Air Force Battles Malignant Melanoma with Enhanced Prevention, Detection, Treatment

by U.S. Medicine

June 18, 2013

By Stephen Spotswood

LACKLAND AIR FORCE BASE, TX – One of the most common cancers among active-duty troops, malignant melanoma was diagnosed in 1,788 servicemembers between 2000 and 2011.1

Because military personnel often are required to be outside for prolong periods of time, increasing the risk of sun exposure, they might be expected to have higher rates of the cancer than the general population. Yet, that is not always the case. Young white males in the armed forces actually have a lower incidence of melanoma than the general population, according to a U.S. Military Cancer Institute study from 1990 to 2004. 2

(Malignant melanoma is far more common in Caucasians than in other races; of the 1,788 military cases between 2000 and 2011, only 129 were in nonwhites.)

On the other hand, rates for older servicemembers are as high or higher than the general population. More than 72% of the malignant melanoma cases were in servicemembers 30 years old or older, according to the June 2012 report from the Armed Forces Health Surveillance Center.

“In general, the strongest demographic correlate of increased risk of a cancer diagnosis was older age,” the authors wrote.

Maj. Wendie Wohltmann, 81st Medical Operations Squadron dermatologist, examines a lesion for possible skin cancer on Robert Fell, a retired captain, in the dermatology clinic. Age is a risk factor for malignant melanoma and other skin cancers. U.S. Air Force photo by Steve Pivnick

Focus on Prevention

That disparity might have much to do with the services’ increased focus on preventing melanoma in recent years. The Air Force has a slightly higher rate of melanoma than the services in total — 15.5 vs. 10.5 — but it also has a range of measures in place to protect its airmen from skin cancer, from very simple preventive measures to cutting-edge pharmaceutical treatments.

The first goal is to cut down on unnecessary exposure to sunlight and keep the development of melanoma and its warning signs to a minimum. Before deployment, troops are instructed about sun safety. None are deployed before being issued sunscreen, and mandatory hat wear has been in place since the 1960s. Pilots and navigators also are protected from the higher levels of radiation they could be exposed to in the upper atmosphere.

The second goal is to catch all melanomas as early as possible.

“We screen aviators and those with flying status on a yearly basis, and flight surgeons screen them with a general skin exam,” explained Lt. Col. Todd Kobayashi, MD, the Air Force Surgeon General Consultant for Dermatology.

The American Academy of Dermatology (AAD) recommends a yearly screening exam for every adult, and servicemembers are asked to screen themselves on a yearly basis.

“We ask they do it on their birthday, so it’s easy to remember — birthday suit screening exams,” Kobayashi said. “You strip down and screen yourself, looking for atypical moles.”

While such moles are rarely malignant themselves, people who develop them are at an increased risk of developing melanomas.

The Air Force also tries to screen its retired population — who, being older, are at a higher risk for skin cancers — at least once a year.

Some of the barriers to success have been societal rather than medical. When the AAD rolled out its melanoma-prevention initiatives, including a campaign against the use of tanning beds, there was a lot of skepticism.

“There was just a lot of pushback in the very beginning when we first told people — general population and servicemembers — to stay out of the sun from a dermatologic perspective. Being in the sun and having a tan was very much in vogue,” Kobayashi said. “But I think the AAD and dermatologists in the Air Force have been pretty successful in manning a campaign against suntanning.”

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Treatment and Research

The push to improve prevention and screening has been very successful, Kobayashi said, both in and out of the military.

“We have been, as a society, very successful in diagnosing and treating melanoma early. There’s been an epidemic of melanoma in the world — not only an increase in risk of getting melanoma but an increase incident reporting of melanoma,” he said. “We’re diagnosing melanomas much earlier and at a [shallower] depth. These melanomas we find are very superficial, and if diagnosed early, we have a great chance of treating them.”

If caught early, surgical treatment has a 100% cure rate, Kobayashi said.

If caught too late, the treatment options become more difficult. Once the melanoma has metastasized to the lymph nodes and internal organs, it becomes necessary to surgically remove the lymph nodes and metastatic lesions. That procedure is followed by chemotherapy.

Air Force physicians also have the option of using two newly-approved medications designed to attack melanoma cells. The first, vemurafenib (marketed as Zelboraf), only works on patients whose cancer has a specific mutation, which accounts for about 60% of melanomas. In clinical trials, patients using the drug had an increased six-month survival rate.

Ipilimumab (marketed as Yervoy) has been on the market since 2011. Designed to help improve immune response to cancer cells, trials show the drug offers as much as a two-year increased survival rate.

“There are a lot more in the pipeline,” Kobayashi said. “But there are a lot of potential side effects that we have to monitor. We work closely with our oncology colleagues, who are the ones prescribing these.”

DoD has its own research program targeting melanoma. A new study at Lackland Air Force Base is trying to identify the expression of MHC Class 1 antigens on melanoma cells. MHC (major histocompatibility complex) is a conglomerate of genes that help the body recognize what belongs in the body and what does not. Previous research suggests that, if expression of MHC antigens are better understood, it could provide keys to new pharmaceutical treatments for cancers and similar diseases.

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1. Armed Forces Health Surveillance Center (AFHSC). Incident diagnoses of cancers and cancer-related deaths, active component, U.S. Armed Forces, 2000-2011. MSMR. 2012 Jun;19(6):18-22. PubMed PMID: 22779436.

2. Zhou J, Enewold L, Zahm SH, Devesa SS, Anderson WF, Potter JF, McGlynn KA, Zhu K.United States Military Cancer Institute. Melanoma incidence rates among whites in the U.S. Military. Cancer Epidemiol Biomarkers Prev. 2011 Feb;20(2):318-23. doi: 10.1158/1055-9965.EPI-10-0869. Epub 2010 Dec 8.

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