  D, Cokkinides  V, Saslow  D, Brawley  OW.  Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening.  CA Cancer J Clin. 2013;63(2):88-105. doi:10.3322/caac.21174PubMedGoogle ScholarCrossref
44.
Williams  MS, Buhalog  B, Blumenthal  L, Stratman  EJ.  Tanning salon compliance rates in states with legislation to protect youth access to UV tanning.  JAMA Dermatol. 2018;154(1):67-72. doi:10.1001/jamadermatol.2017.3736PubMedGoogle ScholarCrossref
45.
Abbasi  NR, Shaw  HM, Rigel  DS,  et al.  Early diagnosis of cutaneous melanoma: revisiting the ABCD criteria.  JAMA. 2004;292(22):2771-2776. doi:10.1001/jama.292.22.2771PubMedGoogle ScholarCrossref
46.
Lovasik  BP, Sharma  I, Russell  MC, Carlson  GW, Delman  KA, Rizzo  M.  Invasive scalp melanoma: role for enhanced detection through professional training.  Ann Surg Oncol. 2016;23(12):4049-4057. doi:10.1245/s10434-016-5334-9PubMedGoogle ScholarCrossref
47.
Yang  C, Gru  AA, Dehner  LP.  Common and not so common melanocytic lesions in children and adolescents.  Pediatr Dev Pathol. 2018;21(2):252-270. doi:10.1177/1093526617751720PubMedGoogle ScholarCrossref
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    Original Investigation
    October 3, 2019

    Head and Neck Melanoma Incidence Trends in the Pediatric, Adolescent, and Young Adult Population of the United States and Canada, 1995-2014

    Author Affiliations
    • 1Saint Louis University School of Medicine, Department of Otolaryngology–Head and Neck Surgery, St Louis, Missouri
    • 2Saint Louis University Cancer Center, St Louis, Missouri
    • 3Medical student, Saint Louis University School of Medicine, St Louis, Missouri
    • 4Sisters of Saint Mary Cardinal Glennon Children's Medical Center, Department of Pediatric Otolaryngology, St Louis, Missouri
    • 5Saint Louis University School of Medicine, Division of Plastic and Reconstructive Surgery, St Louis, Missouri
    • 6Mayo Clinic Jacksonville, Department of Dermatology, Jacksonville, Florida
    • 7Saint Louis University School of Medicine, Department of Dermatology, St Louis, Missouri
    JAMA Otolaryngol Head Neck Surg. Published online October 3, 2019. doi:10.1001/jamaoto.2019.2769
    Key Points

    Question  What are the incidence trends for pediatric, adolescent, and young adult head and neck melanoma in the United States and Canada?

    Findings  In this population-based, North American Association of Central Cancer Registries study of 12 462 cases in the United States and Canada, head and neck melanoma increased by 51.1% from 1995 to 2014 in both countries combined. In the United States, this increasing incidence was mainly associated with white males, aged 15 to 39 years.

    Meaning  The apparent increasing incidence of head and neck melanoma among the pediatric, adolescent, and young adult population of North America warrants increasing public health awareness and education, especially among males.

    Abstract

    Importance  Melanoma is one of the most common cancers worldwide, typically diagnosed in older adults. There is an increasing incidence in the younger population (age ≤40 years) in America. In addition, approximately 1 in 5 cases of melanoma affect the head and neck. However, there are limited data on the incidence of head and neck melanoma in the pediatric, adolescent, and young adult population in North America (United States and Canada).

    Objective  To assess 20-year demographic and incidence changes associated with head and neck melanoma in the pediatric, adolescent, and young adult population in North America.

    Design, Setting, and Participants  A descriptive analysis of retrospective data on head and neck melanoma from the North American Association of Central Cancer Registries’ Cancer in North America public use data set from 1995 to 2014 was conducted. The data set currently includes 93% of the United States and 64% of the Canadian populations. Eligible data were from 12 462 pediatric, adolescent, and young adult patients (aged 0-39 years) with a confirmed diagnosis of melanoma (International Classification of Diseases–Oncology 3 histologic types 8720-8790) in primary head and neck sites: skin of lip, not otherwise specified (C44.0); eyelid (C44.1); external ear (C44.2); skin of other/unspecified parts of face (C44.3); and skin of scalp and neck (C44.4). The study was conducted from January 26 to July 21, 2019.

    Main Outcomes and Measures  Log-linear regression was used to estimate annual percentage change in age-adjusted incidence rates (AAIRs) of head and neck melanoma.

    Results  Of the 12 462 patients with head and neck melanoma included in the study, 6810 were male (54.6%). The AAIR was 0.51 per 100 000 persons (95% CI, 0.50-0.52 per 100 000 persons). In North America, the incidence of head and neck melanoma increased by 51.1% from 1995 to 2014. The rate was higher in the United States (AAIR, 0.52; 95% CI, 0.51-0.53 per 100 000 person-years) than Canada (AAIR, 0.43; 95% CI, 0.40-0.45 per 100 000 persons). In the United States, the incidence increased 4.68% yearly from 1995 to 2000 and 1.15% yearly from 2000 to 2014. In Canada, the incidence increased 2.18% yearly from 1995 to 2014. Male sex (AAIR, 0.55; 95% CI, 0.54-0.57 per 100 000 persons), older age (AAIR, 0.79; 95% CI, 0.79-0.80 per 100 000 persons), and non-Hispanic white race/ethnicity (AAIR, 0.79; 95% CI, 0.77-0.80 per 100 000 persons) were associated with an increased incidence of head and neck melanoma.

    Conclusions and Relevance  The incidence of pediatric, adolescent, and young adult head and neck melanoma in North America appears to have increased by 51.1% in the past 2 decades, with males aged 15 to 39 years the main cohort associated with the increase.

    Introduction

    Melanoma is commonly diagnosed in North America (the United States and Canada). In the United States, melanoma is the fifth most commonly diagnosed cancer in both males and females, with an estimated 96 480 new cases in 2019—a 5.4% increase over 2018.1 In Canada, melanoma is the seventh most common cancer in males and females, with 7200 new cases diagnosed in 2017.2

    Between 18% and 22% of new melanoma cases (about 1 in every 5) may be found in the head and neck region, relative to other more common melanoma sites, such as the trunk and upper extremities.3,4 However, a diagnosis of melanoma in the scalp and/or neck typically portends poor prognosis compared with other anatomic sites.5-8 Although the 5-year survival rate of head and neck melanoma is better among pediatric than adult cases,8 in general, it is worse than the 10-year survival for other sites,7 highlighting the need for ongoing surveillance of this subsite.

    In addition, while the mean age at diagnosis of melanoma is 63 years, it is the most common skin cancer among pediatric and adolescent patients.9,10 The National Cancer Institute defines ages 15 to 39 years as adolescent and young adult,11 and risk factors for melanoma, such as sun exposure and use of indoor tanning beds, are most common among adolescents and young adults in North America.9,12,13 The use of tanning equipment across the pediatric, adolescent, and young adult age spectrum (aged ≤35 years) is known to increase melanoma risk by 35% to 126%.14 While increasing awareness of melanoma has been a public health imperative for decades with the ABCD (asymmetry, border, color, diameter) acronym for early melanoma recognition,15 and although legislation aimed at tanning facilities may have helped to reduce exposure to known melanoma risk factors, indoor tanning remains most prevalent among individuals aged 18 to 25 years.16 Whether there are changes in the incidence of head and neck melanoma in North America relative to risk mitigation legislation is unknown to date. With the increasing incidence of melanoma among children and adolescents9,17 and poor prognosis in the head and neck subsite, ongoing disease surveillance is necessitated. The aim of this study was to test the hypothesis that head and neck melanoma is increasing in incidence among the pediatric, adolescent, and young adult population of the United States and Canada. To our knowledge, this study represents a novel description of head and neck melanoma incidence trends in North America.

    Methods
    Data Source

    Patients from the North American Association of Central Cancer Registries’ (NAACCR) Cancer in North America (CiNA) public use data set were included in this study. This data set comprises registries within the National Program of Cancer Registries; the Cancer Committee at the Center for Cancer Care & Research Provincial and Territorial Registries; Surveillance, Epidemiology, and End Results (SEER); and the North American Association of Central Cancer Registry.18 Current CiNA data include 93% of the US population and 64% of the Canadian population.19 Because NAACCR CiNA is a publicly available database with deidentified data, the Saint Louis University Institutional Review Board determined that this study did not require submission to the review board because NAACCR CiNA is a publicly available database with deidentified data. This study was conducted from January 26 to July 21, 2019.

    Study Population

    The study included patients aged 0 to 39 years diagnosed with head and neck melanoma. Based on the International Classification of Diseases–Oncology 3 (ICD-O-3) codes, primary sites included skin of lip, not otherwise specified (C44.0); eyelid (C44.1); external ear (C44.2); skin of other/unspecified parts of face (C44.3); and skin of scalp and neck (C44.4). Melanoma was defined using ICD-O-3 histologic types 8720 to 8790,20 and all eligible cancers were included.

    To maintain population consistency over the study period, only registries that provided data to the CiNA from 1995 to 2014 were included. While CiNA provides data through 2015, only data through 2014 were included in this study because there were no data in 2015 for Ontario, which is Canada's most populous province. Our analytic sample included data from 26 states of the United States and 6 provinces of Canada (eAppendix in the Supplement).

    Statistical Analysis

    We used SEER*Stat, version 8.3.5 (Surveillance Research Program, National Cancer Institute) to calculate overall and yearly age-adjusted incidence rates (AAIRs) for head and neck melanoma diagnosed from 1995 to 2014 for Canada, the United States, and both countries combined. The AAIRs were stratified by sex (female, male), age at diagnosis (pediatric [0-14 years], National Cancer Institute–defined adolescent and young adult [15-39 years]patients),11 and head and neck subanatomic site. The AAIRs for the United States were further stratified by race/ethnicity (Hispanic, non-Hispanic white, non-Hispanic black or other); race/ethnicity information is not provided by Canadian registries. The AAIRs for both countries were age adjusted in SEER*Stat using the 2000 US standard population.21 All AAIRs are reported as incidence per 100 000 persons. To compare AAIRs in Canada and the United States, 95% CIs for AAIRs were used. SEER*Stat also computed rate ratios (RRs) and 95% CIs for AAIRs between a reference group and other values for each variable within each country grouping.

    Joinpoint Regression Program, version 4.6.0.0 (Statistical Methodology and Applications Branch, Surveillance Research Program, National Cancer Institute) was used to determine the time periods for significant increases or decreases in AAIRs through Joinpoint regression models. Joinpoint regression models determined the starting and ending years of AAIR increases/decreases (Joinpoints) and then estimated the annual percentage change (APC) and 95% CIs in rates based on a regression model between the 2 Joinpoint years. The Joinpoint models were based on log-transformed AAIRs to better ensure normality of residuals.22 The permutation test method (Joinpoint’s default method) determined the model with the fewest number of Joinpoints necessary to characterize trends23 with a maximum of 3 Joinpoints. Trends with multiple APCs were summarized with average APCs (AAPC). We computed Joinpoint regressions for all stratification variables. While beyond the scope of the present study, the incidence trends among patients aged 40 years or older are included for comparison in eFigure 4 in the Supplement. Because CiNA suppresses output for rates based on fewer than 6 cases, some variable groupings did not have Joinpoint regression estimates. Significance for all tests was set at α = .05, and all tests were 2-tailed.

    Results
    Overall Trends

    There were 12 462 patients with head and neck melanoma diagnosed from 1995 to 2014 in the United States and Canada combined; of these, 6810 occurred in male patients (54.6%). A total of 11 342 patients (91.0%) resided in the United States. The overall head and neck melanoma AAIR for both countries was 0.51 per 100 000 persons (95% CI, 0.50-0.52 per 100 000 persons). In the United States, the AAIR was 0.52 per 100 000 persons (95% CI, 0.51-0.53 per 100 000 persons), which was significantly higher than the Canadian AAIR (AAIR, 0.43; 95% CI, 0.40-0.45 per 100 000 persons). In both countries combined, the age-adjusted incidence of head and neck melanoma increased 3.71% yearly from 1995 to 2001 (95% CI, 1.70%-5.75%) and 1.21% yearly from 2001 to 2014 (95% CI, 0.66%-1.76%). This increase resulted in an AAPC of 1.99% from 1995 to 2014 (95% CI, 1.32%-2.67%). The United States followed a similar trend, with age-adjusted incidence increasing 4.68% yearly from 1995 to 2000 (95% CI, 1.65%-7.81%) and 1.15% yearly from 2000 to 2014 (95% CI, 0.59%-1.71%). From 1995 to 2014, the age-adjusted incidence of head and neck melanoma in Canada increased 2.18% yearly (95% CI, 1.15%-3.21%). The AAPC for the United States from 1995 to 2014 was a 2.07% annual increase (95% CI, 1.25%-2.89%), which was not significantly different from the APC in Canada. Combined, head and neck melanoma in North America increased by 51.1% from 1995 to 2014 (Table) (Figure 1).

    Sex

    For both countries combined, among males, the APC from 1995 to 2002 was 5.03 (95% CI, 2.63-7.48); from 2002 to 2005, −4.15 (95% CI, −18.82 to 13.18); and from 2005 to 2014, 2.17 (95% CI, 0.67-3.70). Among females, the APC from 1995 to 2014 was 2.03 (95% CI, 1.72-2.34). In Canada, from 1995 to 2014, the APC among males was 2.56 (95% CI, 1.11-4.04) and, among females, 1.56 (95% CI, −0.07 to 3.22). In the United States, from 1995 to 2001, the APC among males was 4.47 (95% CI, 0.64-8.45) and, from 2001 to 2014, 0.57 (95% CI, −0.49 to 1.64). Among females, from 1995 to 2014, the APC was 2.08 (95% CI, 1.69-2.46) (Figure 2).

    Age at Diagnosis

    In the United States and Canada combined, the head and neck melanoma AAIR for children aged 0 to 14 years (pediatric cohort) was 0.05 per 100 000 persons (95% CI, 0.04-0.05 per 100 000 persons) and 0.79 per 100 000 persons for adolescents and young adults (aged 15-39 years) (95% CI, 0.79-0.80 per 100 000 persons). Cases were 16.41 times more likely in adolescents and young adults than in pediatrics (RR, 16.41; 95% CI, 14.90-18.11). For pediatric patients, the AAIR increased 13.33% yearly from 1995 to 2003 (APC, 13.33%; 95% CI, 6.00%-21.16%) but remained stable from 2003 to 2014. However, from 1995 to 2014, there was an average increase in AAIR of 4.46% yearly (AAPC, 4.46%; 95% CI, 1.28%-7.75%). The AAIR for adolescents and young adults increased 1.71% yearly from 1995 to 2014 (APC, 1.71%; 95% CI, 1.33%-2.10%) (Figure 3).

    Anatomic Site

    In the United States and Canada combined, skin of scalp and neck was the most commonly diagnosed head and neck melanoma site, with an AAIR of 0.23 per 100 000 persons (95% CI, 0.23-0.24 per 100 000 persons) (eFigure 1 in the Supplement). Skin of lip, not otherwise specified, was the least commonly diagnosed site, with an AAIR of 0.01 per 100 000 persons (95% CI, 0.00-0.01 per 100 000 persons). Melanoma of the external ear, skin of other/unspecified parts of face, and skin of scalp and neck were all more likely to be diagnosed than skin of lip (RR range, 14.14-35.14), but the AAIR of eyelid melanoma was not significantly different from that of skin of lip. Trends for skin of lip and eyelid melanoma could not be determined because at least 1 year from 1995 to 2014 had an AAIR of 0 per 100 000 persons. The AAIR for external ear melanoma increased 3.23% yearly from 1995 to 2014 (APC, 3.23%; 95% CI, 2.11%-4.35%). The AAIR for skin of other/unspecified parts of face increased 1.15% yearly from 1995 to 2014 (APC, 1.15%; 95% CI, 0.72%-1.57%). From 1995 to 2001 and 2006 to 2011, the AAIR for melanoma of the skin of scalp (APC, 5.49%; 95% CI, 2.53%-8.53%) and neck (APC, 5.30%; 95% CI, 0.34%-10.50%) increased yearly, but remained stable from 2001 to 2006 and from 2011 to 2014. These changes resulted in an average yearly increase of 2.34% from 1995 to 2014 of the AAIR of skin of scalp and neck melanoma (AAPC, 2.34%, 95% CI, 0.28%-4.44%).

    Race in the United States Only

    In the United States, non-Hispanic white patients had the highest AAIR from 1995 to 2014 (AAIR, 0.79; 95% CI, 0.77-0.80 per 100 000 persons), and non-Hispanic black or other race patients had the lowest AAIR (AAIR, 0.04; 95% CI, 0.03-0.04 per 100 000 persons). Hispanic (RR, 0.16; 95% CI, 0.14-0.17) and non-Hispanic black or other race (RR, 0.05; 95% CI, 0.04-0.05) patients had significantly lower AAIRs than non-Hispanic white patients. The AAIR changes for non-Hispanic black or other race patients could not be determined because at least 1 year from 1995 to 2014 had an AAIR of 0 per 100 000 persons. Among Hispanic individuals, the AAIR remained stable from 1995 to 2014 (APC, 1.18 (95% CI, −0.15 to 2.52). Among non-Hispanic white patients, the AAIR increased 6.17% yearly from 1995 to 2000 (APC, 6.17; 95% CI, 3.41-9.00) and increased 2.11% yearly from 2000 to 2014 (APC, 2.11; 95% CI, 1.60-2.62), resulting in a 3.16% average yearly increase from 1995 to 2014 (AAPC, 3.16%; 95% CI, 2.42%-3.91%) (Figure 4).

    Race/Ethnicity, Sex, and Age

    From 1995 to 2014, for both countries combined, the APC for males aged 15 to 39 years was 1.51 (95% CI, 0.88-2.14) and 1.97 (95% CI 1.67, 2.27) for females aged 15 to 39 years. During the same period in the US for individuals aged 15 to 39 years, the APC for non-Hispanic white males was 2.48 (95% CI, 1.80-3.16), 3.02 (95% CI, 2.61 to 3.43) for non-Hispanic white females, and 1.15 (95% CI, −0.85-3.18) for Hispanic females (eFigure 2, eFigure 3 in the Supplement).

    Discussion

    The objective of this study was to describe incidence trends in head and neck melanoma among the pediatric, adolescent, and young adult population of North America (United States and Canada); to our knowledge, this study is the first to do so. Although there was minimal change in head and neck melanoma incidence among the pediatric cohort, we found a significant increase among adolescents and young adults in North America in the past 2 decades (Figure 3). In the United States, this increase has been seen primarily in white male adolescents and young adults.

    Studies have consistently shown that the increasing incidence of melanoma is skewed toward females, possibly owing to more exposure to environmental risk factors, such as tanning beds, among young females than males.9,16 A differing finding from our study, however, is that across North America, the head and neck melanoma incidence appears to be markedly higher in males than females. A hypothesis is that, while young adult females may be more exposed to UV rays and indoor tanning, they also have photoprotection for their head and neck provided by hair.24 As demonstrated in an experiment by Green et al,25 hair covering potentially reduced UV-B exposure by up to 81%. Another hypothesis is based on epidermal melanin and androgenetic alopecia (male-patterned baldness). Epidermal melanin provides photoprotection, which likely explains the decreased rate of melanoma in general among black and Hispanic individuals, compared with white individuals.26-28 However, there is a preponderance of androgenetic alopecia in white men than other races/ethnicities, affecting about 30% of white men by the age of 30 and at least 50% by age 50 years.29 The link between alopecia and head and neck melanoma is highlighted by a previous cohort study of predominantly white men in the United States that showed a 7-fold increase in the risk of scalp-related melanoma among those with moderate to severe vortex baldness.30 There is therefore a need to increase head and neck melanoma awareness, especially among young white males at a greater risk for baldness. While our study showed increasing incidence trends in head and neck melanoma in North America overall, we found some differences in our United States and Canada data, with the former representing more than 90% of the cases presented in this study. The increasing incidence trends for the United States consisted of 2 different rates of change (4.68% yearly from 1995 to 2000 and 1.15% yearly from 2000 to 2014), while the trend for Canada showed one significant rate of change (2.18%). This 4-fold decrease in the incidence in the United States data from 2000 could likely be due to changes in tanning practices, possibly owing to increased public awareness of the risks of tanning and tanning-related legislation.31 The use of indoor tanning and sun lamps among individuals 25 years and older increased in the 1980s and 1990s; however, the use of sunscreen, sunglasses, and barrier clothing have also increased in the United States from 2000 to 2010.32,33 UV rays from any source were deemed carcinogenic by the National Toxicology Program in 2002.34 In 2003, the World Health Organization released a guidance document on sunbed legislation, bringing global awareness to the adverse effects of tanning beds.35 Future studies are warranted to test the potential effect of the current risk mitigation policies and educational awareness campaigns on decreasing the incidence of melanoma across North America.13,31,36

    Clinical and Public Health Implications

    The importance of safe sun exposure practices as a national public health imperative is highlighted in the Healthy People 2020 initiative (objective C-20), which also aims to reduce harmful exposure to risk factors, such as UV rays and tanning, in children, adolescents, and adults, thereby decreasing the risk of developing skin cancer, which includes melanoma.37 In 2016, the United States Preventive Services Task Force also recommended that individuals between 10 and 24 years with fair skin should minimize their exposure to UV rays.38 Although the task force found insufficient evidence to recommend visual skin examination by a physician,38 there have been several calls by investigators and organizations emphasizing the need for increasing research on the subject and contending that there may yet be benefits of regular skin examination, especially among high-risk individuals, including those aged 50 years or older, transplant recipients and others who are immune compromised, those with a family history or genetic predisposition to skin cancer, or individuals with exposure at higher-risk sites, such as the scalp.39-43 In the presence of existing risk-mitigation legislation,31 despite absence of an evidence base for asymptomatic screening,38 providing public health awareness and surveillance of incidence trends are necessary. Most of the current efforts taken toward reducing the prevalence of melanoma in the United States and Canada have focused on the use of indoor tanning beds and the risk of melanoma in children and adolescents and young adolescent girls.13,16,31,36,44 Our study, however, suggests that males have a greater incidence of head and neck melanoma than females in both countries. More than a decade ago, it was suggested that E be added to the ABCD acronym that was originally coined to sensitize both physicians and laypersons about early detection of melanoma, with the E added to highlight the evolving nature of this cancer. This revision is especially apt in the context of head and neck melanomas, which, unlike melanoma in other major sites, are more common among males than females.45 It is therefore important that future melanoma risk mitigation messages are framed in a gender-neutral manner. In line with the ABCDE campaign, surveillance could and should extend beyond health care professionals to hairdressers and cosmetologists who may be the first to recognize a scalp or neck lesion.46 In addition, tailored messages and interventions could be targeted toward the group found in this study to be the main cohort of incidence in this population: white males aged 15 to 39 years.

    Limitations and Strengths

    Limitations to this study included the inability to make causal inferences from our descriptive, retrospective data. In addition, because melanoma has a relatively low incidence among the pediatric, adolescent, and young adult population, some data included in this study were based on fewer than 25 cases, and these should be interpreted with caution because of statistical instability.19 Also, the lack of racial/ethnic information meant that no information on that area could be estimated for Canada. In addition, melanocytic nevi are common among children and adolescents, and some histologic features could be misdiagnosed as malignant melanoma.47 Also, data on genetic predisposition to melanoma were not available.

    Notwithstanding these limitations, the strengths of the study include the use of the NAACCR database, which is the largest United States and Canada population-based cancer registry. The continuity of data for the United States and Canada spanning 2 decades allowed for estimate of true incidence trends. Furthermore, as what we believe to be the first study to focus exclusively on head and neck melanoma incidence among the pediatric, adolescent, and young adult population in North America, the study makes a novel contribution to cancer surveillance and population health.

    Conclusions

    The incidence of head and neck melanoma in the pediatric, adolescent, and young adult populations in North America appears to have increased by 51.1% in the past 2 decades. While there has been minimal change in the pediatric population, it seems that this increase is most substantial in white adolescent and young adult males (15-39 years), especially in the United States.

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    Article Information

    Accepted for Publication: August 2, 2019.

    Corresponding Author: Haley N. Bray, MD, Saint Louis University School of Medicine, Department of Otolaryngology–Head and Neck Surgery, 3635 Vista Ave, 6th Flr, Desloge Towers, St Louis, MO 63110 (haley.bray@health.slu.edu)

    Published Online: October 3, 2019. doi:10.1001/jamaoto.2019.2769

    Author Contributions: Mr Simpson and Dr Osazuwa-Peters had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Simpson, Zahirsha, Brinkmeier, Walen, Osazuwa-Peters.

    Acquisition, analysis, or interpretation of data: Bray, Simpson, Zahirsha, Brinkmeier, Fosko, Osazuwa-Peters.

    Drafting of the manuscript: Bray, Simpson, Zahirsha, Brinkmeier, Osazuwa-Peters.

    Critical revision of the manuscript for important intellectual content: Bray, Simpson, Zahirsha, Walen, Fosko, Osazuwa-Peters.

    Statistical analysis: Simpson.

    Administrative, technical, or material support: Bray, Osazuwa-Peters.

    Supervision: Brinkmeier, Walen, Osazuwa-Peters.

    Conflict of Interest Disclosures: None reported.

    Additional Contributions: Deniece Webb, BA, Department of Otolaryngology–Head and Neck Surgery at Saint Louis University, provided administrative and technical assistance for this study and during the preparation of the manuscript. No compensation was received.

    References
    1.
    Siegel  RL, Miller  KD, Jemal  A.  Cancer statistics, 2019.  CA Cancer J Clin. 2019;69(1):7-34. doi:10.3322/caac.21551PubMedGoogle ScholarCrossref
    2.
    Canadian Cancer Society. Canadian cancer statistics: a 2018 special report. http://cancer.ca/Canadian-Cancer-Statistics-2018-EN. Published June 2018. Accessed April 17, 2019.
    3.
    Pollack  LA, Li  J, Berkowitz  Z,  et al.  Melanoma survival in the United States, 1992 to 2005.  J Am Acad Dermatol. 2011;65(5)(suppl 1):S78-S86. doi:10.1016/j.jaad.2011.05.030PubMedGoogle ScholarCrossref
    4.
    Pruthi  DK, Guilfoyle  R, Nugent  Z, Wiseman  MC, Demers  AA.  Incidence and anatomic presentation of cutaneous malignant melanoma in central Canada during a 50-year period: 1956 to 2005.  J Am Acad Dermatol. 2009;61(1):44-50. doi:10.1016/j.jaad.2009.01.020PubMedGoogle ScholarCrossref
    5.
    O’Brien  CJ, Coates  AS, Petersen-Schaefer  K,  et al.  Experience with 998 cutaneous melanomas of the head and neck over 30 years.  Am J Surg. 1991;162(4):310-314. doi:10.1016/0002-9610(91)90138-4PubMedGoogle ScholarCrossref
    6.
    Golger  A, Young  DS, Ghazarian  D, Neligan  PC.  Epidemiological features and prognostic factors of cutaneous head and neck melanoma: a population-based study.  Arch Otolaryngol Head Neck Surg. 2007;133(5):442-447. doi:10.1001/archotol.133.5.442PubMedGoogle ScholarCrossref
    7.
    Lachiewicz  AM, Berwick  M, Wiggins  CL, Thomas  NE.  Survival differences between patients with scalp or neck melanoma and those with melanoma of other sites in the Surveillance, Epidemiology, and End Results (SEER) program.  Arch Dermatol. 2008;144(4):515-521. doi:10.1001/archderm.144.4.515PubMedGoogle ScholarCrossref
    8.
    Richards  MK, Czechowicz  J, Goldin  AB,  et al.  Survival and surgical outcomes for pediatric head and neck melanoma.  JAMA Otolaryngol Head Neck Surg. 2017;143(1):34-40. doi:10.1001/jamaoto.2016.2630PubMedGoogle ScholarCrossref
    9.
    Wong  JR, Harris  JK, Rodriguez-Galindo  C, Johnson  KJ.  Incidence of childhood and adolescent melanoma in the United States: 1973-2009.  Pediatrics. 2013;131(5):846-854. doi:10.1542/peds.2012-2520PubMedGoogle ScholarCrossref
    10.
    Barr  RD, Ries  LA, Lewis  DR,  et al; US National Cancer Institute Science of Adolescent and Young Adult Oncology Epidemiology Working Group.  Incidence and incidence trends of the most frequent cancers in adolescent and young adult Americans, including “nonmalignant/noninvasive” tumors.  Cancer. 2016;122(7):1000-1008. doi:10.1002/cncr.29867PubMedGoogle ScholarCrossref
    11.
    National Cancer Advisory Board. Closing the gap: research and care imperatives for adolescents and young adults with cancer: report of the Adolescent and Young Adult Oncology Progress Review Group. https://deainfo.nci.nih.gov/advisory/ncab/archive/139_0906/presentations/AYAO.pdf. Published September 6, 2006. Accessed July 30, 2019.
    12.
    Strouse  JJ, Fears  TR, Tucker  MA, Wayne  AS.  Pediatric melanoma: risk factor and survival analysis of the surveillance, epidemiology and end results database.  J Clin Oncol. 2005;23(21):4735-4741. doi:10.1200/JCO.2005.02.899PubMedGoogle ScholarCrossref
    13.
    McWhirter  JE, Byl  S, Green  A, Sears  W, Papadopoulos  A.  Availability of tanning salons in Ontario relative to indoor tanning policy (2001-2017).  Prev Med Rep. 2018;12:40-45. doi:10.1016/j.pmedr.2018.08.010PubMedGoogle ScholarCrossref
    14.
    International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer.  The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review.  Int J Cancer. 2007;120(5):1116-1122.PubMedGoogle Scholar
    15.
    Friedman  RJ, Rigel  DS, Kopf  AW.  Early detection of malignant melanoma: the role of physician examination and self-examination of the skin.  CA Cancer J Clin. 1985;35(3):130-151. doi:10.3322/canjclin.35.3.130PubMedGoogle ScholarCrossref
    16.
    Centers for Disease Control and Prevention (CDC).  Use of indoor tanning devices by adults—United States, 2010.  MMWR Morb Mortal Wkly Rep. 2012;61(18):323-326.PubMedGoogle Scholar
    17.
    Austin  MT, Xing  Y, Hayes-Jordan  AA, Lally  KP, Cormier  JN.  Melanoma incidence rises for children and adolescents: an epidemiologic review of pediatric melanoma in the United States.  J Pediatr Surg. 2013;48(11):2207-2213. doi:10.1016/j.jpedsurg.2013.06.002PubMedGoogle ScholarCrossref
    18.
    NAACCR Incidence—CiNA Public File, 1995-2015 (which includes data from CDC’s National Program of Cancer Registries (NPCR), CCCR’s Provincial and Territorial Registries, and the NCI’s Surveillance, Epidemiology and End Results (SEER) Registries), North American Association of Central Cancer Registries.
    19.
    Description of CiNA public use dataset. https://www.naaccr.org/wp-content/uploads/2018/09/5-Appendix-A.-CiNA-Public-Use-Dataset.pdf. Accessed August 2, 2018.
    20.
    National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Site recode ICD-O-3/WHO 2008 definition. https://seer.cancer.gov/siterecode/icdo3_dwhoheme/index.html. Accessed August 3, 2018.
    21.
    National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Standard populations (millions) for age-adjustment. https://seer.cancer.gov/stdpopulations/. Accessed January 23, 2019.
    22.
    National Cancer Institute. Surveillance Research Program. Linear or log-linear model. https://surveillance.cancer.gov/help/joinpoint/tech-help/frequently-asked-questions/linear-or-log-linear-model. Accessed August 3, 2018.
    23.
    National Cancer Institute. Surveillance Research Program. Selecting the final model. https://surveillance.cancer.gov/help/joinpoint/tech-help/frequently-asked-questions/selecting-the-final-model. Accessed August 3, 2018.
    24.
    Lesage  C, Barbe  C, Le Clainche  A, Lesage  F-X, Bernard  P, Grange  F.  Sex-related location of head and neck melanoma strongly argues for a major role of sun exposure in cars and photoprotection by hair.  J Invest Dermatol. 2013;133(5):1205-1211. doi:10.1038/jid.2012.405PubMedGoogle ScholarCrossref
    25.
    Green  AC, Kimlin  M, Siskind  V, Whiteman  DC.  Hypothesis: hair cover can protect against invasive melanoma on the head and neck (Australia).  Cancer Causes Control. 2006;17(10):1263-1266. doi:10.1007/s10552-006-0063-1PubMedGoogle ScholarCrossref
    26.
    Weir  HK, Marrett  LD, Cokkinides  V,  et al.  Melanoma in adolescents and young adults (ages 15-39 years): United States, 1999-2006.  J Am Acad Dermatol. 2011;65(5)(suppl 1):S38-S49. doi:10.1016/j.jaad.2011.04.038PubMedGoogle ScholarCrossref
    27.
    Brenner  M, Hearing  VJ.  The protective role of melanin against UV damage in human skin.  Photochem Photobiol. 2008;84(3):539-549. doi:10.1111/j.1751-1097.2007.00226.xPubMedGoogle ScholarCrossref
    28.
    Wu  XC, Eide  MJ, King  J,  et al.  Racial and ethnic variations in incidence and survival of cutaneous melanoma in the United States, 1999-2006.  J Am Acad Dermatol. 2011;65(5)(suppl 1):S26-S37. doi:10.1016/j.jaad.2011.05.034PubMedGoogle ScholarCrossref
    29.
    Stough  D, Stenn  K, Haber  R,  et al.  Psychological effect, pathophysiology, and management of androgenetic alopecia in men.  Mayo Clin Proc. 2005;80(10):1316-1322. doi:10.4065/80.10.1316PubMedGoogle ScholarCrossref
    30.
    Li  W-Q, Cho  E, Han  J, Weinstock  MA, Qureshi  AA.  Male pattern baldness and risk of incident skin cancer in a cohort of men.  Int J Cancer. 2016;139(12):2671-2678. doi:10.1002/ijc.30395PubMedGoogle ScholarCrossref
    31.
    Madigan  LM, Lim  HW.  Tanning beds: impact on health, and recent regulations.  Clin Dermatol. 2016;34(5):640-648. doi:10.1016/j.clindermatol.2016.05.016PubMedGoogle ScholarCrossref
    32.
    Robinson  JK, Rigel  DS, Amonette  RA.  Trends in sun exposure knowledge, attitudes, and behaviors: 1986 to 1996.  J Am Acad Dermatol. 1997;37(2 Pt 1):179-186. doi:10.1016/S0190-9622(97)80122-3PubMedGoogle ScholarCrossref
    33.
    Chang  C, Murzaku  EC, Penn  L,  et al.  More skin, more sun, more tan, more melanoma.  Am J Public Health. 2014;104(11):e92-e99. doi:10.2105/AJPH.2014.302185PubMedGoogle ScholarCrossref
    34.
    National Toxicology Program. Report on Carcinogens, Tenth Edition: Carcinogen Profiles 2002. Research Triangle Park, NC: US Dept. of Health and Human Services, Public Health Service, National Toxicology Program; 2002.
    35.
    World Health Organization.  Artificial Tanning Sunbeds: Risks and Guidance. Geneva, Switzerland: World Health Organization; 2003.
    36.
    Nadalin  V, Marrett  LD, Cawley  C, Minaker  LM, Manske  S.  Intentional tanning among adolescents in seven Canadian provinces: provincial comparisons (CRAYS 2015).  Prev Med. 2018;111:225-230. doi:10.1016/j.ypmed.2018.03.004PubMedGoogle ScholarCrossref
    37.
    Office of Disease Prevention and Health Promotion. Healthy people 2020. https://www.healthypeople.gov/2020/topics-objectives/2020-Topics-and-Objectives-Objectives-A-Z. Accessed August 3, 2018.
    38.
    Bibbins-Domingo  K, Grossman  DC, Curry  SJ,  et al; US Preventive Services Task Force.  Screening for skin cancer: US Preventive Services Task Force recommendation statement.  JAMA. 2016;316(4):429-435. doi:10.1001/jama.2016.8465PubMedGoogle ScholarCrossref
    39.
    Tsao  H, Weinstock  MA.  Visual inspection and the US Preventive Services Task Force recommendation on skin cancer screening.  JAMA. 2016;316(4):398-400. doi:10.1001/jama.2016.9850PubMedGoogle ScholarCrossref
    40.
    Nahar  VK, Mayer  JE, Grant-Kels  JM.  The case for skin cancer screening with total-body skin examinations.  JAMA Oncol. 2016;2(8):999-1001. doi:10.1001/jamaoncol.2016.2440PubMedGoogle ScholarCrossref
    41.
    Swetter  SM, Geller  AC, Halpern  AC.  What the USPSTF “insufficient” skin cancer screening recommendation means for primary care clinicians and dermatologists.  JAMA Dermatol. 2016;152(9):973-975. doi:10.1001/jamadermatol.2016.2606PubMedGoogle ScholarCrossref
    42.
    Linos  E, Katz  KA, Colditz  GA.  Skin cancer—the importance of prevention.  JAMA Intern Med. 2016;176(10):1435-1436. doi:10.1001/jamainternmed.2016.5008PubMedGoogle ScholarCrossref
    43.
    Smith  RA, Brooks  D, Cokkinides  V, Saslow  D, Brawley  OW.  Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening.  CA Cancer J Clin. 2013;63(2):88-105. doi:10.3322/caac.21174PubMedGoogle ScholarCrossref
    44.
    Williams  MS, Buhalog  B, Blumenthal  L, Stratman  EJ.  Tanning salon compliance rates in states with legislation to protect youth access to UV tanning.  JAMA Dermatol. 2018;154(1):67-72. doi:10.1001/jamadermatol.2017.3736PubMedGoogle ScholarCrossref
    45.
    Abbasi  NR, Shaw  HM, Rigel  DS,  et al.  Early diagnosis of cutaneous melanoma: revisiting the ABCD criteria.  JAMA. 2004;292(22):2771-2776. doi:10.1001/jama.292.22.2771PubMedGoogle ScholarCrossref
    46.
    Lovasik  BP, Sharma  I, Russell  MC, Carlson  GW, Delman  KA, Rizzo  M.  Invasive scalp melanoma: role for enhanced detection through professional training.  Ann Surg Oncol. 2016;23(12):4049-4057. doi:10.1245/s10434-016-5334-9PubMedGoogle ScholarCrossref
    47.
    Yang  C, Gru  AA, Dehner  LP.  Common and not so common melanocytic lesions in children and adolescents.  Pediatr Dev Pathol. 2018;21(2):252-270. doi:10.1177/1093526617751720PubMedGoogle ScholarCrossref
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