Background:Sézary syndrome is an extremely rare and fatal cutaneous T-cell lymphoma (CTCL). Mogamulizumab, an anti-CCR4 monoclonal antibody, has recently been associated with increased progression-free survival in a randomized clinical trial in CTCL. We aimed to evaluate OS and prognostic factors in Sézary syndrome, including treatment with mogamulizumab, in a real-life setting. Methods:Data from patients with Sézary (ISCL/EORTC stage IV) and pre-Sézary (stage IIIB) syndrome diagnosed from 2000 to 2020 were obtained from 24 centers in Europe. Age, disease stage, plasma lactate dehydrogenases levels, blood eosinophilia at diagnosis, large-cell transformation and treatment received were analyzed in a multivariable Cox proportional hazard ratio model. This study has been registered in ClinicalTrials (SURPASSe01 study: NCT05206045). Findings:Three hundred and thirty-nine patients were included (58% men, median age at diagnosis of 70 years, Q1-Q3, 61-79): 33 pre-Sézary (9.7% of 339), 296 Sézary syndrome (87.3%), of whom 10 (2.9%) had large-cell transformation. One hundred and ten patients received mogamulizumab. Median follow-up was 58 months (95% confidence interval [CI], 53-68). OS was 46.5% (95% CI, 40.6%-53.3%) at 5 years. Multivariable analysis showed that age ≥ 80 versus <50 (HR: 4.9, 95% CI, 2.1-11.2, p = 0.001), and large-cell transformation (HR: 2.8, 95% CI, 1.6-5.1, p = 0.001) were independent and significant factors associated with reduced OS. Mogamulizumab treatment was significantly associated with decreased mortality (HR: 0.34, 95% CI, 0.15-0.80, p = 0.013). Interpretation:Treatment with mogamulizumab was significantly and independently associated with decreased mortality in Sézary syndrome. Funding:French Society of Dermatology, Swiss National Science Foundation (IZLIZ3_200253/1) and SKINTEGRITY.CH collaborative research program.

BACKGROUND:Basal cell carcinoma (BCC) is the most frequent malignancy reported in populations with fair skin. In most countries, BCCs are only partially or not at all recorded, and incidence data are lacking. OBJECTIVES:This study assessed the current incidence rates and trends in the only two French départements where BCCs have been recorded for several decades. METHODS:This regional population-based study thus used data from two French cancer registries (Doubs and Haut-Rhin) where first-time BCC diagnoses were recorded. The European age-standardized incidence rates (EASR) were calculated per 100 000 person-years (PY). The trends and the annual percentages of change were assessed using joinpoint analysis. RESULTS:In all, 48 989 patients were diagnosed with a first BCC in the study period. The median age at diagnosis was 69 years and the BCCs were mainly located on the head and neck (68.8%). In the Doubs area between 1980 and 2016, the EASR of BCC increased from 59.9 to 183.1 per 100 000 PY. The annual increase for men was 5.73% before 1999 and 1.49% thereafter, and among women 4.56% before 2001 and 1.31% thereafter. In the Haut-Rhin area, the EASR increased from 139.2 in 1991 to 182.8 per 100 000 PY in 2019. Among men, the EASR increased annually by 2.31% before 2000, and by 0.29% after 2000; among women, it increased by 0.95% over the entire period (1991-2019). In the most recent period and for these two départements, the age-specific incidence rates of BCC for men and women were close before the age of 60 years, except for the 40-49-year age group, where the rates were significantly higher among women. For patients aged 60 years and over, men had much higher rates of BCC. CONCLUSIONS:BCC incidence has increased since 1980 and is still rising, particularly among men and the elderly. A slowing was observed from 2000, which could be explained by a shift in the management of BCCs and by the possible efficacy of prevention actions. This study provides insight into the BCC burden in France and highlights the need to maintain effective prevention strategies, as incidence is still increasing.

Background With more than 15,000 new cases /year in France and 2,000 deaths, cutaneous melanoma represents approximately 4% of incidental cancers and 1.2% of cancer related deaths. In locally advanced (stage III) or resectable metastatic (stage IV) melanomas, medical adjuvant treatment is proposed and recent advances had shown the benefit of anti-PD1/PDL1 and anti-CTLA4 immunotherapy as well as anti-BRAF and anti-MEK targeted therapy in BRAF V600 mutated tumors. However, the recurence rate at one year is approximately 30% and justify extensive research of predictive biomarkers. If in metastatic disease, the follow-up of circulating tumor DNA (ctDNA) has been demonstrated, its interest in adjuvant setting remains to be precised, especially because of a lower detection rate. Further, the definition of a molecular response could prove useful to personalized treatment. Methods PERCIMEL is an open prospective multicentric study executed through collaboration of the Institut de Cancérologie de Lorraine (non-profit comprehensive cancer center) and 6 French university and community hospitals. A total of 165 patients with resected stage III and IV melanoma, eligible to adjuvant imunotherapy or anti-BRAF/MEK kinase inhibitors will be included. The primary endpoint is the presence of ctDNA, 2 to 3 weeks after surgery, defined as mutated ctDNA copy number calculated as the allelic fraction of a clonal mutation relative to total ctDNA. Secondary endpoints are recurrence-free survival, distant metastasis-free survival and specific survival. We will follow ctDNA along treatment, quantitatively through ctDNA mutated copy number variation, qualitatively through the presence of cfDNA and its clonal evolution. Relative and absolute variations of ctDNA during follow-up will be also analyzed. PERCIMEL study aims at provide scientific evidence that ctDNA quantitative and qualitative variations can be used to predict the recurrence of patients with melanoma treated with adjuvant immunotherapy or kinase inhibitors, thus defining the notion of molecular recurrence.

BackgroundAdverse pregnancy outcomes (APO) occur in 35% of patients with pemphigoid gestationis (PG). No biological predictor of APO has been established yet. ObjectivesTo assess a potential relationship between the occurrence of APO and the serum value of anti-BP180 antibodies at the time of PG diagnosis. MethodsMulticentre retrospective study conducted from January 2009 to December 2019 in 35 secondary and tertiary care centres. Inclusion criteria: (i) diagnosis of PG according to clinical, histological and immunological criteria, (ii) ELISA measurement of anti-BP180 IgG antibodies determined at the time of PG diagnosis with the same commercial kit and (iii) obstetrical data available. ResultsOf the 95 patients with PG included, 42 had one or more APO, which mainly corresponded to preterm birth (n = 26), intrauterine growth restriction (IUGR) (n = 18) and small weight for gestational age at birth (n = 16). From a ROC curve, we identified a threshold of 150 IU ELISA value as the most discriminating to differentiate between patients with or without IUGR, with 78% sensitivity, 55% specificity, 30% positive and 91% negative predictive value. The threshold >150 IU was confirmed using a cross-validation based on bootstrap resampling, which showed that the median threshold was 159 IU. Upon adjusting for oral corticosteroid intake and main clinical predictors of APO, an ELISA value of >150 IU was associated with the occurrence of IUGR (OR = 5.11; 95% CI: 1.48-22.30; p = 0.016) but not with any other APO. The combination of blisters and ELISA values higher than 150 IU led to a 2.4-fold higher risk of all-cause APO (OR: 10.90; 95% CI: 2.33-82.3) relative to patients with blisters but lower values of anti-BP180 antibodies (OR of 4.54; 95% CI 0.92-34.2). ConclusionThese findings suggest that anti-BP180 antibody ELISA value in combination with clinical markers is helpful in managing the risk of APO, in particular IUGR, in patients with PG.

To the Editor: The incidence and severity of COVID-19 among patients with autoimmune bullous skin diseases (AIBD) have not been characterized in large populations.1Zhang X. Epidemiology of Covid-19.N Engl J Med. 2020; 382: 1869Crossref PubMed Scopus (29) Google Scholar, 2Shakshouk H. Daneshpazhooh M. Murrell D.F. Lehman J.S. Treatment considerations for patients with pemphigus during the COVID-19 pandemic.J Am Acad Dermatol. 2020; 82: e235-e236Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 3Kasperkiewicz M. Schmidt E. Amagai M. et al.Updated international expert recommendations for the management of autoimmune bullous diseases during the COVID-19 pandemic.J Eur Acad Dermatol Venereol. 2021; 35: e412-e414PubMed Google Scholar We assessed the severity and mortality of COVID-19 in patients with AIBD, with a special interest in a potential risk factor related to previous treatment with rituximab. This study was conducted from February 2020 to June 2020 in 49 dermatology departments located in 12 administrative regions of France. Possible (suggestive clinical symptoms and contact with COVID-19), probable (suggestive computed tomography scan), and confirmed (positive reverse transcriptase polymerase chain reaction result) cases of COVID-19 with AIBD were identified using data from the hospitals' electronic health records (hospitalized patients) and by spontaneous reporting (nonhospitalized patients). Patients who had received at least 1 infusion of rituximab from September 2019 to June 2020 were identified from the database of each hospital pharmacy. Data on the hospitalization of patients with AIBD and COVID-19 and COVID-19–related deaths were recorded. Region- and age-specific incidence and lethality of hospitalized confirmed COVID-19 in the general population were retrieved from the Santé Publique France website. Detailed methodology is available in the Supplementary Material (available via Mendeley at https://data.mendeley.com//datasets/yg3gv392x6/1). Of 5180 patients with AIBD, 59 were diagnosed with possible, probable, or confirmed COVID-19, of whom 30 (50.8%) were hospitalized, 7 (11.9%) were admitted to an intensive care unit, and 15 (25.4%) died. We identified 21 patients with bullous pemphigoid, 19 patients with mucous membrane pemphigoid, 18 patients with pemphigus, and 1 patient with pregnancy-associated pemphigoid (Table I).Table IAge, sex, main comorbidities, AIBD treatments, and management (hospitalization vs outpatient management) of COVID-19–infected patients depending on the type of AIBDData recordedBP n (%)MMP n (%)Pemphigus n (%)PG n (%)COVID-19 Confirmed9 (42.9)13 (68.4)6 (33.3)1 (100) Probable4 (19)3 (15.8)1 (5.6)0 (0) Possible8 (38.1)3 (15.8)11 (61.1)0 (0)Sex, M/F10/116/139/90/1Age, years, mean ± SD81.8 ± 8.274.9 ± 12.260.9 ± 18.132Body mass index, kg/m2, mean ± SD26.2 ± 7.327.5 ± 5.426.0 ± 4.5NAKarnofsky score, mean ± SD54.5 ± 21.167.4 ± 21.076.5 ± 39.090Medical history Diabetes mellitus11 (52.4)6 (31.6)2 (11.1)0 (0) Hypertension11 (52.4)2 (10.5)3 (16.7)0 (0) Renal disorder5 (23.8)1 (5.3)0 (0)0 (0) Cardiovascular disorder5 (23.8)3 (15.8)0 (0)0 (0) Lung disorder5 (23.8)3 (15.8)1 (5.6)0 (0) Neurological disorder5 (23.8)2 (10.5)2 (11.1)0 (0) Neoplasia7 (33.3)2 (10.5)1 (5.6)0 (0) Dyslipidemia3 (14.3)0 (0)1 (5.6)0 (0) Other3 (14.3)3 (15.8)0 (0)0 (0)Treatment of AIBD∗During the previous 9 months. (nonexclusive) Systemic corticosteroids5 (23.8)3 (15.8)4 (22.2)1 (100) Topical corticosteroids12 (57.1)6 (31.6)2 (11.1)0 (0) Conventional immunosuppressants7 (33.3)3 (15.8)1 (5.6)0 (0) Rituximab1 (4.8)9 (47.4)13 (72.2)0 (0) Dapsone1 (4.8)14 (73.7)0 (0)0 (0) Omalizumab1 (4.8)2 (10.5)0 (0)0 (0) Cyclines1 (4.8)4 (21.1)0 (0)0 (0) Sulfasalazine0 (0)2 (10.5)0 (0)0 (0)Management of COVID-19 (nonexclusive) Hospitalization12 (57.1)10 (52.6)1 (5.6)0 (0) Intensive care unit1 (4.8)1 (5.3)5 (27.8)0 (0) Outpatient management8 (38.1)8 (42.1)12 (66.7)1 (100)AIBD, Autoimmune bullous skin disease; BP, bullous pemphigoid; MMP, mucous membrane pemphigoid; NA, not applicable; PG, pemphigoid gestationis; SD, standard deviation.∗ During the previous 9 months. Open table in a new tab AIBD, Autoimmune bullous skin disease; BP, bullous pemphigoid; MMP, mucous membrane pemphigoid; NA, not applicable; PG, pemphigoid gestationis; SD, standard deviation. The age- and region-standardized incidence ratio of hospitalized confirmed COVID-19 infection was 0.42 (95% confidence interval [CI], 0.20-0.80; P = .005) for bullous pemphigoid, 1.02 (95% CI, 0.37-2.26; P = .91) for pemphigus, and 1.18 (95% CI, 0.55-2.23; P = .62) for mucous membrane pemphigoid. The apparently low risk of COVID-19 infection in patients with bullous pemphigoid must therefore be interpreted with caution since it is very likely that some older patients with bullous pemphigoid in poor general condition died from an undiagnosed COVID-19 infection in their nursing homes. The incidence ratio of COVID-19 in patients treated with rituximab ranged from 3.62 (95% CI, 1.29-8.85) in patients with AIBD hospitalized with a confirmed diagnosis of COVID-19 to 5.37 (95% CI, 3.15-8.96) in patients with a confirmed, probable, or possible diagnosis of COVID-19 infection (Table II).Table IIProportions of patients with a confirmed, probable, or possible diagnosis of COVID-19 infection among patients with AIBD, according to whether or not they were treated with rituximabDiagnosis of COVID-19Patients with AIBD treated with rituximab n/N (%)Patients with AIBD who did not receive rituximab n/N (%)Incidence ratio (95% CI)Possible, probable or confirmed22/516 (4.26%)37/4664 (0.79%)5.37 (3.15-8.96)Probable or confirmed13/516 (2.52%)24/4664 (0.51%)4.90 (2.43-9.40)Confirmed and hospitalized6/516 (1.16%)15/4664 (0.32%)3.62 (1.29-8.85)AIBD, Autoimmune bullous skin disease; CI, confidence interval. Open table in a new tab AIBD, Autoimmune bullous skin disease; CI, confidence interval. The lethality of confirmed COVID-19 (n = 8/21, 38.1%) was 1.63-fold (95% CI, 0.83-2.55; P = .13) higher in hospitalized patients with AIBD than in the general population of the same age (23%). Patients with AIBD and COVID-19 had a 5.9-fold (95% CI, 3.9-8.4) higher 3-month death risk than patients with AIBD without COVID-19.4Joly P. Benichou J. Lok C. et al.Prediction of survival for patients with bullous pemphigoid: a prospective study.Arch Dermatol. 2005; 141: 691-698Crossref PubMed Scopus (146) Google Scholar,5Jelti L. Cordel N. Gillibert A. et al.Incidence and mortality of pemphigus in France.J Invest Dermatol. 2019; 139: 469-473Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Patients with AIBD and a hospitalized or lethal form of COVID-19 were older than those with a benign form (77.9 ± 11.2 years vs 65.0 ± 19.3 years; P = .006). The major finding of this study is the notably higher risk of COVID-19 infection in patients with AIBD treated with rituximab, corresponding to a more than 5-fold higher incidence of COVID-19 infection than in patients who did not receive rituximab. Patients with AIBD and COVID-19 had a 5.9-fold higher risk of dying during the first wave of the COVID-19 pandemic in France than patients with AIBD and without COVID-19. Overall, this study showed that treatment with rituximab is a major risk factor of COVID-19 infection. Given the high lethality of COVID-19 in patients with AIBD, physicians should carefully evaluate the benefit-risk balance of rituximab therapy during this pandemic period. Dr Joly is a consultant for Roche, Amgen, Principia Biopharma, Argenx, Astra Zeneca, Sanofi-Regeneron, Innovaderm, and ThermoFisher. Dr Caux is a consultant for Principia Biopharma and is an investigator in clinical trials sponsored by Principia Biopharma and Roche. Drs Gillibert, Bohelay, Aouar, Ingen-Housz-Oro, Bedane, Lepelletier, Bohin, Viguier, Dupin, Debarbieux, Jullien, Quéreux, Morice, Mahe, Michel, Litrowski, Jeudy, Richard, Picard, Chosidow, Ledard, Hebert, Duvert-Lehembre, Cordel, Alexandre, and Le Roux-Villet have no conflicts of interest to disclose.

OBJECTIVE:Immune checkpoint inhibitors (ICIs) for cancer therapy frequently induce immune-related adverse effects (IRAEs). Therefore, most patients with preexisting autoimmune diseases have been excluded from clinical trials of ICIs. This study was undertaken to evaluate the safety and efficacy of ICIs in patients with preexisting autoimmune disease and cancer.METHODS:A retrospective cohort study was conducted from January 2017 to January 2018 via 3 French national networks of experts in oncology and autoimmunity. Adults with preexisting autoimmune disease who were receiving ICIs were assessed for the occurrence of flare of preexisting autoimmune disease, other IRAEs, and cancer response.RESULTS:The study included 112 patients who were followed up for a median of 8 months. The most frequent preexisting autoimmune diseases were psoriasis (n = 31), rheumatoid arthritis (n = 20), and inflammatory bowel disease (n = 14). Twenty-four patients (22%) were receiving immunosuppressive therapy at ICI initiation. Autoimmune disease flare and/or other IRAE(s) occurred in 79 patients (71%), including flare of preexisting autoimmune disease in 53 patients (47%) and/or other IRAE(s) in 47 patients (42%), with a need for immunosuppressive therapy in 48 patients (43%) and permanent discontinuation of ICI in 24 patients (21%). The median progression-free survival was shorter in patients receiving immunosuppressive therapy at ICI initiation (3.8 months versus 12 months; P = 0.006), confirmed by multivariable analysis. The median progression-free survival was shorter in patients who experienced a flare of preexisting autoimmune disease or other IRAE, with a trend toward better survival in the subgroup without immunosuppressant use or ICI discontinuation.CONCLUSION:Our findings indicate that flares or IRAEs occur frequently but are mostly manageable without ICI discontinuation in patients with a preexisting autoimmune disease. Immunosuppressive therapy at baseline is associated with poorer outcomes.

IMPORTANCE:Although predisposing factors for bullous pemphigoid (BP) have been recently established, no clinical or immunologic factors have yet been identified to predict disease outcome.OBJECTIVE:To identify risk factors for BP relapse during the first year of treatment.DESIGN, SETTING, AND PARTICIPANTS:Multicenter prospective study of 120 consecutive patients with newly diagnosed BP in 8 French dermatology departments. Baseline and 6 follow-up visits were planned to record disease activity and collect blood samples for measurement of serum anti-BP180 and anti-BP230 levels by means of enzyme-linked immunosorbent assay (ELISA).MAIN OUTCOMES AND MEASURES:The end point was clinical relapse within the first year of therapy. Associations of clinical and immunologic (including serum levels of anti-BP180 and anti-BP230 autoantibodies) parameters with clinical relapse were assessed using univariate and multivariate analyses.RESULTS:During the 1-year follow-up, 35 patients (29.2%) experienced relapse, whereas anti-BP180 and anti-BP230 ELISA results were similar at baseline between patients who did and did not experience relapse. Factors at baseline independently associated with relapse were extensive disease at inclusion (hazard ratio [HR], 2.37 [95% CI, 1.2-4.8]) and an associated dementia (HR, 2.09 [95% CI, 1.0-4.2]). Use of superpotent topical corticosteroids alone (by 100 patients [83.3%]) induced a dramatic, early decrease in serum levels of anti-BP180 and anti-BP230 autoantibodies. Mean early decreases in autoantibody levels between baseline and day 60 were lower in patients with relapse compared with patients with ongoing remission (-10.0% and -45.2%, respectively, for anti-BP180 levels [P < .001] and -11.8% and -35.4%, respectively, for anti-BP230 levels [P = .046]). A higher serum level of anti-BP180 at day 150, with a cutoff of 23 U/mL, provided 84.2% sensitivity, 44.8% specificity, 33.3% positive predictive value, and 89.7% negative predictive value for the occurrence of relapses between days 150 and 360.CONCLUSIONS AND RELEVANCE:The pronounced decrease in the level of anti-BP180 autoantibodies and, to a lesser extent, those directed against BP230 confirmed the use of superpotent topical corticosteroids alone as a reference BP treatment. Furthermore, our study suggests that neurological diseases play a major role in BP, not only as a predisposing but also as a prognostic factor.

IMPORTANCE:Life expectancy is increasing in most developed countries, and elderly people have the highest incidence of melanoma.OBJECTIVE:To identify characteristics of melanoma and its management in the elderly compared with younger patients.DESIGN, SETTING, AND PARTICIPANTS:Retrospective population-based study of incident cases of primary melanoma in 1621 patients with stage I or II melanoma in 2004 and 2008. Questionnaires administered to physicians and a survey of cancer registries and pathology laboratories were used to obtain data. The study was conducted in 5 regions in northeastern France.MAIN OUTCOMES AND MEASURES:Characteristics of patients and tumors, circumstances of diagnosis, and further management in older patients (≥70 years, 487 patients [30.0%]) compared with younger ones (<70 years, 1134 [70.0%]).RESULTS:Older patients had more frequent melanomas of the head and neck (29.4% vs 8.7%; P < .001) and of the nodular, lentigo maligna, or acral lentiginous histologic subtypes. They had thicker and more frequently ulcerated tumors, categorized as T3 or T4 in 36.7% of cases vs 20.1% in younger patients. Diagnosis of melanoma occurred more frequently in a general practice setting and less frequently in direct consultation with a dermatologist or regular screening for skin cancer. Time to definitive excision was longer in older patients, and 16.8% of them compared with 5.0% of the younger population had insufficient excision margins (P < .001). A sentinel lymph node biopsy was performed in 23.3% of the older patients with melanoma thicker than 1 mm vs 41.4% in the younger patients (P < .001). Adjuvant therapy was less frequently started in older patients and was prematurely stopped in a higher proportion of that population.CONCLUSIONS AND RELEVANCE:Age-related variations are observed at every step of melanoma management. The most important concerns are access of elderly people to settings for early diagnosis and excision with appropriate margins.

OBJECTIVE:To identify clinical and sociodemographic factors associated with very thick melanoma (VTM) (Breslow thickness, 3 mm) in France.DESIGN:Retrospective, population-based, case-case study using a survey of cancer registries and questionnaires to practitioners.SETTING:Five regions covering 19.2% of the French territory and 8.2 million inhabitants.CASES:Cases included all incident melanomas with a Breslow thickness of 3 mm or greater (ie, VTM), diagnosed between January 1 and December 31, 2008, in residents of the study area (Alsace, Bourgogne, Champagne-Ardenne, Franche-Comte', and Lorraine, France), and a randomly selected sample of melanomas thinner than 3 mm.MAIN OUTCOME MEASURES:Circumstances of diagnosis,clinical and pathological characteristics of melanomas,and sociodemographic characteristics of patients(age, sex, residence, home and family life conditions, educational level, and smoking habits).RESULTS:Among 898 melanomas, 149 (16.6%) were VTMs. Very thick melanomas were more often diagnosed in a general-practice setting than thinner melanomas.The rate of immediate clinical recognition by dermatologists was lower for VTMs than for thinner melanomas. In a multivariate logistic regression analysis,factors associated with VTM were the nodular and acrolentiginous types; the head and neck and lower limb locations; older age; male sex; and being single, separated,divorced, or widowed. When only factors related to patients were taken into account, older age, male sex,and living alone were independent risk factors for VTM.The most significant risk was observed for patients living alone.CONCLUSIONS:Intrinsic factors related to the tumor and socio demographic characteristics of patients contribute to the occurrence of VTM. These factors should be better targeted in future secondary prevention programs.

Objectives To describe circumstances of the diagnosis and access to dermatological care for patients with cutaneous melanoma (CM) and to investigate factors associated with early detection. Design Retrospective population-based study of incident cases of invasive CM in 2004, using questionnaires to physicians and a survey of cancer registries and pathology laboratories. Setting Five regions in northeastern France. Patients Six hundred fifty-two patients who were referred to dermatologists by general practitioners (group 1) or by other specialists (group 2), who directly consulted a dermatologist for CM (group 3), or who were diagnosed as having CM during a prospective follow-up of nevi (group 4) or when consulting a dermatologist for other diseases (group 5). Main Outcome Measures Characteristics of patients, tumors, and patients' residence in each group, including the geographical concentration of dermatologists. We performed multivariate analysis of these factors to determine association with Breslow thickness. Results Age, tumor location, Breslow thickness, ulceration, histological type, and geographical concentration of dermatologists significantly differed among groups. Patients consulting dermatologists directly formed the largest group (45.1%). Those referred by general practitioners (26.1%) were the oldest and had the highest frequency of thick (>3 mm), nodular, and/or ulcerated CM. Patients from groups 4 (8.4%) and 5 (14.1%) had the thinnest CMs. Ulcerated and/or thick tumors were absent in group 4. In multivariate analysis, histological types superficial spreading melanoma and lentigo maligna melanoma, younger age, high concentration of dermatologists, and detection by dermatologists were significantly associated with thinner CMs. Conclusion Easy access of patients to dermatologists, information campaigns targeting elderly people, and education of general practitioners are complementary approaches to improving early detection.

OBJECTIVE:To describe current management of cutaneous melanoma (CM) and identify factors accounting for disparities.DESIGN:Retrospective population-based study using survey of cancer registries and pathology laboratories, and questionnaires to physicians.SETTING:Five regions covering 19.2% of the French territory and including 8.2 million inhabitants.PATIENTS:Incident cases of patients with stage I to stage II (hereinafter, stage I-II) tumors staged according to the American Joint Committee on Cancer Staging guidelines and nodal stage III CM in 2004.MAIN OUTCOME MEASURES:Modalities of diagnosis and excision, surgical margins, sentinel lymph node biopsy, adjuvant therapies and surveillance procedures, and their variations according to age, sex, residence, location of primary CM, Breslow thickness, type of physicians, modalities of decisions, and health care patterns.RESULTS:Clinical stage I-II CMs (n = 710 cases) slightly predominated in females (53%), with a lower mean Breslow thickness (1.4 mm) than in males (1.9 mm). Initial excisions were most often performed by private dermatologists and wide excisions by surgeons. Narrow margins (8%) were associated with advanced age, higher Breslow thickness, and head location. Sentinel lymph node biopsy was performed in 34% of CMs thicker than 1.0 mm, depending on geographical regions, distance from reference centers, and health care patterns. Adjuvant therapies (mainly low-dose interferon) were proposed in 53% of thick CMs (>1.5 mm), depending on the patient's age and geographical region. In contrast with French recommendations, surveillance procedures frequently included systematic medical imaging. Stage III nodal CMs (n = 89 cases) predominated in males (62%). After lymphadenectomy, adjuvant therapies (including high-dose interferon in 32% of cases and chemotherapies in 24% of cases) were proposed in 68% of cases, depending on the patient's age and geographical region. A complete 1-year high-dose interferon regimen was administered in less than 10% of cases.CONCLUSION:Large disparities still exist in the management of CM in France, depending to a greater extent on medical and geographical environment than on the characteristics of either patients or tumors.