The Skin Cancer Foundation Journal

MAY 2013

The 2012 edition of The Skin Cancer Foundation Journal features medically reviewed, reader-friendly articles such as tanning, the increasing incidence of skin cancer diagnoses among young women, & the prevalence of melanoma among white males over 50.

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Page 62 of 103

The ABCDs and Beyond Visual Clues For Early Detection Of Melanoma SARAH YAGERMAN, BS, AND ASHFAQ MARGHOOB, MD T he ABCD acronym for the early detection of melanoma, frst proposed in 1985,1 has become a standard public health message for clinicians and patients alike. The now well-known ABCDs refers to Asymmetry, Border irregularity, Color variegation, and Diameter greater than 6 mm. These have been considered melanoma's most frequent, salient features, and the more of them a lesion has, the more it may be suspected of being a melanoma. The acronym was intended to capture these features in a simple, memorable expression that would facilitate early detection and call popular attention to its importance. The overall 5-year survival rate for patients whose melanoma is detected early, before the tumor has spread to regional lymph nodes or other organs, is about 98 percent in the US, but the survival rate falls to 15 percent when the disease spreads to distant organs.2 ADDING THE "E" Using the ABCDs allows doctors to spot potential melanomas from 57 to 99 percent of the time, and those lesions prove to be melanomas 59 to 90 percent of the time.1 This degree of sensitivity and specifcity clearly has value, but leaves room for improvement. In the past decade, despite the ABCDs' widespread acceptance and utility, it became clear that many melanomas do not ft the ABCD criteria [Figure 1]. For these lesions, other memorable acronyms and catchphrases have been introduced. The first of these to be universally embraced was simply an "E" added to the ABCDs. That "E" now represents "Evolution or change," but it went through an evolution process itself. It f rst began being used most often to represent "Elevated."3 Since nodular melanoma (an often aggressive type of melanoma) is not suffciently recognizable using the ABCD criteria, a trio of letters was proposed for it as an addition or alternative to the ABCDs: "EFG," representing "Elevated, Firm, and Growing progressively for over a month.4" "Growing" was an especially meaningful warning sign, since for both physicians and the lay public it clearly suggests the biology of a worrisome, worsening tumor. Some doctors, in fact, began proposing an "E" for "Enlarged" to represent this concept of growing.5 In 2004, the NYU-based doctors who originally introduced the ABCDs added the "E" for "Evolution or change" to their acronym to improve detection of melanomas not manifesting any of the ABCDs.6 They considered this catchall term more complete than either "Elevation" or "Enlarged,"3,5,6 since enlargement and elevation are just two of several changes that should alert one to the possibility of a lesion being a melanoma: changes in shape or color (darkening and taking on other hues); new symptoms (such as itching and tenderness); and changes to the surface (especially bleeding) are also melanoma warning signs.6 "E" for "Evolution" encompassed the full range of changes in contour, structure, and symptoms that should be considered suspicious. This was a powerful modifcation of the standard acronym, given melanoma's inherent potential for growth and change. DERMOSCOPY CHANGES THE PICTURE AGAIN Since the advent of the ABCDs, new technological tools have been incorporated into clinical practice to augment the physician's naked eye. The technique most widely used now to review suspicious lesions before deciding to undertake a biopsy is dermoscopy, also known as dermatoscopy. Dermoscopy is the study of skin lesions with a dermatoscope, a noninvasive imaging device that uses a magnifer and light source to analyze skin lesions. With dermoscopy, substantially more lesions lacking the 61

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