- Email: [email protected]
Practices and beliefs concerning screening family members of patients with melanoma
Volume 26 Number 3 March 1992
7. 8.
9. 10.
Kidney changes during cyclosporine therapy for psoriasis
pIe and efficient sterealogical methods and their use in pathological research and diagnosis. APMIS 1988;96:37994. Mihatsch M, Thiel G, Ryffel B. Morphologic diagnosis of cyc1osporine nephrotoxicity. Semin Diagn Pathol 1988; 5:104-21. Zachariae H, Kragballe K, Hansen HE, et al. Changes in renal biopsies during low dosage cyc1osporine treatment. Acta Derm Venereal (Stockh) 1990;70:361-2. Mason J. Renal side-effects of cyclosporin A. Br J DermatolI990;122(suppI36):71-7. Mihatsch M, Thiel G, Ryffel B. Renal side-effects of
11. 12. 13. 14.
cyclosporin A with special reference to autoimmune diseases. Br J Dermatol 1990;122(suppl 36):101-15. Zachariae H, Hansen HE, S~gaard H, et al. Kidney biopsies in methotrexate-treated psoriatics. Dermatologica 1990;181:273-6. Meyers B. Cyclosporine nephrotoxicity. Kidney Int 1986;30:964-74. Kuncio GS, Neilson EG, Haverty T. Mechanisms of tubulointerstitial fibrosis. Kidney Int 1991 ;39:550-6. Mihatsch M, Thiel G, Ryffel B. Hazards of cyclosporin A therapy and recommendation for its use. J Autoimmun 1988;1:533-43.
Practices and beliefs concerning screening family members of patients with melanoma Results of a survey of New England dermatologists Alan C. Geller, RN, MPH, Howard K. Koh, MD, Donald R. Miller, SeD, and Robert A. Lew, PhD Boston, Massachusetts Background: First-degree relatives of patients with melanoma are roughly two to eight times more likely than the general public to be diagnosed with melanoma. Several organizations recommend regular screening for these and other persons at high risk for melanoma. However, there are no data as to how frequently such persons receive skin cancer examinations. Objective: Our purpose was to determine the current screening recommendations and practices of dermatologists regarding family screening for melanoma. Methods: With a one-page questionnaire, we surveyed dermatologists attending a 1989 meeting of the New England Dermatological Society. Results: Seventy-three dermatologists completed the questionnaire. Most dermatologists (70%) reported that they encouraged screening offamily members ofpatients with melanoma but also reported that family members infrequently appeared for skin examinations. Conclusion: Although most dermatologists encouraged screening of first degree relatives of melanoma patients, there appears to be infrequent acceptance by the patient of these recommendations. Recording family screening in the patients' charts, reminders to patients, and distributing literature on familial melanoma may increase acceptanc~ by the patient of these recommendations. (J AM ACAD DERMATOL 1992;26:419-22.)
Early detection through screening is a theoretically appealing approach to reduce death from maFrom the Departments of Dermatology and Medicine and the Section of Epidemiology and Biostatistics, Boston University Schools of Medicine and Public Health. Supported in part by the National Cancer Institute Grant K07 CA01380-03. Dr. Koh is a recipient of the Preventive Oncology Academic Award from the National Cancer Institute. Accepted for publication Oct. 3, 1991. Reprint requests: Howard K. Koh, MD, Boston University Medical Center, 80 E. Concord St., Boston, MA 02118. 16/1/34145
lignant melanoma,l Screening family members of persons who have had melanoma merits special consideration because first-degree relatives are roughly two to eight times more likely than the general public to develop the disease2 and comprise up to 10% of all melanoma cases. 3 Screening of family members of persons with melanoma has been recommended. 4-13 Specifically, the U.S. Preventive Services Task Force recommends screening for high-risk persons, including those with a family history.ll However, no data have been published on family screening practices by
419
Journal of the American Academy of Dermatology
420 Geller et at.
Table 1. Practices concerning screening of family members of melanoma patients reported in survey of New England dermatologists Dematologist's practice
Encouraged screening of family members* Checked at later visit to ensure that family members were screenedt Recorded regularly in chart whether family members were screenedt
No. (% ) reported No. (Up to 25 %)
No. (26%-50%)
No. (51 %-75%)
No. (76%-100%)
8 (10)
10 (14)
4 (6)
51 (70)
10 (20)
5 (10)
12 (24)
24 (47)
18 (35)
33 (65)
*All dermatologists in survey (n =73). tor dermatologists who encouraged screening with more than 75% of patients (n '" 51). dermatologists, the physicians most likely to care for patients with melanoma and their families. We conducted a survey of New England dermatologists to assess their current screening recommendations and practices and to determine what obstacles might impede screening of family members. MATERIAL AND METHODS We surveyed practicing dermatologists at a meeting of the New England Dermatological Society in October 1989. One hundred ten dermatologists attended the meeting, representing approximately 40% of all boardcertified dermatologists currently practicing in New England. Each dermatologist was given a one-page questionnaire. Seventy-three (66%) completed it. The dermatologists were asked about their type of practice, duration of practice, and the number of melanoma diagnoses made in the past 2years. Theywere asked whether they encouraged screening offamily members of their patients with melanoma, and, if so, whether their patients actually brought in family members for screening. Those who did not routinely recommend screening of family members were asked for the reasons for not doing so. In addition, they were asked whether they checked with patients at subsequent visits to ensure that family members had been screened and whether they regularly recorded such information in the patients' charts. Finally, the dermatologists were asked whether they thought certain measures, such as the provision of educational materials specifically designed for families, would be beneficial in encouraging screening of family members. Weusedchi-squareanalysis (with Yatescorrection) to test for differences in responses between subgroups. RESULTS More than half the 73 dermatologists who completed the survey were in private practice (54%);
38% were in academic practice. Most (85%) had been practicing dermatology for at least 3 years, and 65% had been in practice for more than 10 years (compared to 61 % for all New England dermatologists). All respondents noted that they had diagnosed at least one melanoma during the previous 2 years. Most (74%) had diagnosed fewer than 11 cases, and 10% had diagnosed more than 16 cases in that 2-year period. Most dermatologists (51 of 73 [70%]) encouraged their melanoma patients to have their immediate family members screened (Table I). However, of these 51 dermatologists, most (28 [55%]) reported that family members of less than half the patients actually appeared for screening. Thirty-six of the 51 dermatologists (70%) reported asking most of their patients at subsequent visits whether immediate family members had been screened, but only 35% regularly recorded such screening in the chart (Table I). Dermatologists from academic settings were more likely than private dermatologists to report screening of immediate family members (42% vs 26%). Among the 22 dermatologists who noted that they did not routinely encourage family screening, reasons cited most often were lack of written material to give to patients (7 physicians), doubt that family members would show up for a visit (6), and lack of time to raise this issue and follow through with families (4). Only one dermatologist was unaware that a family history of melanoma is an important risk factor. To encourage screening of family members, 82% of the respondents thought that specific educational materials should be made available for patients and
Volume 26 Number 3 March 1992
Screening offamily members of melanoma patients 421
their families; 44% favored communications from the American Academy of Dermatology regarding family screening, and 25% wanted facilitation of appointments for family members by clerical or nursing staff. For the dermatologists who encouraged screening offamily members (more than 75% of the time), we examined the relation between their actual screening of family members and practices that might promote such screening. Regular recording of such screening in the patient's chart was associated with a higher proportion of actual screening (57% vs 14%; p = 0.0l). Dermatologists who checked with patients at later visits and recorded screening in the chart were significantly more likely than those who practiced neither measure to report actual screening of family members (71 % vs 16%; p = 0.02). DISCUSSION
Although most dermatologists in this study encouraged screening of family members of patients with melanoma, they reported that family members infrequently appeared for screening. These dermatologists estimated that only one third to one half of immediate family members were screened, a conclusion also reached in a separate statewide study of patients with melanoma in Massachusetts. 14 Dermatologists who regularly recorded family screening in the patients' charts were more successful in reaching family members of their patients. This implies that careful monitoring and attention to family screening by dermatologists may increase the likelihood that relatives of melanoma patients will seek skin cancer examinations. However, there may bepatient-related factors (lack of access to all family members, lack of understanding of the problem) that may continue to impede screening of immediate family members. A National Cancer Institute study of 14 families with dysplastic nevus syndrome and cutaneous malignant melanoma achieved a high compliance with screening recommendations; 96% of affected family members had examined their skin in the previous 2 months, and 80% stated that they had seen a physician at least once specifically for a skin cancer examination. 4 Intensive educational efforts helped facilitate compliance. Lesions detected during this study (and a similar one in the Netherlands) were thinner than ones diagnosed before onset of surveillance. 9, 10 Family members of patients with other types of cancer, such as breast cancer, are often en-
couraged to seek cancer screening and rates of screening tend to be higher in such relatives. I5 Screening higher risk groups, such as family members, may also have a more favorable cost-benefit ratio than screening of the general population. 16 The response rate to our survey was less than complete (67%). However, those dermatologists who responded to the survey were representative of New England dermatologists in terms of years of experience (number of years past residency).17 We note that all of our data is self-reported and must be verified by other studies, including those using medical record review. In addition, although the sub· stantial majority of our respondents reported that they encouraged screening of immediate family members, previous studies in other cancers have shown that physicians tend to overestimate their screening performance.. On the other hand, the number of immediate family members screened may be underestimated as dermatologists were asked what percentage of patients "actually brought" in family members for screening. Finally, some, if not many, family members may have sought skin cancer examinations from physicians not included in this survey. Although first-degree relatives of melanoma patients comprise only up to 10% of all cases, family history of melanoma is an easily identifiable risk factor that should serve as a useful tool for targeted screening. Most dermatologists encouraged family screening but the majority of relatives did not appear to comply. Hence additional measures (used for other cancer screening efforts) may be necessary to increase screening rates. IS Examples of such measures that may be applied to screening of family members of patients with melanoma include (I) reminders to the patients at subsequent visits about the elevated risk for immediate family members and the importance of family screening, (2) a regular place in the chart that highlights screening of family members and documents compliance, and (3) the distribution of easily comprehended literature that describes the risk for family members, encourages self and physician screening, and informs families on the use of sunscreens. Most surveyed dermatologists supported the idea of making educational materials available to patients and their families. Future research must verify our results and study the impact of implementing such measures. We await definite proof that screening for melanoma reduces mortality. Until such evidence is available,
422
Geller et at.
screening of family members appears to be one reasonable strategy for melanoma control. We thank the New England Dermatological Society for allowing use of a survey to make this study possible. We are grateful to Cynthia Barber, MPH, for her careful review of this manuscript and to Claudia Arrigg, MD, for unending encouragement and support. REFERENCES 1. Koh HK, Lew RA, Prout MN. Screening for melanoma/ skin cancer: theoretic and practical considerations. J AM ACAD DERMATOL 1989;20:159-72. 2. Rhodes AR, Weinstock MA, Fitzpatrick TB, et al. Risk factors for cutaneous melanoma: a practical method of recognizing predisposed individuals. JAMA 1987;258:314654. 3. Greene MH, Fraumeni JF. The hereditary variant of malignant melanoma. In: Clark WH, Goldman LI, Mastrangelo MJ, eds. Human malignant melanomas. New York: Grune & Stratton, 1979:139-66. 4. McGuire DB. Preventive health practices and educational needs in families with hereditary melanoma. Cancer Nursing 1985;8:29-36. 5. Lynch HT, Krush AJ. Hereditary and malignant melanoma: implications for early cancer detection. Can Med Assoc J 1968;99:17-21. 6. Duggleby WF, Stoll H, Priore RL, et al. A genetic analysis of melanoma-polygenic inheritance as a threshold trait. Am J EpidemioI1981;1l4:63-72. 7. Kopf AW, Hellman LJ, Rogers GS, et al. Familial malignant melanoma. JAMA 1986;256:1915-9.
Journal of the American Academy of Dermatology 8. Monk BE, Bennett JP, Brett J, et al. Familial malignant melanoma. Br J Plast Surg 1988;41:316-8. 9. Masri GD, Clark WH Jr, Guerry DIV, et al. Screening and surveillance of patients at high risk for malignant melanoma result in detection of earlier disease. J AM ACAD DERMATOL 1990;22:1042-8. 10. Vasen HFA,Bergman W, Van HaeringenA,etaL The familial dysplastic nevus syndrome: natural history and the impact of screening on prognosis-a study of nine families in the Netherlands. Eur J Cancer Clin OncoI1989;25:33741. 11. Fisher M, Eckhart C, eds. Screening for skin cancer: guide to clinical preventive services. An assessment of the effectiveness of 169 interventions. Report of the U.S. Preventive Services Task Force. Baltimore: Williams & Wilkins, 1989. 12. Hayward RSA, Steinberg EP, Ford DE, et al. Preventive care guidelines: 1991. Ann Intern Med 1991;114:758-83. 13. Oboler SK, LaForce FM. The periodic physical examination in asymptomatic adults. Ann Intern Moo 1989; 110:214-26. 14. Koh HK, Miller DR, Geller AC, et al. Who discovers melanoma? Patterns from a population-based survey. J AM ACAD DERMATOL (In press.) 15. Houts PS, Wojtkowiak SL, Simmonds MA, et al. Using a state cancer registry to increase screening behaviors of sisters and daughters of breast cancer patients. Am J Public Health 1990;81:386-8. 16. Cole P, Morrison AS. Basic issues in population screening for cancer. JNCI 1980;64:1263-72. 17. Directory of Medical Specialists; vol 1. 24th ed. Wilmette, Ill: Marquis, Macmillan Directory Division, 1989-1990. 18. McPhee SJ, Bird JA, Jenkins CNH, et al. Promoting cancer screening: a randomized, controlled trial of three interventions. Arch Intern Med 1989;149:1866-72.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY are available to subscribers (only) for the 1992 issues from the Publisher at a cost of $66.00 for domestic, $88.62 for Canadian, and $84.00 for international for volume 26 (January-June) and volume 27 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318. USA: phone (800) 325-4177, ext. 4351; (314) 453-4351. Subscriptions must be in force to qualifY. Bound volumes are not available in place ofa regular journal subscription.
7. 8.
9. 10.
Kidney changes during cyclosporine therapy for psoriasis
pIe and efficient sterealogical methods and their use in pathological research and diagnosis. APMIS 1988;96:37994. Mihatsch M, Thiel G, Ryffel B. Morphologic diagnosis of cyc1osporine nephrotoxicity. Semin Diagn Pathol 1988; 5:104-21. Zachariae H, Kragballe K, Hansen HE, et al. Changes in renal biopsies during low dosage cyc1osporine treatment. Acta Derm Venereal (Stockh) 1990;70:361-2. Mason J. Renal side-effects of cyclosporin A. Br J DermatolI990;122(suppI36):71-7. Mihatsch M, Thiel G, Ryffel B. Renal side-effects of
11. 12. 13. 14.
cyclosporin A with special reference to autoimmune diseases. Br J Dermatol 1990;122(suppl 36):101-15. Zachariae H, Hansen HE, S~gaard H, et al. Kidney biopsies in methotrexate-treated psoriatics. Dermatologica 1990;181:273-6. Meyers B. Cyclosporine nephrotoxicity. Kidney Int 1986;30:964-74. Kuncio GS, Neilson EG, Haverty T. Mechanisms of tubulointerstitial fibrosis. Kidney Int 1991 ;39:550-6. Mihatsch M, Thiel G, Ryffel B. Hazards of cyclosporin A therapy and recommendation for its use. J Autoimmun 1988;1:533-43.
Practices and beliefs concerning screening family members of patients with melanoma Results of a survey of New England dermatologists Alan C. Geller, RN, MPH, Howard K. Koh, MD, Donald R. Miller, SeD, and Robert A. Lew, PhD Boston, Massachusetts Background: First-degree relatives of patients with melanoma are roughly two to eight times more likely than the general public to be diagnosed with melanoma. Several organizations recommend regular screening for these and other persons at high risk for melanoma. However, there are no data as to how frequently such persons receive skin cancer examinations. Objective: Our purpose was to determine the current screening recommendations and practices of dermatologists regarding family screening for melanoma. Methods: With a one-page questionnaire, we surveyed dermatologists attending a 1989 meeting of the New England Dermatological Society. Results: Seventy-three dermatologists completed the questionnaire. Most dermatologists (70%) reported that they encouraged screening offamily members ofpatients with melanoma but also reported that family members infrequently appeared for skin examinations. Conclusion: Although most dermatologists encouraged screening of first degree relatives of melanoma patients, there appears to be infrequent acceptance by the patient of these recommendations. Recording family screening in the patients' charts, reminders to patients, and distributing literature on familial melanoma may increase acceptanc~ by the patient of these recommendations. (J AM ACAD DERMATOL 1992;26:419-22.)
Early detection through screening is a theoretically appealing approach to reduce death from maFrom the Departments of Dermatology and Medicine and the Section of Epidemiology and Biostatistics, Boston University Schools of Medicine and Public Health. Supported in part by the National Cancer Institute Grant K07 CA01380-03. Dr. Koh is a recipient of the Preventive Oncology Academic Award from the National Cancer Institute. Accepted for publication Oct. 3, 1991. Reprint requests: Howard K. Koh, MD, Boston University Medical Center, 80 E. Concord St., Boston, MA 02118. 16/1/34145
lignant melanoma,l Screening family members of persons who have had melanoma merits special consideration because first-degree relatives are roughly two to eight times more likely than the general public to develop the disease2 and comprise up to 10% of all melanoma cases. 3 Screening of family members of persons with melanoma has been recommended. 4-13 Specifically, the U.S. Preventive Services Task Force recommends screening for high-risk persons, including those with a family history.ll However, no data have been published on family screening practices by
419
Journal of the American Academy of Dermatology
420 Geller et at.
Table 1. Practices concerning screening of family members of melanoma patients reported in survey of New England dermatologists Dematologist's practice
Encouraged screening of family members* Checked at later visit to ensure that family members were screenedt Recorded regularly in chart whether family members were screenedt
No. (% ) reported No. (Up to 25 %)
No. (26%-50%)
No. (51 %-75%)
No. (76%-100%)
8 (10)
10 (14)
4 (6)
51 (70)
10 (20)
5 (10)
12 (24)
24 (47)
18 (35)
33 (65)
*All dermatologists in survey (n =73). tor dermatologists who encouraged screening with more than 75% of patients (n '" 51). dermatologists, the physicians most likely to care for patients with melanoma and their families. We conducted a survey of New England dermatologists to assess their current screening recommendations and practices and to determine what obstacles might impede screening of family members. MATERIAL AND METHODS We surveyed practicing dermatologists at a meeting of the New England Dermatological Society in October 1989. One hundred ten dermatologists attended the meeting, representing approximately 40% of all boardcertified dermatologists currently practicing in New England. Each dermatologist was given a one-page questionnaire. Seventy-three (66%) completed it. The dermatologists were asked about their type of practice, duration of practice, and the number of melanoma diagnoses made in the past 2years. Theywere asked whether they encouraged screening offamily members of their patients with melanoma, and, if so, whether their patients actually brought in family members for screening. Those who did not routinely recommend screening of family members were asked for the reasons for not doing so. In addition, they were asked whether they checked with patients at subsequent visits to ensure that family members had been screened and whether they regularly recorded such information in the patients' charts. Finally, the dermatologists were asked whether they thought certain measures, such as the provision of educational materials specifically designed for families, would be beneficial in encouraging screening of family members. Weusedchi-squareanalysis (with Yatescorrection) to test for differences in responses between subgroups. RESULTS More than half the 73 dermatologists who completed the survey were in private practice (54%);
38% were in academic practice. Most (85%) had been practicing dermatology for at least 3 years, and 65% had been in practice for more than 10 years (compared to 61 % for all New England dermatologists). All respondents noted that they had diagnosed at least one melanoma during the previous 2 years. Most (74%) had diagnosed fewer than 11 cases, and 10% had diagnosed more than 16 cases in that 2-year period. Most dermatologists (51 of 73 [70%]) encouraged their melanoma patients to have their immediate family members screened (Table I). However, of these 51 dermatologists, most (28 [55%]) reported that family members of less than half the patients actually appeared for screening. Thirty-six of the 51 dermatologists (70%) reported asking most of their patients at subsequent visits whether immediate family members had been screened, but only 35% regularly recorded such screening in the chart (Table I). Dermatologists from academic settings were more likely than private dermatologists to report screening of immediate family members (42% vs 26%). Among the 22 dermatologists who noted that they did not routinely encourage family screening, reasons cited most often were lack of written material to give to patients (7 physicians), doubt that family members would show up for a visit (6), and lack of time to raise this issue and follow through with families (4). Only one dermatologist was unaware that a family history of melanoma is an important risk factor. To encourage screening of family members, 82% of the respondents thought that specific educational materials should be made available for patients and
Volume 26 Number 3 March 1992
Screening offamily members of melanoma patients 421
their families; 44% favored communications from the American Academy of Dermatology regarding family screening, and 25% wanted facilitation of appointments for family members by clerical or nursing staff. For the dermatologists who encouraged screening offamily members (more than 75% of the time), we examined the relation between their actual screening of family members and practices that might promote such screening. Regular recording of such screening in the patient's chart was associated with a higher proportion of actual screening (57% vs 14%; p = 0.0l). Dermatologists who checked with patients at later visits and recorded screening in the chart were significantly more likely than those who practiced neither measure to report actual screening of family members (71 % vs 16%; p = 0.02). DISCUSSION
Although most dermatologists in this study encouraged screening of family members of patients with melanoma, they reported that family members infrequently appeared for screening. These dermatologists estimated that only one third to one half of immediate family members were screened, a conclusion also reached in a separate statewide study of patients with melanoma in Massachusetts. 14 Dermatologists who regularly recorded family screening in the patients' charts were more successful in reaching family members of their patients. This implies that careful monitoring and attention to family screening by dermatologists may increase the likelihood that relatives of melanoma patients will seek skin cancer examinations. However, there may bepatient-related factors (lack of access to all family members, lack of understanding of the problem) that may continue to impede screening of immediate family members. A National Cancer Institute study of 14 families with dysplastic nevus syndrome and cutaneous malignant melanoma achieved a high compliance with screening recommendations; 96% of affected family members had examined their skin in the previous 2 months, and 80% stated that they had seen a physician at least once specifically for a skin cancer examination. 4 Intensive educational efforts helped facilitate compliance. Lesions detected during this study (and a similar one in the Netherlands) were thinner than ones diagnosed before onset of surveillance. 9, 10 Family members of patients with other types of cancer, such as breast cancer, are often en-
couraged to seek cancer screening and rates of screening tend to be higher in such relatives. I5 Screening higher risk groups, such as family members, may also have a more favorable cost-benefit ratio than screening of the general population. 16 The response rate to our survey was less than complete (67%). However, those dermatologists who responded to the survey were representative of New England dermatologists in terms of years of experience (number of years past residency).17 We note that all of our data is self-reported and must be verified by other studies, including those using medical record review. In addition, although the sub· stantial majority of our respondents reported that they encouraged screening of immediate family members, previous studies in other cancers have shown that physicians tend to overestimate their screening performance.. On the other hand, the number of immediate family members screened may be underestimated as dermatologists were asked what percentage of patients "actually brought" in family members for screening. Finally, some, if not many, family members may have sought skin cancer examinations from physicians not included in this survey. Although first-degree relatives of melanoma patients comprise only up to 10% of all cases, family history of melanoma is an easily identifiable risk factor that should serve as a useful tool for targeted screening. Most dermatologists encouraged family screening but the majority of relatives did not appear to comply. Hence additional measures (used for other cancer screening efforts) may be necessary to increase screening rates. IS Examples of such measures that may be applied to screening of family members of patients with melanoma include (I) reminders to the patients at subsequent visits about the elevated risk for immediate family members and the importance of family screening, (2) a regular place in the chart that highlights screening of family members and documents compliance, and (3) the distribution of easily comprehended literature that describes the risk for family members, encourages self and physician screening, and informs families on the use of sunscreens. Most surveyed dermatologists supported the idea of making educational materials available to patients and their families. Future research must verify our results and study the impact of implementing such measures. We await definite proof that screening for melanoma reduces mortality. Until such evidence is available,
422
Geller et at.
screening of family members appears to be one reasonable strategy for melanoma control. We thank the New England Dermatological Society for allowing use of a survey to make this study possible. We are grateful to Cynthia Barber, MPH, for her careful review of this manuscript and to Claudia Arrigg, MD, for unending encouragement and support. REFERENCES 1. Koh HK, Lew RA, Prout MN. Screening for melanoma/ skin cancer: theoretic and practical considerations. J AM ACAD DERMATOL 1989;20:159-72. 2. Rhodes AR, Weinstock MA, Fitzpatrick TB, et al. Risk factors for cutaneous melanoma: a practical method of recognizing predisposed individuals. JAMA 1987;258:314654. 3. Greene MH, Fraumeni JF. The hereditary variant of malignant melanoma. In: Clark WH, Goldman LI, Mastrangelo MJ, eds. Human malignant melanomas. New York: Grune & Stratton, 1979:139-66. 4. McGuire DB. Preventive health practices and educational needs in families with hereditary melanoma. Cancer Nursing 1985;8:29-36. 5. Lynch HT, Krush AJ. Hereditary and malignant melanoma: implications for early cancer detection. Can Med Assoc J 1968;99:17-21. 6. Duggleby WF, Stoll H, Priore RL, et al. A genetic analysis of melanoma-polygenic inheritance as a threshold trait. Am J EpidemioI1981;1l4:63-72. 7. Kopf AW, Hellman LJ, Rogers GS, et al. Familial malignant melanoma. JAMA 1986;256:1915-9.
Journal of the American Academy of Dermatology 8. Monk BE, Bennett JP, Brett J, et al. Familial malignant melanoma. Br J Plast Surg 1988;41:316-8. 9. Masri GD, Clark WH Jr, Guerry DIV, et al. Screening and surveillance of patients at high risk for malignant melanoma result in detection of earlier disease. J AM ACAD DERMATOL 1990;22:1042-8. 10. Vasen HFA,Bergman W, Van HaeringenA,etaL The familial dysplastic nevus syndrome: natural history and the impact of screening on prognosis-a study of nine families in the Netherlands. Eur J Cancer Clin OncoI1989;25:33741. 11. Fisher M, Eckhart C, eds. Screening for skin cancer: guide to clinical preventive services. An assessment of the effectiveness of 169 interventions. Report of the U.S. Preventive Services Task Force. Baltimore: Williams & Wilkins, 1989. 12. Hayward RSA, Steinberg EP, Ford DE, et al. Preventive care guidelines: 1991. Ann Intern Med 1991;114:758-83. 13. Oboler SK, LaForce FM. The periodic physical examination in asymptomatic adults. Ann Intern Moo 1989; 110:214-26. 14. Koh HK, Miller DR, Geller AC, et al. Who discovers melanoma? Patterns from a population-based survey. J AM ACAD DERMATOL (In press.) 15. Houts PS, Wojtkowiak SL, Simmonds MA, et al. Using a state cancer registry to increase screening behaviors of sisters and daughters of breast cancer patients. Am J Public Health 1990;81:386-8. 16. Cole P, Morrison AS. Basic issues in population screening for cancer. JNCI 1980;64:1263-72. 17. Directory of Medical Specialists; vol 1. 24th ed. Wilmette, Ill: Marquis, Macmillan Directory Division, 1989-1990. 18. McPhee SJ, Bird JA, Jenkins CNH, et al. Promoting cancer screening: a randomized, controlled trial of three interventions. Arch Intern Med 1989;149:1866-72.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY are available to subscribers (only) for the 1992 issues from the Publisher at a cost of $66.00 for domestic, $88.62 for Canadian, and $84.00 for international for volume 26 (January-June) and volume 27 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318. USA: phone (800) 325-4177, ext. 4351; (314) 453-4351. Subscriptions must be in force to qualifY. Bound volumes are not available in place ofa regular journal subscription.