Susan M. Swetter, M.D., is a Professor of Dermatology, Assistant Chief of the Dermatology Service at the VA Palo Alto, and Director of the Pigmented Lesion and Melanoma Program at Stanford University Medical Center and Cancer Institute. She also serves as Physician Leader of the Cancer Care Program in Cutaneous Oncology at Stanford. Dr. Swetter's research interests encompass both primary and secondary melanoma prevention, including therapeutic prevention strategies in patients with atypical nevi and targeted screening/education of high-risk groups for improved melanoma awareness and early detection. Her clinical interests are in cutaneous oncology/melanoma (at both Stanford and VA Palo Alto) and adult general medical dermatology (at VA Palo Alto).

Clinical Focus

  • Cancer > Cutaneous (Dermatologic) Oncology
  • Pigmented Skin Lesions
  • Melanoma
  • Skin Cancer
  • Basal/ Squamous Cell Carcinomas - VA Dermatology
  • Dermatology
  • Cutaneous Oncology
  • Basal / Squamous Cell Carcinomas - Dermatology
  • Pigmented Lesion and Melanoma Program
  • Melanoma - Dermatology
  • Pigmented Skin Lesions - Dermatology
  • Pigmented Skin Lesions - Medical Oncology
  • Skin Cancer - Dermatology

Academic Appointments

Administrative Appointments

  • Member, Melanoma/Skin Cancer Committee, American Academy of Dermatology (1999 - 2009)
  • Member, Scientific Programs Committee, Melanoma Section, American Society of Clinical Oncology (2006 - 2008)
  • Member, Melanoma Clinical Guidelines Task Force, American Academy of Dermatology (2006 - 2012)
  • Member, Board of Directors, American Cancer Society, Santa Clara County Unit (2007 - Present)
  • Member, Melanoma Panel, National Comprehensive Cancer Network (2007 - Present)
  • President, Board of Directors, American Cancer Society, Santa Clara County Unit (2009 - 2011)
  • Medical Advisory Panel, Melanoma Research Alliance (2013 - Present)
  • Advisory Board, Stanford Women and Sex Differences in Medicine (WSDM) Center (2014 - Present)
  • Physician Leader, Cancer Care Program in Cutaneous Oncology, Stanford Cancer Institute (2012 - Present)
  • Director, Pigmented Lesion and Melanoma Program, Stanford Cancer Institute (1995 - Present)

Honors & Awards

  • Nominated, Kaiser Award for Clinical Teaching, Stanford University School of Medicine (2003, 2004, 2005)
  • Nominated, Franklin G. Ebaugh, Jr. Award (outstanding dedication to advising medical students), Stanford University School of Medicine (1999, 2001, 2004, 2009)
  • Recognition for Excellence in Teaching, Stanford University School of Medicine (2004, 2009)
  • President’s Volunteer Service Award, President’s Council on Service & Civic Participation, Corporation for National & Community Service (2007)
  • Leadership Award, Melanoma Care Coalition (2007)
  • Elected Member, American Dermatological Association (2011)
  • Humanitarian Award Recipient, Melanoma Research Foundation (2012)

Professional Education

  • Board Certification: Dermatology, American Board of Dermatology (1994)
  • Residency:Stanford University School of Medicine (1994) CA
  • Chief Residency, Stanford University, Dermatology (1994)
  • Dermatology Residency, Stanford University, Dermatology (1994)
  • Internship:UCSF Medical Center (1991) CA
  • Internship, Univ. of California, San Francisco, Internal Medicine (1991)
  • Medical Education:University of Pennsylvania School of Medicine (1990) PA
  • MD, University of Pennsylvania, Medicine (1990)
  • BA, University of Virginia, Interdisciplinary Studies (1986)

Community and International Work

  • Philos Health Medical Relief Trips to Bohol, Philippines, Bohol, Philippines


    Skin care/primary care

    Partnering Organization(s)

    Philos Health

    Populations Served

    Indigent villagers



    Ongoing Project


    Opportunities for Student Involvement


  • President, Board of Directors, American Cancer Society Santa Clara County Unit, Campbell, CA


    Leadership in ACS community-based cancer outreach, advocacy, and volunteer efforts.

    Partnering Organization(s)

    American Cancer Society

    Populations Served

    Cancer patients in Santa Clara County


    Bay Area

    Ongoing Project


    Opportunities for Student Involvement


  • Program Director, Stanford Skin Cancer Screening Program, 1995-2011, Stanford Medicine Outpatient Clinics


    Skin cancer screening

    Partnering Organization(s)

    American Academy of Dermatology, Stanford Dermatology Department, Stanford Cancer Institute

    Populations Served

    Individuals at increased risk for skin cancer/melanoma


    Bay Area

    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

Dr. Swetter has directed the Pigmented Lesion and Melanoma Programs at Stanford University Medical Center and Cancer Institute and VA Palo Alto since 1995. She serves as the national dermatology liaison to the Eastern Cooperative Oncology Group (ECOG) Melanoma Committee and Co-Chairs the Melanoma Prevention Working Group, a national forum for research collaboration among academic oncologists, dermatologists, epidemiologists, and surgeons dedicated to cancer control and prevention, comprised of Intergroup (ECOG, SWOG, CALGB) melanoma centers in the US.

Dr. Swetter's research interests include primary and secondary prevention of melanoma, including early detection and screening of high-risk groups, melanoma chemoprevention in individuals with atypical mole syndrome and other risk factors, and research focused on increasing professional and public education to improve melanoma awareness and recognition. She is also engaged in clinical studies of the epidemiology, prognostic factors, and therapy of melanoma and nonmelanoma skin cancers at both Stanford and VA Palo Alto.

Dr. Swetter serves on the National Comprehensive Cancer Network (NCCN) Melanoma Panel and American Academy of Dermatology Melanoma Work Group to establish clinical practice guidelines for melanoma.

Clinical Trials

  • Sulindac in Preventing Melanoma in Healthy Participants Who Are at Increased Risk of Melanoma Not Recruiting

    This randomized phase II trial is studying how well sulindac works in preventing melanoma in healthy participants who are at increased risk of melanoma. Sulindac may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. It is not yet known whether sulindac is more effective than a placebo in preventing melanoma in individuals with many moles and abnormal moles.

    Stanford is currently not accepting patients for this trial. For more information, please contact Susan Swetter, (650) 852 - 3494.

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  • Vaccine Therapy Using Melanoma Peptides for Cytotoxic T Cells and Helper T Cells in Treating Patients With Metastatic Melanoma Not Recruiting

    RATIONALE: Vaccines made from peptides may make the body build an immune response to kill tumor cells. PURPOSE: This randomized phase II trial is studying four different vaccines using melanoma peptides from cytotoxic T cells and helper T cells to see how well they work in treating patients with metastatic melanoma.

    Stanford is currently not accepting patients for this trial. For more information, please contact Sunil Arani Reddy, (650) 736 - 1234.

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  • A Pharmacokinetic/Pharmacodynamic Study of RO5185426 in Previously Treated Patients With Metastatic Melanoma Not Recruiting

    This open-label study will assess the pharmacokinetics, efficacy and safety of RO5185426 administered as 240mg tablets in previously treated patients with metastatic melanoma. Patients will be randomized to receive one of four dose-levels of RO5185426 [RG7204; PLEXXIKON; PLX4032] orally twice daily on days 1 to 15 (morning dose). Starting on day 22, treatment with RO5185426 may be resumed at a dose of 960 mg twice daily and continued until disease progression. Target sample size is <100 patients.

    Stanford is currently not accepting patients for this trial. For more information, please contact Dana Supan, (650) 736 - 1684.

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  • Dasatinib in Treating Patients With Locally Advanced or Metastatic Mucosal Melanoma, Acral Melanoma, or Vulvovaginal Melanoma That Cannot Be Removed By Surgery Not Recruiting

    RATIONALE: Dasatinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. PURPOSE: This phase II trial is studying how well dasatinib works in treating patients with locally advanced or metastatic mucosal melanoma or acral melanoma.

    Stanford is currently not accepting patients for this trial. For more information, please contact Jennifer Wong, 650-723-1002.

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  • Compassionate Use Trial for Unresectable Melanoma With Ipilimumab Not Recruiting

    The primary objective of the study is to provide treatment with Ipilimumab to subjects who have serious or immediately life-threatening unresectable Stage III or Stage IV melanoma, who have no alternative treatment options, and whose physicians believe, based upon available data on benefit and risk, that it is appropriate to administer Ipilimumab at a dose of 3 mg/kg induction (with re-induction, if eligible), or for eligible subjects previously enrolled in Ipilimumab studies CA184-042, CA184-078, CA184-087, MDX010-16, or MDX010-20.

    Stanford is currently not accepting patients for this trial. For more information, please contact Sunil Arani Reddy, (650) 736 - 1234.

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  • BRIM8: A Study of Vemurafenib Adjuvant Therapy in Patients With Resected Cutaneous BRAF Mutant Melanoma Not Recruiting

    This multicenter, randomized, double-blind, placebo-controlled study will evaluate the efficacy and safety of vemurafenib in participants with completely resected, cutaneous BRAF mutation-positive melanoma at high risk for recurrence. Participants will be randomized to receive oral doses of vemurafenib 960 milligrams (mg) twice daily or matching placebo. The anticipated time on study treatment is 52 weeks.

    Stanford is currently not accepting patients for this trial. For more information, please contact Deborah Miller, 650-723-0670.

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  • Pilot Ipilimumab in Stage IV Melanoma Receiving Palliative Radiation Therapy Not Recruiting

    This study hopes to determine the effect of a combination of docetaxel, cisplatin, and cetuximab in weekly treatment of squamous cell carcinoma of the head and neck. The study would like to determine if giving the combination of these drugs at lower, more frequent doses will result in less severe side effects and be an effective anti-cancer treatment.

    Stanford is currently not accepting patients for this trial. For more information, please contact Chuck Di Bari, 650-498-4073.

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  • Analysis of Cutaneous and Hematologic Disorders by High-Throughput Nucleic Acid Sequencing Not Recruiting

    The goal of this study is to identify genetic changes associated with the initiation, progression, and treatment response of response of cutaneous and hematologic disorders using recently developed high-throughput sequencing technologies. The improved understanding of the genetic changes associated with cutaneous and hematologic disorders may lead to improved diagnostic, prognostic and therapeutic options for these disorders.

    Stanford is currently not accepting patients for this trial. For more information, please contact Alexander Ungewickell, 650-723-6661.

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  • Ipilimumab With or Without Sargramostim in Treating Patients With Stage III or Stage IV Melanoma That Cannot Be Removed by Surgery Not Recruiting

    This randomized phase II trial is studying how well giving ipilimumab with or without sargramostim (GM-CSF) works in treating patients with stage III or stage IV melanoma that cannot be removed by surgery. Ipilimumab works by activating the patient's immune system to fight cancer. Colony-stimulating factors, such as sargramostim, may increase the number of immune cells found in bone marrow or peripheral blood and may help the immune system recover from the side effects of treatment. It is not yet known whether giving ipilimumab together with sargramostim is more effective than ipilimumab alone in treating melanoma.

    Stanford is currently not accepting patients for this trial. For more information, please contact Vani Jain, (650) 725 - 5459.

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  • Study of the Safety and Tolerability of Urelumab Administered in Combination With Nivolumab in Solid Tumors and B-cell Non-Hodgkins Lymphoma Recruiting

    The purpose of this study is to determine which doses of Urelumab and Nivolumab are safe and tolerable when they are given together.

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  • A Phase 1 Study of Atezolizumab (an Engineered Anti-PDL1 Antibody) in Patients With Locally Advanced or Metastatic Solid Tumors Not Recruiting

    This Phase I, multicenter, first in human, open-label, dose escalation study will evaluate the safety, tolerability, and pharmacokinetics of Atezolizumab administered as single agent by intravenous (IV) infusion to patients with locally advanced or metastatic solid malignancies or hematologic malignancies.

    Stanford is currently not accepting patients for this trial. For more information, please contact Maria Pitsiouni, 650-721-6977.

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  • A Trial of Intratumoral Injections of SD-101 in Combination With Pembrolizumab in Patients With Metastatic Melanoma Recruiting

    This is a Phase 1b/2 open-label trial to assess the safety, tolerability, biologic-activity, and preliminary efficacy of intratumoral SD-101 injections in combination with intravenous pembrolizumab in patients with advance or metastatic melanoma.

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  • Ipilimumab or High-Dose Interferon Alfa-2b in Treating Patients With High-Risk Stage III-IV Melanoma That Has Been Removed by Surgery Not Recruiting

    This randomized phase III trial studies ipilimumab to see how well it works compared to high-dose interferon alfa-2b in treating patients with high-risk stage III-IV melanoma that has been removed by surgery. Monoclonal antibodies, such as ipilimumab, may interfere with the ability of tumor cells to grow and spread. Interferon alfa-2b may interfere with the growth of tumor cells and slow the growth of melanoma and other cancers. It is not yet known whether ipilimumab is more effective than interferon alfa-2b in treating patients with melanoma.

    Stanford is currently not accepting patients for this trial. For more information, please contact Preeti Chavan, 650-725-0426.

    View full details


2016-17 Courses

Stanford Advisees

Graduate and Fellowship Programs


All Publications

  • Association of nevus count with prevention attitudes and behaviors before melanoma diagnosis. Melanoma research Mayer, J. E., Swetter, S. M., Miller, D. R., Sober, A. J., Johnson, T. M., Geller, A. C. 2016; 26 (5): 513-516


    Although melanoma risk factors are commonly known to healthcare professionals, the extent to which the at-risk public is either aware of these factors or perceives their risk accordingly has rarely been studied. We sought to investigate whether the presence of known melanoma risk factors, such as high total nevus and atypical nevus counts, was associated with increased prevention attitudes and behaviors, such as skin self-examinations and physician skin examinations. This was a retrospective study of 566 individuals recently diagnosed with melanoma in two large academic centers. Most prevention attitudes and behaviors did not vary on the basis of total nevi or atypical nevi counts. However, younger patients (<60 years) with many total nevi (>50) were more likely than those with fewer nevi (<20) to believe that they were at-risk for melanoma (42 vs. 23%; P<0.05), and more likely to state that they had been instructed on the signs of melanoma (36 vs. 21%; P<0.05). Patient and health provider recognition of the impact of nevus count on melanoma risk presents a unique and mostly untapped opportunity for earlier detection.

    View details for DOI 10.1097/CMR.0000000000000279

    View details for PubMedID 27387129

  • What the USPSTF "Insufficient" Skin Cancer Screening Recommendation Means for Primary Care Clinicians and Dermatologists. JAMA dermatology Swetter, S. M., Geller, A. C., Halpern, A. C. 2016; 152 (9): 973-975

    View details for DOI 10.1001/jamadermatol.2016.2606

    View details for PubMedID 27459324

  • NCCN Guidelines Insights: Melanoma, Version 3.2016. Journal of the National Comprehensive Cancer Network Coit, D. G., Thompson, J. A., Algazi, A., Andtbacka, R., Bichakjian, C. K., Carson, W. E., Daniels, G. A., Dimaio, D., Fields, R. C., Fleming, M. D., Gastman, B., Gonzalez, R., Guild, V., Johnson, D., Joseph, R. W., Lange, J. R., Martini, M. C., Materin, M. A., Olszanski, A. J., Ott, P., Gupta, A. P., Ross, M. I., Salama, A. K., Skitzki, J., Swetter, S. M., Tanabe, K. K., Torres-Roca, J. F., Trisal, V., Urist, M. M., McMillian, N., Engh, A. 2016; 14 (8): 945-958


    The NCCN Guidelines for Melanoma have been significantly revised over the past few years in response to emerging data on a number of novel agents and treatment regimens. These NCCN Guidelines Insights summarize the data and rationale supporting extensive changes to the recommendations for systemic therapy in patients with metastatic or unresectable melanoma.

    View details for PubMedID 27496110

  • Total Nevi, Atypical Nevi, and Melanoma Thickness: An Analysis of 566 Patients at 2 US Centers. JAMA dermatology Geller, A. C., Mayer, J. E., Sober, A. J., Miller, D. R., Argenziano, G., Johnson, T. M., Swetter, S. M. 2016; 152 (4): 413-418


    Nevi are among the strongest risk factors for melanoma. However, little is known about the association of many total nevi (TN) or atypical nevi (AN) with tumor thickness.To examine the association between age and the number of TN and AN and to explore whether there was a relationship between TN or AN and tumor thickness, controlling for multiple variables.Survey of patients with melanoma at 2 academic sites and an affiliated Veteran Affairs medical center. Participants included 566 patients surveyed within 3 months of diagnosis. Patients were surveyed in the melanoma clinics from May 17, 2006, through March 31, 2009, within 3 months of diagnostic biopsy. The dates of the analysis were April 1, 2015, to August 1, 2015.Counts of TN and AN were performed at the first visit after diagnosis and were categorized as 0 to 20, 20 to 50, or more than 50 for TN and as 0, 1 to 5, or more than 5 for AN. Tumor thickness was categorized as 2.00 mm or less or as 2.01 mm or greater. All analyses were stratified by patient age (<60 or ?60 years). Logistic regression was used to test associations, controlling for age, sex, anatomic location of melanoma, institution, histologic subtype, marital status, performance of skin self-examination, number of health care visits in the past year, mode of melanoma discovery, and receipt of skin examination by a physician.The study population included 566 patients. Their mean (SD) age was 56.7 (15.9) years, and 39.0% (n?=?221) were female. Of 566 patients, the number of TN was classified as 0 to 20 (66.4% [n?=?376]), 20 to 50 (20.5% [n?=?116]), or more than 50 (13.1% [n?=?74]). Atypical nevus counts were 0 (73.3% [n?=?415]), 1 to 5 (14.5% [n?=?82]), or more than 5 (12.2% [n?=?69]). For those younger than 60 years, the presence of more than 50 TN was associated with a sharply reduced risk of thick melanoma (odds ratio, 0.32; 95% CI, 0.12-0.81), and the presence of more than 5 AN compared with no AN was associated with thicker melanoma (odds ratio, 2.43; 95% CI, 1.02-5.75).Most patients with melanoma had few nevi and no AN. In younger patients (<60 years), thick melanomas were commonly found in those with fewer TN but more AN, suggesting that physicians and patients should not rely on the total nevus count as a sole reason to perform skin examinations or to determine a patient's at-risk status. Younger patients should be educated on the increased risk of thicker melanomas that is associated with having more AN.

    View details for DOI 10.1001/jamadermatol.2016.0027

    View details for PubMedID 26934430

  • Melanoma, Version 2.2016, NCCN Clinical Practice Guidelines in Oncology. Journal of the National Comprehensive Cancer Network Coit, D. G., Thompson, J. A., Algazi, A., Andtbacka, R., Bichakjian, C. K., Carson, W. E., Daniels, G. A., Dimaio, D., Ernstoff, M., Fields, R. C., Fleming, M. D., Gonzalez, R., Guild, V., Halpern, A. C., Hodi, F. S., Joseph, R. W., Lange, J. R., Martini, M. C., Materin, M. A., Olszanski, A. J., Ross, M. I., Salama, A. K., Skitzki, J., Sosman, J., Swetter, S. M., Tanabe, K. K., Torres-Roca, J. F., Trisal, V., Urist, M. M., McMillian, N., Engh, A. 2016; 14 (4): 450-473


    This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Melanoma focuses on adjuvant therapy and treatment of in-transit disease, because substantial changes were made to the recommendations for the 2016 update. Depending on the stage of the disease, options for adjuvant therapy now include biochemotherapy and high-dose ipilimumab. Treatment options for in-transit disease now include intralesional injection with talimogene laherparepvec (T-VEC), a new immunotherapy. These additions prompted re-assessment of the data supporting older recommended treatment options for adjuvant therapy and in-transit disease, resulting in extensive revisions to the supporting discussion sections.

    View details for PubMedID 27059193

  • Melanoma, Version 2.2016 JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Coit, D. G., Thompson, J. A., Algazi, A., Andtbacka, R., Bichakjian, C. K., Carson, W. E., Daniels, G. A., Dimaio, D., Ernstoff, M., Fields, R. C., Fleming, M. D., Gonzalez, R., Guild, V., Halpern, A. C., Hodi, F. S., Joseph, R. W., Lange, J. R., Martini, M. C., Materin, M. A., Olszanski, A. J., Ross, M. I., Salama, A. K., Skitzki, J., Sosman, J., Swetter, S. M., Tanabe, K. K., Torres-Roca, J. F., Trisal, V., Urist, M. M., McMillian, N., Engh, A. 2016; 14 (4): 450-?
  • Aberrant lymphatic drainage and risk for melanoma recurrence after negative sentinel node biopsy in middle-aged and older men HEAD AND NECK-JOURNAL FOR THE SCIENCES AND SPECIALTIES OF THE HEAD AND NECK Kaveh, A. H., Seminara, N. M., Barnes, M. A., Berger, A. J., Chen, F. W., Yao, M., Johnson, D., Parsa, S., Quon, A., Swetter, S. M., Sunwoo, J. B. 2016; 38: E754-E760


    Background Aberrant lymphatic drainage is believed to contribute to the high recurrence rate of head and neck melanomas. This study aimed to identify the clinical significance of unexpected lymphatic drainage patterns. Methods A single institution retrospective analysis was performed of middle-aged and older males (mean age 66.2 years, range 41-87 years) who underwent successful lymphoscintigraphy with sentinel node (SLN) biopsy from 1997 through 2012. Node status, distribution, and recurrence were assessed comparing patients with expected and unexpected drainage patterns. Results Sixty-six patients were identified with 55.8 months median follow-up (range 5.6-206.1 months). Unexpected SLN drainage was associated with multiple basin drainage (p?

    View details for DOI 10.1002/hed.24094

    View details for Web of Science ID 000375116400090

    View details for PubMedID 25914266

  • Molecular Profiling in Cutaneous Melanoma. Journal of the National Comprehensive Cancer Network Ji, A. L., Bichakjian, C. K., Swetter, S. M. 2016; 14 (4): 475-480


    Molecular profiling of malignant tumors is gaining increasing interest in oncology. In recent years, several molecular techniques have been studied in melanoma, with the goal to improve upon the diagnostic and prognostic abilities of currently available clinical and histopathologic parameters. Reliable tests performed early in the diagnosis and management of melanoma could lead to decreased morbidity and mortality by selecting appropriate patients for more-aggressive therapy and sparing those for whom it is not indicated. This article reviews the molecular diagnostic and prognostic techniques currently available for melanoma and evaluates their potential role in clinical practice.

    View details for PubMedID 27059194

  • Loss of primary cilia correlates withcytologic severity in dysplastic melanocytic nevi JOURNAL OF CUTANEOUS PATHOLOGY Lang, U. E., Cheung, C., Vladar, E. K., Swetter, S. M., Kim, J. 2016; 43 (2): 113-119


    Primary cilia are ubiquitously present in cell surface organelles with essential functions in cellular proliferation, differentiation and development. We have previously shown that cilia in melanoma in situ, invasive melanoma and metastatic melanoma are nearly completely lost, whereas benign nevi are ciliated. Dysplastic nevi (DN) have a wide range of histopathologic features from mild (low-grade) to severe (high-grade) cytologic atypia and represent a key clinical and histopathologic marker for melanomagenesis. We sought to identify whether cilia are retained in these melanocytic lesions and whether increasing degree of dysplasia correlates with loss of ciliation.We measured the percentage of ciliated melanocytes (ciliation index) in DN with mild (n?=?9) and severe dysplasia (n?=?10). We identified the primary cilium and basal bodies by immunofluorescence staining of sections with acetylated alpha-tubulin and gamma-tubulin, respectively.Our results showed a significant decrease in the ciliation index from mild dysplastic (55%) to severe DN (14%) (p?=?0.005).These data support the hypothesis that primary cilium loss may play a role in the underlying biology of severe DN. The ciliation index is a novel quantitative tool that may increase the reproducibility in grading severity of dysplasia for diagnostic and clinical management of melanocytic neoplasms.

    View details for DOI 10.1111/cup.12612

    View details for Web of Science ID 000371431100003

    View details for PubMedID 26272818

  • Methods of Melanoma Detection. Cancer treatment and research Leachman, S. A., Cassidy, P. B., Chen, S. C., Curiel, C., Geller, A., Gareau, D., Pellacani, G., Grichnik, J. M., Malvehy, J., North, J., Jacques, S. L., Petrie, T., Puig, S., Swetter, S. M., Tofte, S., Weinstock, M. A. 2016; 167: 51-105


    Detection and removal of melanoma, before it has metastasized, dramatically improves prognosis and survival. The purpose of this chapter is to (1) summarize current methods of melanoma detection and (2) review state-of-the-art detection methods and technologies that have the potential to reduce melanoma mortality. Current strategies for the detection of melanoma range from population-based educational campaigns and screening to the use of algorithm-driven imaging technologies and performance of assays that identify markers of transformation. This chapter will begin by describing state-of-the-art methods for educating and increasing awareness of at-risk individuals and for performing comprehensive screening examinations. Standard and advanced photographic methods designed to improve reliability and reproducibility of the clinical examination will also be reviewed. Devices that magnify and/or enhance malignant features of individual melanocytic lesions (and algorithms that are available to interpret the results obtained from these devices) will be compared and contrasted. In vivo confocal microscopy and other cellular-level in vivo technologies will be compared to traditional tissue biopsy, and the role of a noninvasive "optical biopsy" in the clinical setting will be discussed. Finally, cellular and molecular methods that have been applied to the diagnosis of melanoma, such as comparative genomic hybridization (CGH), fluorescent in situ hybridization (FISH), and quantitative reverse transcriptase polymerase chain reaction (qRT-PCR), will be discussed.

    View details for DOI 10.1007/978-3-319-22539-5_3

    View details for PubMedID 26601859

  • Tumor Ulceration Does Not Fully Explain Sex Disparities in Melanoma Survival among Adolescents and Young Adults. journal of investigative dermatology Keegan, T. H., Swetter, S. M., Tao, L., Sunwoo, J. B., Clarke, C. A. 2015; 135 (12): 3195-3197

    View details for DOI 10.1038/jid.2015.325

    View details for PubMedID 26288356

  • Imiquimod 5% cream as primary or adjuvant therapy for melanoma in situ, lentigo maligna type JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Swetter, S. M., Chen, F. W., Kim, D. D., Egbert, B. M. 2015; 72 (6): 1047-1053


    Surgical resection of lentigo maligna (LM) is complicated by noncontiguous, subclinical extension and actinic melanocytic hyperplasia in sun-damaged skin of older individuals.We sought to determine the long-term effectiveness of imiquimod as primary or adjuvant therapy for LM.Patients were retrospectively identified from January 1, 2003, to December 31, 2013, with LM, early/evolving LM, and LM melanoma who had used topical imiquimod 5% cream for either primary therapy after diagnostic biopsy, or adjuvant therapy after narrow-margin surgical resection or complete clinical but not histologic resection of LM. Follow-up occurred through December 31, 2014.In all, 63 cases were identified in 61 patients, mean (SD) age 71.1 (12.4) years; 58 were analyzed for local recurrence. Imiquimod was used as primary therapy in 22 of 63 (34.9%) and adjuvant therapy in 41 of 63 (65.1%) for mean duration of 11.7 (range 2-60) weeks. Fifty cases (86.2%) demonstrated clinical clearance at mean (SD) follow-up of 42.1 (27.4) months: 72.7% primary and 94.4% adjuvant at 39.7 (23.9) and 43.1 (28.9) months, respectively.Retrospective cohort study and lack of standardized imiquimod application are limitations.Imiquimod cream appears to be a viable option for primary or adjuvant treatment of LM in older patients who are poor surgical candidates.

    View details for DOI 10.1016/j.jaad.2015.02.008

    View details for Web of Science ID 000354604200034

    View details for PubMedID 25791801

  • Focus on early detection to reduce melanoma deaths. journal of investigative dermatology Geller, A. C., Swetter, S. M., Weinstock, M. A. 2015; 135 (4): 947-949


    Thin fatal melanomas are a relatively new clinical and public health concern, representing an estimated 20% of melanoma deaths. Understanding this phenomenon will require a multi-pronged approach, including in-depth investigation of its behavioral and biological underpinnings. As we proceed with relevant studies, the benefits in lives saved will grow via early detection.

    View details for DOI 10.1038/jid.2014.534

    View details for PubMedID 25785949

  • The Impact of Indoor Tanning Legislation: Newspaper Coverage of the Risks of Indoor Tanning Before and After the California Indoor Tanning Ban for Minors JOURNAL OF CANCER EDUCATION Mayer, J. E., Swetter, S. M., Guild, S., Geller, A. C. 2015; 30 (1): 124-129


    On June 1, 2011, the California Senate passed a bill banning minors from indoor tanning. We aimed to determine whether the bill's passage was associated with longer-term media coverage regarding skin protection and the risks associated with indoor tanning. Articles from 31 English-language California newspapers between June 2010-May 2011 (PRE) and June 2011-May 2012 (POST) were searched using terms related to skin protection. Ninety articles were found for in-depth coding and analysis. There were more skin protection articles in the POST period than in the PRE period (57 vs 33; p?

    View details for DOI 10.1007/s13187-014-0672-4

    View details for Web of Science ID 000349759300019

  • Addressing the Knowledge Gap in Clinical Recommendations for Management and Complete Excision of Clinically Atypical Nevi/Dysplastic Nevi Pigmented Lesion Subcommittee Consensus Statement JAMA DERMATOLOGY Kim, C. C., Swetter, S. M., Curiel-Lewandrowski, C., Grichnik, J., Grossman, D., Halpern, A. C., Kirkwood, J. M., Leachman, S. A., Marghoob, A. A., Ming, M. E., Nelson, K. C., Veledar, E., Venna, S. S., Chen, S. C. 2015; 151 (2): 212-218


    The management of clinically atypical nevi/dysplastic nevi (CAN/DN) is controversial, with few data to guide the process. Management recommendations for DN with positive histologic margins were developed by the Delphi method to achieve consensus among members of the Pigmented Lesion Subcommittee (PLS) of the Melanoma Prevention Working Group (MPWG) after reviewing the current evidence.To outline key issues related to the management of CAN/DN: (1) biopsies of CAN and how positive margins arise, (2) whether incompletely excised DN evolve into melanoma, (3) current data on the outcomes of DN with positive histologic margins, (4) consensus recommendations, and (5) a proposal for future studies, including a large-scale study to help guide the management of DN with positive margins.The literature, including recent studies examining management and outcomes of DN with positive margins between 2009 to 2014, was reviewed.A consensus statement by the PLS of the MPWG following review of the literature, group discussions, and a structured Delphi method consensus.This consensus statement reviews the complexities of management of CAN/DN. A review of the literature and 2 rounds of a structured Delphi consensus resulted in the following recommendations: (1) mildly and moderately DN with clear margins do not need to be reexcised, (2) mildly DN biopsied with positive histologic margins without clinical residual pigmentation may be safely observed rather than reexcised, and (3) observation may be a reasonable option for management of moderately DN with positive histologic margins without clinically apparent residual pigmentation; however, more data are needed to make definitive recommendations in this clinical scenario.

    View details for DOI 10.1001/jamadermatol.2014.2694

    View details for Web of Science ID 000349754200022

    View details for PubMedID 25409291

  • Indocyanine Green and Fluorescence Lymphangiography for Sentinel Lymph Node Identification in Cutaneous Melanoma JOURNAL OF SURGICAL ONCOLOGY Cloyd, J. M., Wapnir, I. L., Read, B. M., Swetter, S., Greco, R. S. 2014; 110 (7): 888-892

    View details for DOI 10.1002/jso.23745

    View details for Web of Science ID 000344552200020

  • Non-melanoma skin cancer and NSAID use in women with a history of skin cancer in the Women's Health Initiative PREVENTIVE MEDICINE Wysong, A., Ally, M. S., Gamba, C. S., Desai, M., Swetter, S. M., Seiffert-Sinha, K., Sinha, A. A., Stefanick, M. L., Tang, J. Y. 2014; 69: 8-12
  • Non-melanoma skin cancer and NSAID use in women with a history of skin cancer in the Women's Health Initiative. Preventive medicine Wysong, A., Ally, M. S., Gamba, C. S., Desai, M., Swetter, S. M., Seiffert-Sinha, K., Sinha, A. A., Stefanick, M. L., Tang, J. Y. 2014; 69: 8-12


    Evidence for the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on non-melanoma skin cancer (NMSC) risk is inconsistent. We prospectively examined whether regular, inconsistent, or no/low-use of NSAIDs is associated with lower NMSC risk among 54,728 postmenopausal Caucasian women in the Women's Health Initiative Observational Study enrolled between 1993 and 1998.Logistic regression models were used to assess odds of NMSC after adjusting for skin type, sun exposure history and indication for NSAID use.There were 7652 incident cases of NMSC (median follow-up: 6.9years). There was no association between regular NSAID-use and NMSC risk relative to no/low-users. However, in a subgroup analysis of 5325 women with a history of skin cancer (incident NMSC: 1897), odds of NMSC were lower among regular NSAID users whether <5years (OR 0.82, 95% CI: 0.70-0.95) or ?5years (OR 0.82, 95% CI: 0.69-0.98) of use compared to no/low-users. Inconsistent NSAID use and acetaminophen use were not associated with NMSC risk.Overall, NSAID use was not associated with NMSC risk. However, in women with a history of skin cancer, regular NSAID use was associated with 18% lower odds of NMSC. Future studies on potential chemopreventative effects of NSAIDs should focus on subjects with prior history of NMSC.

    View details for DOI 10.1016/j.ypmed.2014.08.024

    View details for PubMedID 25150382

  • Indocyanine green and fluorescence lymphangiography for sentinel lymph node identification in cutaneous melanoma. Journal of surgical oncology Cloyd, J. M., Wapnir, I. L., Read, B. M., Swetter, S., Greco, R. S. 2014; 110 (7): 888-892


    Sentinel lymph node (SLN) biopsy has become the standard method of determining regional lymph node involvement in cutaneous melanoma. Although traditionally performed via injection of radioisotope tracers and blue dyes, fluorescent lymphangiography with indocyanine green (ICG) is an attractive alternative.Fifty two consecutive patients with cutaneous melanoma of the trunk or extremities underwent SLNB. Preoperative lymphoscintigraphy was performed with technetium-99m sulfur colloid (TSC). Peritumoral intradermal injection of isosulfan blue (ISB) and ICG was then performed. Successful identification of a sentinel lymph node via each modality was then assessed.A total of 77 lymph nodes were identified from the 52 patients (range 1-3). The majority of melanomas were extremity-based, superficial spreading type, and had SLN localized to the axilla. There were no complications related to IcG administration. Rates of SLN detection were 96.2% for TSC, 59.6% for ISB, and 88.5% for IcG (P?

    View details for DOI 10.1002/jso.23745

    View details for PubMedID 25124992

  • Perspective: catch melanoma early. Nature Swetter, S. M., Geller, A. C. 2014; 515 (7527): S117-?

    View details for DOI 10.1038/515S117a

    View details for PubMedID 25407708

  • Involution of eruptive melanocytic nevi on combination BRAF and MEK inhibitor therapy. JAMA dermatology Chen, F. W., Tseng, D., Reddy, S., Daud, A. I., Swetter, S. M. 2014; 150 (11): 1209-1212


    Eruptive melanocytic nevi (EMN) are characterized by the sudden onset of numerous melanocytic nevi and have been traditionally described in the setting of immunosuppression. Selective BRAF inhibitors, such as vemurafenib cause multiple cutaneous adverse effects, including the formation of cutaneous squamous cell carcinoma, as well as EMN. We describe the first reported case, to our knowledge, of involution of BRAF inhibitor-induced EMN following the concomitant addition of a MEK inhibitor, cobimetinib.A woman in her 20s with a history of metastatic melanoma developed EMN while receiving therapy with vemurafenib, a selective BRAF inhibitor. After disease progression, the patient was placed on a clinical trial that combined vemurafenib with a MEK inhibitor, cobimetinib. Within months, we noted clinical involution of many of her EMN. In addition, numerous preexisting nevi were noted to fade in color on the dual regimen. Over a year after initiating this combination therapy, most of the patient's EMN were no longer clinically evident.Our case report describing the involution of EMN supports data from previous clinical trials indicating that combination BRAF and MEK inhibition may reduce cutaneous proliferative effects that arise on BRAF inhibitor monotherapy. Further studies are necessary to characterize the biological mechanisms underlying this phenomenon.

    View details for DOI 10.1001/jamadermatol.2014.838

    View details for PubMedID 25142409

  • Involution of Eruptive Melanocytic Nevi on Combination BRAF and MEK Inhibitor Therapy JAMA DERMATOLOGY Chen, F. W., Tseng, D., Reddy, S., Daud, A. I., Swetter, S. M. 2014; 150 (11): 1209-1212
  • Tumor Volume: An Adjunct Prognostic Factor in Cutaneous Melanoma CUTIS Walton, R. G., Kim, J., Velasco, C., Swetter, S. M. 2014; 94 (5): 226-230
  • Health behaviors and needs of melanoma survivors SUPPORTIVE CARE IN CANCER Palesh, O., Aldridge-Gerry, A., Bugos, K., Pickham, D., Chen, J. J., Greco, R., Swetter, S. M. 2014; 22 (11): 2973-2980
  • Health behaviors and needs of melanoma survivors. Supportive care in cancer Palesh, O., Aldridge-Gerry, A., Bugos, K., Pickham, D., Chen, J. J., Greco, R., Swetter, S. M. 2014; 22 (11): 2973-2980


    Little is known about melanoma survivors' long-term symptoms, sun protection practices, and support needs from health providers.Melanoma survivors treated at Stanford Cancer Center from 1995 through 2011 were invited to complete a heath needs survey. We compared responses of survivors by sex, education, time since diagnosis (long-term vs. short-term survivors), and extent of treatment received (wide local excision (WLE) alone versus WLE plus additional surgical or medical treatment (WLE+)).One hundred sixty melanoma survivors (51 % male; 61 % long-term; 73 % WLE+) provided evaluable data. On average, patients were 62 years of age (SD?=?14), highly educated (75 % college degree), and Caucasian (94 %). Overall, participants rated anxiety as the most prevalent symptom (34 %). Seventy percent reported that their health provider did not address their symptoms, and 53 % requested education about melanoma-specific issues. Following treatment, women spent significantly less time seeking a tan compared with men (p?=?0.01), had more extremity swelling (p?=?0.014), and expressed higher need for additional services (p?=?0.03). Long-term survivors decreased their use of tanning beds (p?=?0.03) and time spent seeking a tan (p?=?0.002) and were less likely to receive skin screening every 3-6 months (p?

    View details for DOI 10.1007/s00520-014-2286-0

    View details for PubMedID 24879390

  • Demographic, behavioural and physician-related determinants of early melanoma detection in a low-incidence population BRITISH JOURNAL OF DERMATOLOGY Talaganis, J. A., Biello, K., Plaka, M., Polydorou, D., Papadopoulos, O., Trakatelli, M., Sotiriadis, D., Tsoutsos, D., Kechagias, G., Gogas, H., Antoniou, C., Swetter, S. M., Geller, A. C., Stratigos, A. J. 2014; 171 (4): 832-838


    Knowledge of the factors that influence early detection of melanoma is important in developing strategies to reduce associated mortality.To identify sociodemographic, behavioural and medical care-related factors associated with melanoma thickness in a low incidence population but with a high case fatality.In a multi-center, retrospective, survey-based study of 202 patients with a recent diagnosis of invasive melanoma (< 1 year), we collected data on demographic and behavioural factors, attitudes towards prevention, access to medical care, frequency of skin self-examination (SSE) and physician skin examination (PSE) in relation to melanoma thickness.Thinner tumours (? 1 mm) (80 melanomas) were associated with female gender (P ? 0?049), non-nodular (SSM, LMM and ALM) histologic subtypes (P < 0?001), absence of ulceration (P ? 0?001), and location other than lower extremity or trunk location (P ? 0?004). Patients married at the time of diagnosis or who performed SSE during the year prior to diagnosis were more likely to have thinner tumours than those who did not (OR 3?45; 95% CI 1?48-8?04 and OR 2?43; 95% CI 1?10-5?34, respectively). Full body skin examination by a physician was not significantly associated with thinner melanoma (OR 1?99; 95% CI 0?66-6?07).SSE was shown to be an important factor in the detection of thin melanoma, in contrast to partial or full body PSE which did not show any statistically significant effect on tumour thickness. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/bjd.13068

    View details for Web of Science ID 000344007500028

    View details for PubMedID 24749902

  • Screening, early detection, education, and trends for melanoma: current status (2007-2013) and future directions: Part I. Epidemiology, high-risk groups, clinical strategies, and diagnostic technology. Journal of the American Academy of Dermatology Mayer, J. E., Swetter, S. M., Fu, T., Geller, A. C. 2014; 71 (4): 599 e1-599 e12


    While most cancers have shown both decreased incidence and mortality over the past several decades, the incidence of melanoma has continued to grow, and mortality has only recently stabilized in the United States and in many other countries. Certain populations, such as men >60 years of age and lower socioeconomic status groups, face a greater burden from disease. For any given stage and across all ages, men have shown worse melanoma survival than women, and low socioeconomic status groups have increased levels of mortality. Novel risk factors can help identify populations at greatest risk for melanoma and can aid in targeted early detection. Risk assessment tools have been created to identify high-risk patients based on various factors, and these tools can reduce the number of patients needed to screen for melanoma detection. Diagnostic techniques, such as dermatoscopy and total body photography, and new technologies, such as multispectral imaging, may increase the accuracy and reliability of early melanoma detection.

    View details for DOI 10.1016/j.jaad.2014.05.046

    View details for PubMedID 25219716

  • Screening, early detection, education, and trends for melanoma: current status (2007-2013) and future directions: Part II. Screening, education, and future directions. Journal of the American Academy of Dermatology Mayer, J. E., Swetter, S. M., Fu, T., Geller, A. C. 2014; 71 (4): 611 e1-611 e10


    New evidence has accumulated over the past several years that supports improved melanoma outcomes associated with both clinician and patient screening. Population-based and workplace studies conducted in Australia and the Unites States, respectively, have shown decreases in the incidence of thick melanoma and overall melanoma mortality, and a year-long statewide screening program in Germany has shown a nearly 50% reduction in mortality 5 years after the screening ended. Current melanoma screening guidelines in the United States are inconsistent among various organizations, and therefore rates of both physician and patient skin examinations are low. As policymaking organizations update national screening recommendations in the United States, the latest research reviewed in part II of this continuing medical education article should be considered to establish the most effective recommendations. Patient and provider education will be necessary to ensure that appropriate patients receive recommended screening.

    View details for DOI 10.1016/j.jaad.2014.05.045

    View details for PubMedID 25219717

  • Screening, early detection, education, and trends for melanoma: Current status (2007-2013) and future directions Part I. Epidemiology, high-risk groups, clinical strategies, and diagnostic technology JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Mayer, J. E., Swetter, S. M., Fu, T., Geller, A. C. 2014; 71 (4)
  • Screening, early detection, education, and trends for melanoma: Current status (2007-2013) and future directions Part II. Screening, education, and future directions JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Mayer, J. E., Swetter, S. M., Fu, T., Geller, A. C. 2014; 71 (4)
  • Fluorescence In Situ Hybridization Analysis of Atypical Melanocytic Proliferations and Melanoma in Young Patients PEDIATRIC DERMATOLOGY Demarchis, E. H., Swetter, S. M., Jennings, C. D., Kim, J. 2014; 31 (5): 561-569


    Morphologic heterogeneity among melanocytic proliferations is a common challenge in the diagnosis of melanoma. In particular, atypical melanocytic lesions in children, adolescents, and young adults may be difficult to classify because of significant morphologic overlap with melanoma. Recently a four-probe fluorescence in situ hybridization (FISH) protocol to detect chromosomal abnormalities in chromosomes 6 and 11 has shown promise for improving the classification of melanocytic lesions. We sought to determine the correlation between FISH results, morphology, and clinical outcomes in a series of challenging melanocytic proliferations in young patients. We retrospectively performed the standard four-probe FISH analysis on 21 melanocytic neoplasms from 21 patients younger than 25 years of age (range 5-25 years, mean 14.6 years) from Stanford University Medical Center who were prospectively followed for a median of 51 months (range 1-136 months). The study cohort included patients with 5 confirmed melanomas, 2 melanocytic tumors of uncertain malignant potential (MelTUMPs), 10 morphologically challenging atypical Spitz tumors (ASTs), and 4 typical Spitz nevi. FISH detected chromosomal aberrations in all five melanomas and in one MelTUMP, in which the patient developed subsequent lymph node and distant metastasis. All 10 ASTs, 4 Spitz nevi, and 1 of 2 MelTUMPs were negative for significant gains or losses in chromosomes 6 and 11q. Our findings demonstrated a strong correlation between positive FISH results and the histomorphologic impression of melanoma. This finding was also true for the MelTUMP with poor clinical outcome. Therefore FISH may serve as a helpful adjunct in the classification of controversial melanocytic tumors in young patients.

    View details for DOI 10.1111/pde.12382

    View details for Web of Science ID 000341811700005

  • Acquired blue nevi in older individuals: retrospective case series from a Veterans Affairs population, 1991 to 2013. JAMA dermatology Cabral, E. S., Chen, F. W., Egbert, B. M., Swetter, S. M. 2014; 150 (8): 873-876


    IMPORTANCE Apart from the atypical mole phenotype, development of new melanocytic nevi in older individuals is uncommon and considered worrisome for melanoma. We performed a retrospective case series in a Veterans Affairs population from 1991 to 2013 to characterize blue nevi (BN) by patient age at biopsy, location, self-reported duration, and relation to prior or subsequent development of cutaneous melanoma. OBSERVATIONS A total of 204 BN were identified in 194 predominantly male patients (90.7%) who had a mean (SD) age of 62.8 (14.4) years. Clinical duration of 10 years or less was reported by 90.3% of patients with available data (32.0%). Histopathologic examination classified 74.0% of BN as common, 1.5% as cellular, and 24.5% as combined type. No malignant BN were identified; however, 18 primary melanomas were diagnosed, most (72.2%) prior to blue nevus biopsy, including 38.9% in situ and 61.1% with mean (SD) Breslow thickness of 1.02 (0.99) mm. CONCLUSIONS AND RELEVANCE The later patient-reported onset of BN suggests a potential alternative mechanism of nevogenesis compared with common acquired nevi and differs from prior reports of BN development in younger adults. The lack of association with melanoma in older individuals suggests that most benign-appearing BN may be safely observed, even in a cohort at higher risk for skin cancer.

    View details for DOI 10.1001/jamadermatol.2013.7366

    View details for PubMedID 24788980

  • Acquired Blue Nevi in Older Individuals Retrospective Case Series From a Veterans Affairs Population, 1991 to 2013 JAMA DERMATOLOGY Cabral, E. S., Chen, F. W., Egbert, B. M., Swetter, S. M. 2014; 150 (8): 873-876
  • Measuring the severity of topical 5-Fluorouracil toxicity. Journal of cutaneous medicine and surgery Korgavkar, K., Firoz, E. F., Xiong, M., Lew, R., Marcolivio, K., Burnside, N., Dyer, R., Weinstock, M. A. 2014; 18 (4): 229-235


    Topical 5% 5-fluorouracil (5-FU) is known to cause toxicity, such as erythema, pain, and crusting/erosions.We sought to develop a scale to measure this toxicity and test the scale for reliability.A scale was developed involving four parameters: erythema severity, percentage of face involved in erythema, crusting/erosions severity, and percentage of face involved in crusting/erosions. Thirteen raters graded 99 sets of photographs from the Veterans Affairs Keratinocyte Carcinoma Chemoprevention (VAKCC) Trial using these parameters.Intraclass correlation overall for 13 raters was 0.82 (95% CI 0.77-0.86). There was no statistically significant trend in reliability by level of training in dermatology.This scale is a reliable method of evaluating the severity of toxicity from topical 5-fluorouracil and can be used by dermatologists and nondermatologists alike.

    View details for PubMedID 25008439

  • Melanoma, Version 4.2014 Featured Updates to the NCCN Guidelines JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Coit, D. G., Thompson, J. A., Andtbacka, R., Anker, C. J., Bichakjian, C. K., Carson, W. E., Daniels, G. A., Daud, A., Dimaio, D., Fleming, M. D., Gonzalez, R., Guild, V., Halpern, A. C., Hodi, S., Kelley, M. C., Khushalani, N. I., Kudchadkar, R. R., Lange, J. R., Martini, M. C., Olszanski, A. J., Ross, M. I., Salama, A., Swetter, S. M., Tanabe, K. K., Trisal, V., Urist, M. M., McMillian, N. R., Ho, M. 2014; 12 (5): 621-629


    The NCCN Guidelines for Melanoma provide multidisciplinary recommendations for the management of patients with melanoma. These NCCN Guidelines Insights highlight notable recent updates. Dabrafenib and trametinib, either as monotherapy (category 1) or combination therapy, have been added as systemic options for patients with unresectable metastatic melanoma harboring BRAF V600 mutations. Controversy continues regarding the value of adjuvant radiation for patients at high risk of nodal relapse. This is reflected in the category 2B designation to consider adjuvant radiation following lymphadenectomy for stage III melanoma with clinically positive nodes or recurrent disease.

    View details for Web of Science ID 000335718600004

  • Dermatomyositis associated with capecitabine in the setting of malignancy JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Chen, F. W., Zhou, X., Egbert, B. M., Swetter, S. M., Sarin, K. Y. 2014; 70 (2): E47-E48

    View details for DOI 10.1016/j.jaad.2013.10.025

    View details for Web of Science ID 000329851500013

    View details for PubMedID 24438983

  • Dermatomyositis associated with capecitabine in the setting of malignancy. Journal of the American Academy of Dermatology Chen, F. W., Zhou, X., Egbert, B. M., Swetter, S. M., Sarin, K. Y. 2014; 70 (2): e47-8

    View details for DOI 10.1016/j.jaad.2013.10.025

    View details for PubMedID 24438983

  • Reliability of quantification measures of actinic keratosis BRITISH JOURNAL OF DERMATOLOGY Chen, S. C., Hill, N. D., Veledar, E., Swetter, S. M., Weinstock, M. A. 2013; 169 (6): 1219-1222


    Enumerating actinic keratoses (AKs) is highly variable but important to standardize as new therapies are emerging.To assess the reliability of four different methods used to quantify AKs and to investigate whether a consensus meeting affects the reliability.This was a single-blinded study of 12 experienced dermatologist raters counting AKs on the face and ears of nine subjects before and after a consensus meeting. Raters were recruited from investigators of a multicentre Veterans Affairs cooperative study. The intraclass correlation coefficient (ICC) among raters for pre- and post-consensus evaluations was the primary outcome measure.Of the four assessment methods, the 'total count' method had the greatest ICC for both pre- (0·18, P = 0·04) and post-consensus (0·66, P = < 0·0001) assessments. Total count was also the only pre-consensus ICC for which the null hypothesis of no association among assessments was rejected.Total AK count appears to be the most reliable measure of quantifying AKs on the face and ears. Educational consensus discussion prior to assessment improves reliability of this measure.

    View details for DOI 10.1111/bjd.12591

    View details for Web of Science ID 000327564200012

    View details for PubMedID 24033340

  • Pediatric Melanoma: Analysis of an International Registry CANCER Averbook, B. J., Lee, S. J., Delman, K. A., Gow, K. W., Zager, J. S., Sondak, V. K., Messina, J. L., Sabel, M. S., Pittelkow, M. R., Ecker, P. M., Markovic, S. N., Swetter, S. M., Leachman, S. A., Testori, A., Curiel-Lewandrowski, C., Go, R. S., Jukic, D. M., Kirkwood, J. M. 2013; 119 (22): 4012-4019

    View details for DOI 10.1002/cncr.28289

    View details for Web of Science ID 000326418500019

  • Role of aspirin and non-aspirin NSAIDs in preventing melanoma. Future oncology Ally, M. S., Swetter, S. M., Tang, J. Y. 2013; 9 (11): 1671-1674

    View details for DOI 10.2217/fon.13.112

    View details for PubMedID 23731359

  • Activating HRAS Mutation in Agminated Spitz Nevi Arising in a Nevus Spilus JAMA DERMATOLOGY Sarin, K. Y., Sun, B. K., Bangs, C. D., Cherry, A., Swetter, S. M., Kim, J., Khavari, P. A. 2013; 149 (9): 1077-1080
  • Melanoma Survival Disadvantage in Young, Non-Hispanic White Males Compared With Females JAMA DERMATOLOGY Gamba, C. S., Clarke, C. A., Keegan, T. H., Tao, L., Swetter, S. M. 2013; 149 (8): 912-920
  • Aspirin is associated with lower melanoma risk among postmenopausal Caucasian women The Women's Health Initiative CANCER Gamba, C. A., Swetter, S. M., Stefanick, M. L., Kubo, J., Desai, M., Spaunhurst, K. M., Sinha, A. A., Asgari, M. M., Sturgeon, S., Tang, J. Y. 2013; 119 (8): 1562-1569


    Nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with decreased risk of gastric, colorectal, and breast cancer. However, the impact of NSAIDs on the risk of melanoma has been inconsistent. The authors evaluated the association between NSAID use and cutaneous melanoma risk in the Women's Health Initiative (WHI) Observational Study (OS).At study entry, use of aspirin (acetylsalicylic acid [ASA]) and nonaspirin NSAIDs was assessed among 59,806 postmenopausal Caucasian women ages 50 to 79 years. Cox proportional hazards models were constructed after adjusting for participant skin type, sun exposure history, and medical indications for NSAID use among other confounders.During a median follow-up of 12 years, 548 incident melanomas were confirmed by medical review. Women who used ASA had a 21% lower risk of melanoma (hazard ratio, 0.79; 95% confidence interval, 0.63-0.98) relative to nonusers. Increased duration of ASA use (<1 year, 1-4 years, and ? 5 years) was associated with an 11% lower risk of melanoma for each categorical increase (Ptrend = .01), and women with ? 5 years of use had a 30% lower melanoma risk (hazard ratio, 0.70; 95% confidence interval, 0.55-0.94). In contrast, use of non-ASA NSAIDs and acetaminophen were not associated with melanoma risk.Postmenopausal women who used ASA had a significantly lower risk of melanoma, and longer duration of ASA use was associated with greater protection. Although this study was limited by the observational design and self-report of NSAID use, the findings suggest that ASA may have a chemopreventive effect against the development of melanoma and warrant further clinical investigation.

    View details for DOI 10.1002/cncr.27817

    View details for Web of Science ID 000317618700016

  • Melanoma, Version 2.2013 Featured Updates to the NCCN Guidelines JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Coit, D. G., Andtbacka, R., Anker, C. J., Bichakjian, C. K., Carson, W. E., Daud, A., Dimaio, D., Fleming, M. D., Guilds, V., Halpern, A. C., Hodi, F. S., Kelley, M. C., Khushalani, N. I., Kudchadkar, R. R., Lange, J. R., Lind, A., Martini, M. C., Olszanski, A. J., Pruitt, S. K., Ross, M. I., Swetter, S. M., Tanabe, K. K., Thompson, J. A., Trisal, V., Urist, M. M., McMillian, N., Ho, M. 2013; 11 (4): 395-407


    The NCCN Guidelines for Melanoma provide multidisciplinary recommendations on the clinical management of patients with melanoma. This NCCN Guidelines Insights report highlights notable recent updates. Foremost of these is the exciting addition of the novel agents ipilimumab and vemurafenib for treatment of advanced melanoma. The NCCN panel also included imatinib as a treatment for KIT-mutated tumors and pegylated interferon alfa-2b as an option for adjuvant therapy. Also important are revisions to the initial stratification of early-stage lesions based on the risk of sentinel lymph node metastases, and revised recommendations on the use of sentinel lymph node biopsy for low-risk groups. Finally, the NCCN panel reached clinical consensus on clarifying the role of imaging in the workup of patients with melanoma.

    View details for Web of Science ID 000317543800007

  • A Systemic Complete Response of Metastatic Melanoma to Local Radiation and Immunotherapy TRANSLATIONAL ONCOLOGY Hiniker, S. M., Chen, D. S., Reddy, S., Chang, D. T., Jones, J. C., Mollick, J. A., Swetter, S. M., Knox, S. J. 2012; 5 (6): 404-407


    Melanoma is a relatively immunogenic tumor, in which infiltration of melanoma cells by T lymphocytes is associated with a better clinical prognosis. We hypothesized that radiation-induced cell death may provide additional stimulation of an anti-tumor immune response in the setting of anti-CTLA-4 treatment.In a pilot melanoma patient, we prospectively tested this hypothesis. We treated the patient with two cycles of ipilimumab, followed by stereotactic ablative radiotherapy to two of seven hepatic metastases, and two additional cycles of ipilimumab.Subsequent positron emission tomography-computed tomography scan indicated that all metastases, including unirradiated liver lesions and an unirradiated axillary lesion, had completely resolved, consistent with a complete response by RECIST.The use of radiotherapy in combination with targeted immunotherapy as a noninvasive in vivo tumor vaccine strategy appears to be a promising method of enhancing the induction of systemic immune responses and anti-tumor effect.

    View details for DOI 10.1593/tlo.12280

    View details for Web of Science ID 000313359800002

    View details for PubMedID 23323154

  • Randomized, double-blind, placebo-controlled trial of sulindac in individuals at risk for melanoma CANCER Curiel-Lewandrowski, C., Swetter, S. M., Einspahr, J. G., Hsu, C., Nagle, R., Sagerman, P., Tangrea, J., Parnes, H., Alberts, D. S., Chow, H. 2012; 118 (23): 5848-5856


    Reduced melanoma risk has been reported with regular use of nonsteroidal anti-inflammatory drugs (NSAIDs). However, the ability of NSAIDs to reach melanocytes in vivo and modulate key biomarkers in preneoplastic lesions such as atypical nevi has not been evaluated.This randomized, double-blind, placebo-controlled trial of sulindac was conducted in individuals with atypical nevi (AN) to determine bioavailability of sulindac and metabolites in nevi and effect on apoptosis and vascular endothelial growth factor A (VEGFA) expression in AN. Fifty subjects with AN ? 4 mm in size and 1 benign nevus (BN) were randomized to sulindac (150 mg twice a day) or placebo for 8 weeks. Two AN were randomized for baseline excision, and 2 AN and BN were excised after intervention.Postintervention sulindac, sulindac sulfone, and sulindac sulfide concentrations were 0.31 ± 0.36, 1.56 ± 1.35, and 2.25 ± 2.24 ?g/mL in plasma, and 0.51 ± 1.05, 1.38 ± 2.86, and 0.12 ± 0.12 ?g/g in BN, respectively. Sulindac intervention did not significantly change VEGFA expression but did increase expression of the apoptotic marker cleaved caspase-3 in AN (increase of 3 ± 33 in sulindac vs decrease of 25 ± 45 in the placebo arm, P = .0056), although significance was attenuated (P = .1103) after adjusting for baseline expression.Eight weeks of sulindac intervention resulted in high concentrations of sulindac sulfone, a proapoptotic metabolite, in BN but did not effectively modulate VEGFA and cleaved caspase-3 expression. Study limitations included limited exposure time to sulindac and the need to optimize a panel of biomarkers for NSAID intervention studies.

    View details for DOI 10.1002/cncr.27540

    View details for Web of Science ID 000311306000017

  • Screening and Prevention Measures for Melanoma: Is There a Survival Advantage? CURRENT ONCOLOGY REPORTS Curiel-Lewandrowski, C., Chen, S. C., Swetter, S. M. 2012; 14 (5): 458-467


    Controversy has emerged over the past decades regarding the value and impact of melanoma screening to detect early stage disease for improved prognosis. Those questioning the benefits of prevention efforts base their arguments on the absence of prospective, randomized studies demonstrating decreased melanoma mortality to justify the cost associated with screening and educational campaigns. For those in favor of melanoma screening, the lack of proven survival benefit is not a justification to abandon this approach, but rather a reflection of the lack of resources necessary to conduct a long-term trial. In 2009, the US Preventive Services Task Force (USPSTF)report did not recommend routine primary care screening for the general population given the absence of evidence. However, since the USPSTF report, a series of new studies are available, which support the potential benefit of screening and have the potential to significantly impact current policies regarding skin cancer screening, particularly for melanoma.

    View details for DOI 10.1007/s11912-012-0256-6

    View details for Web of Science ID 000308286700013

    View details for PubMedID 22907282

  • Examining the pathways linking lower socioeconomic status and advanced melanoma CANCER Pollitt, R. A., Swetter, S. M., Johnson, T. M., Patil, P., Geller, A. C. 2012; 118 (16): 4004-4013


    Low socioeconomic status (SES) is associated with more advanced melanoma at diagnosis and decreased survival. Exploring the pathways linking lower SES and thicker melanoma will help guide public and professional strategies to reduce deaths.The authors surveyed 566 newly diagnosed patients at Stanford University Medical Center, Veterans Affairs Palo Alto Health Care System, and University of Michigan. SES was assessed by education level (high school/general education degree or less [HS], associate/technical school degree, or ?college graduate). All data was obtained by self-report among patients within three months of their diagnosis.HS-educated individuals were significantly more likely than college graduates to believe that melanoma was not very serious (odds ratio [OR], 2.90; 95% confidence interval [CI], 1.79-4.71) and were less likely to know the asymmetry, borders (irregular), color (variegated), and diameter (>6 mm) (ABCD) melanoma rule or the difference between melanoma and ordinary skin growths (OR, 0.34 [95% CI, 0.23-0.52] and 0.26 [95% CI, 0.16-0.41] respectively). Physicians were less likely to have ever told HS-educated versus college-educated individuals they were at risk for skin cancer (OR, 0.46; 95% CI, 0.31-0.71) or instructed them on how to examine their skin for signs of melanoma (OR, 0.40; 95% CI, 0.25-0.63). HS-educated individuals were less likely to have received a physician skin examination within the year before diagnosis (OR, 0.54; 95% CI, 0.37-0.80).Decreased melanoma risk perception and knowledge among low-SES individuals and decreased physician communication regarding skin examinations of these individuals may be key components of the consistently observed socioeconomic gradient in mortality. The current findings suggest the need to raise melanoma awareness among lower-SES patients and to increase physician awareness of socioeconomic disparities in clinical communication and care.

    View details for DOI 10.1002/cncr.26706

    View details for Web of Science ID 000307116900019

    View details for PubMedID 22179775

  • Behavioral determinants of successful early melanoma detection CANCER Swetter, S. M., Pollitt, R. A., Johnson, T. M., Brooks, D. R., Geller, A. C. 2012; 118 (15): 3725-3734


    Reduced melanoma mortality should result from an improved understanding of modifiable factors related to early detection. The authors of this report surveyed newly diagnosed patients to identify differences in prediagnosis behavioral and medical care factors associated with thinner versus thicker melanoma.In total, 566 adults with invasive melanoma completed questionnaires within 3 months of diagnosis on demographics, health care access, skin self-examination (SSE), and physician skin examination (PSE) practices in the year before diagnosis. SSE was measured by us e of a melanoma picture aid and routine examination of some/all body sites versus none. Patient-reported partial or full-body PSE also was assessed. Melanoma thickness was dichotomized at 1 mm.Patient ranged in age from 18 years to 99 years, and 61% were men. The median tumor thickness was 1.25 mm, and 321 tumors (57%) were >1 mm thick. Thinner tumors (?1 mm) were associated with age ?60 years (P = .0002), women (P = .0127), higher education level (P = .0122), and physician discovery (P ? .0001). Patients who used a melanoma picture aid and performed routine SSE were more likely to have thinner tumors than those who did not (odds ratio [OR], 2.66; 95% confidence interval [CI], 1.48-4.80). Full-body PSE was associated with thinner tumors (OR, 2.51; 95% CI, 1.62-3.87), largely because of the effect of PSE in men aged >60 years (OR, 4.09 95% CI, 1.88-8.89).SSE and PSE were identified as complementary early detection strategies, particularly in men aged >60 years, in whom both partial and full-body PSE were associated with thinner tumors. Given the high rates of physician access, PSE may be a more practical approach for successful early detection in this subgroup with highest mortality.

    View details for DOI 10.1002/cncr.26707

    View details for Web of Science ID 000306671300010

  • Gender Disparities in Patients With Melanoma: Breaking the Glass Ceiling JOURNAL OF CLINICAL ONCOLOGY Sondak, V. K., Swetter, S. M., Berwick, M. A. 2012; 30 (18): 2177-2178

    View details for DOI 10.1200/JCO.2011.41.3849

    View details for Web of Science ID 000305413200007

    View details for PubMedID 22547593

  • Survival Is Not the Only Valuable End Point in Melanoma Screening JOURNAL OF INVESTIGATIVE DERMATOLOGY Curiel-Lewandrowski, C., Kim, C. C., Swetter, S. M., Chen, S. C., Halpern, A. C., Kirkwood, J. M., Leachman, S. A., Marghoob, A. A., Ming, M. E., Grichnik, J. M. 2012; 132 (5): 1332-1337

    View details for DOI 10.1038/jid.2012.3

    View details for Web of Science ID 000302856200008

    View details for PubMedID 22336950

  • Reporting and registering nonmelanoma skin cancers: a compelling public health need BRITISH JOURNAL OF DERMATOLOGY Geller, A. C., Swetter, S. M. 2012; 166 (5): 913-915
  • Melanoma JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Colt, D. G., Andtbacka, R., Anker, C. J., Bichakjian, C. K., Carson, W. E., Daud, A., Dilawari, R. A., Dimaio, D., Guild, V., Halpern, A. C., Stephen Hodi, F., Kelley, M. C., Khushalani, N. I., Kudchadkar, R. R., Lange, J. R., Lind, A., Martini, M. C., Olszanski, A. J., Pruitt, S. K., Ross, M. I., Swetter, S. M., Tanabe, K. K., Thompson, J. A., Trisal, V., Urist, M. M. 2012; 10 (3): 366-400
  • Attitudes Toward Indoor Tanning Among Users of Sunless Tanning Products ARCHIVES OF DERMATOLOGY Mahoney, A., Swetter, S. M., Biello, K. B., Resnick, E. A., Feuerstein, I., Geller, A. C. 2012; 148 (1): 124-126

    View details for Web of Science ID 000299653900030

    View details for PubMedID 22250251

  • Guidelines of care for the management of primary cutaneous melanoma JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Bichakjian, C. K., Halpern, A. C., Johnson, T. M., Hood, A. F., Grichnik, J. M., Swetter, S. M., Tsao, H., Barbosa, V. H., Chuang, T., Duvic, M., Ho, V. C., Sober, A. J., Beutner, K. R., Bhushan, R., Begolka, W. S. 2011; 65 (5): 1032-1047


    The incidence of primary cutaneous melanoma has been increasing dramatically for several decades. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is nearly always curative with early detection of disease. In this update of the guidelines of care, we will discuss the treatment of patients with primary cutaneous melanoma. We will discuss biopsy techniques of a lesion clinically suspicious for melanoma and offer recommendations for the histopathologic interpretation of cutaneous melanoma. We will offer recommendations for the use of laboratory and imaging tests in the initial workup of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, we will provide recommendations for surgical margins and briefly discuss nonsurgical treatments. Finally, we will discuss the value and limitations of sentinel lymph node biopsy and offer recommendations for its use in patients with primary cutaneous melanoma.

    View details for DOI 10.1016/j.jaad.2011.04.031

    View details for Web of Science ID 000296268000014

    View details for PubMedID 21868127

  • Reducing mortality in individuals at high risk for advanced melanoma through education and screening JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Geller, A. C., Swetter, S. M., Oliveria, S., Dusza, S., Halpern, A. C. 2011; 65 (5): S87-S94


    Incidence and mortality rates of melanoma throughout most of the developed world have increased in the past 25 years. We propose that reduction of deaths from melanoma can be best enhanced by strong collaborations between experts in dermatology, primary care, oncology, cancer education and health systems research, epidemiologists, and behavioral scientists, among others. Public and professional educational campaigns should be guided by an understanding of 3 underlying but overlapping roots: epidemiology and preventable mortality (an understanding of who is most likely to be given the diagnosis of thick or late-stage melanoma), biology (an investigation of tumor types that are relatively common but potentially most lethal), and sociology (an analysis of the changes needed in social structures to improve access to those most in need of early detection programs). We review these major concepts, concentrating on the key risk factors for advanced melanoma.

    View details for DOI 10.1016/j.jaad.2011.05.045

    View details for Web of Science ID 000296268100011

    View details for PubMedID 22018072

  • Increases in Melanoma Among Adolescent Girls and Young Women in California Trends by Socioeconomic Status and UV Radiation Exposure ARCHIVES OF DERMATOLOGY Hausauer, A. K., Swetter, S. M., Cockburn, M. G., Clarke, C. A. 2011; 147 (7): 783-789


    During the past 3 decades in the United States, melanoma incidence among non-Hispanic white girls and women aged 15 to 39 years has more than doubled. To better understand which specific subpopulations of girls and women experienced this increase and thereby to target public health interventions, we assessed the relationship between melanoma incidence and small-area level measures of socioeconomic status (SES) and UV radiation (UV-R) exposure.Longitudinal study of California Cancer Registry, US Census, and National Oceanic and Atmospheric Administration data from pericensal periods January 1, 1988, through December 31, 1992, and January 1, 1998, through December 31, 2002.State of California.A total of 3800 non-Hispanic white girls and women aged 15 to 39 years, in whom 3842 melanomas were diagnosed.Incidence rates per 100 000 person-years and rate ratios according to SES quintiles and UV-R exposure tertiles.Whereas melanoma rates increased over time for all SES categories, only changes among the highest 3 categories achieved statistical significance. UV radiation was significantly and positively associated with melanoma incidence only among adolescent girls and young women in the 2 highest quintiles ranked by SES, which suggests that SES is not a proxy for UV-R exposure. Those living in neighborhoods with the highest SES and UV-R categories had 80.0% higher rates of melanoma than those in neighborhoods in the lowest categories (rate ratio, 1.80; 95% confidence interval, 1.13-3.01).Understanding the ways that SES and UV-R exposure work together to influence melanoma incidence is important for planning effective prevention and educational efforts. Interventions should target adolescent girls and young women living in high SES and high UV-R neighborhoods because they have experienced a significantly greater increase in disease burden.

    View details for DOI 10.1001/archdermatol.2011.44

    View details for Web of Science ID 000292840700003

    View details for PubMedID 21422322

  • Effect of oral sulindac on biomarkers of drug bioavailability and carcinogenesis in melanocytic nevi-A double-blind, randomized, placebo-controlled trial Curiel-Lewandrowski, C., Swetter, S., Einspahr, J., Hsu, C., Saboda, K., Nagle, R., LaPresto, L., Sagerman, P., Lian, F., Tangrea, J., Parnes, H., Chow, H. NATURE PUBLISHING GROUP. 2011: S129-S129
  • The Expanding Melanoma Burden in California Hispanics Importance of Socioeconomic Distribution, Histologic Subtype, and Anatomic Location CANCER Pollitt, R. A., Clarke, C. A., Swetter, S. M., Peng, D. H., Zadnick, J., Cockburn, M. 2011; 117 (1): 152-161


    The incidence patterns and socioeconomic distribution of cutaneous melanoma among Hispanics are poorly understood.The authors obtained population-based incidence data for all Hispanic and non-Hispanic white (NHW) patients who were diagnosed with invasive cutaneous melanoma from 1988 to 2007 in California. By using a neighborhood-level measure of socioeconomic status (SES), the variables investigated included incidence, thickness at diagnosis, histologic subtype, anatomic site, and the relative risk (RR) for thicker (>2 mm) versus thinner (? 2 mm) tumors at diagnosis for groups categorized by SES.Age-adjusted melanoma incidence rates per million were higher in NHWs (P < .0001), and tumor thickness at diagnosis was greater in Hispanics (P < .0001). Sixty-one percent of melanomas in NHWs occurred in the High SES group. Among Hispanics, only 35% occurred in the High SES group; and 22% occurred in the Low SES group. Lower SES was associated with thicker tumors (P < .0001); this association was stronger in Hispanics. The RR of thicker tumors versus thinner tumors (? 2 mm) in the Low SES group versus the High SES group was 1.48 (95% confidence interval [CI], 1.37-1.61) for NHW men and 2.18 (95% CI, 1.73-2.74) for Hispanic men. Patients with lower SES had less of the superficial spreading melanoma subtype (especially among Hispanic men) and more of the nodular melanoma subtype. Leg/hip melanomas were associated with higher SES in NHW men but with lower SES in Hispanic men.The socioeconomic distribution of melanoma incidence and tumor thickness differed substantially between Hispanic and NHW Californians, particularly among men. Melanoma prevention efforts targeted to lower SES Hispanics and increased physician awareness of melanoma patterns among Hispanics are needed.

    View details for DOI 10.1002/cncr.25355

    View details for Web of Science ID 000285368300021

    View details for PubMedID 20737564

  • Interaction of Area-Level Socioeconomic Status and UV Radiation on Melanoma Occurrence in California CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Clarke, C. A., Moy, L. M., Swetter, S. M., Zadnick, J., Cockburn, M. G. 2010; 19 (11): 2727-2733


    Melanoma incidence has been correlated strongly and positively with both socioeconomic status (SES) and lower latitude and other measures of ambient UV radiation (UVR). However, because high-SES populations may be colocated in areas of high UVR, we assessed their joint influences on melanoma occurrence to better target subpopulations for melanoma education and screening.We obtained from the California Cancer Registry information regarding 23,564 incident cases of invasive cutaneous melanoma among non-Hispanic white residents between January 1, 1998, and December 31, 2002. We geocoded each case based on residence at diagnosis and linked previously tested neighborhood measures of SES and average annual UVR to calculate age-adjusted incidence rates, rate ratios, and the corresponding 95% confidence intervals. Poisson regression was used to calculate multivariately adjusted rate ratios.UVR was significantly and positively associated with melanoma incidence only among persons living in the top 40% of California neighborhoods ranked by SES. People in neighborhoods of the highest SES and UVR categories had 60% higher rates of melanoma than those from neighborhoods in the lowest categories (rate ratio, 1.60; 95% confidence interval, 1.02-2.51).Our findings indicate that UVR and SES interact to influence melanoma occurrence and suggest that socioeconomic gradients in melanoma incidence are not explained entirely by UVR.Cancer prevention and early detection educational efforts should be targeted to high-SES groups in areas of high UVR exposure. Contextual measures of both SES and UVR should be considered important determinants of melanoma occurrence in future studies.

    View details for DOI 10.1158/1055-9965.EPI-10-0692

    View details for Web of Science ID 000283991600005

    View details for PubMedID 20978173

  • Melanoma and Melanocytic Tumors of Uncertain Malignant Potential in Children, Adolescents and Young Adults-The Stanford Experience 1995-2008 PEDIATRIC DERMATOLOGY Berk, D. R., LaBuz, E., Dadras, S. S., Johnson, D. L., Swetter, S. M. 2010; 27 (3): 244-254


    Pediatric melanoma is difficult to study because of its rarity, possible biological differences in preadolescents compared with adolescents, and challenges of differentiating true melanoma from atypical spitzoid neoplasms. Indeterminant lesions are sometimes designated as melanocytic tumors of uncertain malignant potential (MelTUMPs). We performed a retrospective, single-institution review of melanomas, MelTUMPs and Spitz nevi with atypical features (SNAFs) in patients at 21 years of age and younger from 1995 to 2008. We identified 13 patients with melanoma, seven with MelTUMPs, and five with SNAFs. The median age for melanoma patients was 17 years, 10 for MelTUMPs, and six for SNAFs. Of the 13 melanoma patients, only four were younger than 15 years, while six were adolescents, and three were young adults. Nine melanoma patients (69%) were female. The most common histologic subtype was superficial spreading. The median depth for melanomas was 1.2 mm, and 3.4 mm for MelTUMPs. Microscopic regional nodal involvement detected on elective or sentinel lymph node (SLN) dissection was present in 2/10 (20%) of primary melanomas and 2/6 (33%) of Mel-TUMPs. Complete lymphadenectomy was performed on four melanoma patients, with three positive cases. Patient outcome through March 31, 2009 revealed no in-transit or visceral metastasis in patients with MelTUMPs or SNAFs. One SLN-positive patient (8%) with melanoma developed recurrent lymph node and liver metastasis and died 15 months after primary diagnosis. Our data highlight the rarity, female predominance, and significant rate of SLN positivity of pediatric melanoma. The high rate of MelTUMPs with regional nodal disease reinforces the need for close follow-up.

    View details for DOI 10.1111/j.1525-1470.2009.01078.x

    View details for Web of Science ID 000278037100005

    View details for PubMedID 20403119

  • Risk of second primary malignancies following cutaneous melanoma diagnosis: A population-based study JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Spanogle, J. P., Clarke, C. A., Aroner, S., Swetter, S. M. 2010; 62 (5): 757-767


    Understanding risk patterns for developing a second primary malignancy (SPM) after cutaneous melanoma (CM) has implications for both research and clinical practice, including cancer screening.We sought to describe incidence patterns of SPMs occurring after CM.We calculated incidence rates and relative risks for the development of 65 different SPMs occurring in 16,591 CM survivors during 1.3 million person-years of observation in the Surveillance, Epidemiology, and End Results program data from 1973 to 2003.Compared with the general population, CM survivors had a 32% higher risk of developing any SPM and demonstrated significantly elevated risks for 13 cancers: melanoma of the skin (standardized incidence ratio [SIR] 8.99), soft tissue (SIR 2.80), melanoma of the eye and orbit (SIR 2.64), nonepithelial skin (SIR 2.31), salivary gland (SIR 2.18), bone and joint (SIR 1.70), thyroid (SIR 1.90), kidney (SIR 1.29), chronic lymphocytic leukemia (SIR 1.29), brain and nervous system (SIR 1.31), non-Hodgkin lymphoma (SIR 1.25), prostate (SIR 1.13), and female breast (SIR 1.07). Risks of second primary melanoma of the skin, melanoma of the eye and orbit, and cancers of the prostate, soft tissue, salivary gland, and bone and joint were elevated throughout the study period, implying no surveillance bias.Possible underreporting of CM incidence in cancer registries is a limitation. In addition, the lack of individual-level data in cancer registry data precludes detailed examination of coincident risk factors.Risks of particular SPMs after CM may be explained by surveillance bias or shared risk factors. However, these probably do not explain the increased risks observed for prostate, soft tissue, salivary gland, and bone and joint cancers years after CM diagnosis. Further investigation into genetic or environmental commonalities between CM and these cancers is warranted.

    View details for DOI 10.1016/j.jaad.2009.07.039

    View details for Web of Science ID 000277190100004

    View details for PubMedID 20223559

  • Recurrence rates associated with incompletely excised low-risk nonmelanoma skin cancer JOURNAL OF CUTANEOUS PATHOLOGY Rieger, K. E., Linos, E., Egbert, B. M., Swetter, S. M. 2010; 37 (1): 59-67


    Reported recurrence rates for transected nonmelanoma skin cancer (NMSC) vary widely, and few studies have addressed recurrence of tumors followed clinically or treated with nonsurgical modalities.Retrospective review of dermatopathology records from January 1999 to January 2005 was conducted to identify biopsies or excision specimens with histologically transected basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) which were not subsequently excised. Patient and tumor characteristics associated with recurrence were analyzed in a subgroup of patients with predominantly 'low-risk' and/or minimally transected NMSCs. Prospective follow up was performed through March 31, 2008. Data was analyzed with Chi-square and Fishers exact tests and multivariate logistic regression.Of 376 transected NMSCs, 27 (7.2%) recurred, including 20 (9%) of 223 BCCs and 7 (4.6%) SCCs in situ of 153 SCCs. The overall recurrence rate of the 124 minimally transected NMSCs was even lower (5.6%). Multivariate logistic regression identified three significant predictors of recurrence: tumor location on the head and neck (p = 0.041), tumor size (p = 0.00741) and superficial subtype of BCC (p = .035).Although surgical excision of NMSC remains the standard of care, observation or nonsurgical treatment may be acceptable in many cases of incompletely excised low-risk or minimally transected NMSCs.

    View details for DOI 10.1111/j.1600-0560.2009.01340.x

    View details for Web of Science ID 000272165500010

    View details for PubMedID 19615009

  • Efficacy of Skin Self-Examination Practices for Early Melanoma Detection CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Pollitt, R. A., Geller, A. C., Brooks, D. R., Johnson, T. M., Park, E. R., Swetter, S. M. 2009; 18 (11): 3018-3023


    Although skin self-examination (SSE) may increase rates of early melanoma detection, the efficacy of different SSE practices has not been thoroughly studied. We examined associations between SSE practices and tumor thickness in patients with recently diagnosed melanoma.321 melanoma patients at three hospitals completed questionnaires on demographics and SSE practices. Patient-reported SSE was measured by routine examination of 13 specific body areas, frequency of mole examination, and use of a melanoma picture aid to assist with SSE. Histologic diagnoses and Breslow depth were confirmed by dermatopathologists. Regression analyses were used to calculate ratios of geometric mean tumor thickness and odds ratios for having thicker versus thinner tumors for different SSE behaviors.Rates of SSE varied considerably by SSE item. Patients routinely examining at least some of their skin had thinner melanomas [adjusted geometric mean tumor ratio, 0.73; 95% confidence interval (95% CI), 0.50-0.94]. Frequency of mole examination did not predict tumor thickness. Using a melanoma picture as a SSE aid was strongly associated with reduced tumor thickness (adjusted ratio, 0.75; 95% CI, 0.66-0.85 for ever versus never use). A composite measure of thoroughness of SSE was the best predictor of thickness (adjusted ratio, 0.58; 95% CI, 0.36-0.75) for high versus low thoroughness.SSE was associated with decreased tumor thickness by most measures. However, the diverse rates of SSE practices and the distinct associations between these practices and melanoma thickness suggest a complexity in SSE that should be addressed in future studies. SSE should be evaluated by more than one measure.

    View details for DOI 10.1158/1055-9965.EPI-09-0310

    View details for Web of Science ID 000271562600031

    View details for PubMedID 19861521

  • Selection criteria for genetic assessment of patients with familial melanoma JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Leachman, S. A., Carucci, J., Kohlmann, W., Banks, K. C., Asgari, M. M., Bergman, W., Bianchi-Scarra, G., Brentnall, T., Bressac-de Paillerets, B., Bruno, W., Curiel-Lewandrowski, C., de Snoo, F. A., Debniak, T., Demierre, M., Elder, D., Goldstein, A. M., Grant-Kels, J., Halpern, A. C., Ingvar, C., Kefford, R. F., Lang, J., MacKie, R. M., Mann, G. J., Mueller, K., Newton-Bishop, J., Olsson, H., Peterson, G. M., Puig, S., Rigel, D., Swetter, S. M., Tucker, M. A., Yakobson, E., Zitelli, J. A., Tsao, H. 2009; 61 (4): 677-684
  • Increasing Burden of Melanoma in the United States JOURNAL OF INVESTIGATIVE DERMATOLOGY Linos, E., Swetter, S. M., Cockburn, M. G., Colditz, G. A., Clarke, C. A. 2009; 129 (7): 1666-1674


    It is controversial whether worldwide increases in melanoma incidence represent a true epidemic. Dramatic increases in incidence in the setting of relatively stable mortality trends have also been attributed to expanded skin screening and detection of biologically indolent tumors with low metastatic potential. To better understand how melanoma incidence trends varied by severity at diagnosis and factors relevant to screening access, we assessed recent United States incidence and mortality trends by histologic type, tumor thickness, and area-level socioeconomic status (SES). We obtained population-based data regarding diagnoses of invasive melanoma among non-Hispanic whites from nearly 291 million person-years of observation by the Surveillance Epidemiology and End Results (SEER) program (1992-2004). Age-adjusted incidence and mortality rates were calculated for SEER and a subset (California) for which small-area SES measure was available. Overall, melanoma incidence increased at 3.1% (P<0.001) per year. Statistically significant rises occurred for tumors of all histologic subtypes and thicknesses, including those >4 mm. Melanoma incidence rates doubled in all SES groups over a 10-year period whereas melanoma mortality rates did not increase significantly. We conclude that screening-associated diagnosis of thinner melanomas cannot explain the increasing rates of thicker melanomas among low SES populations with poorer access to screening.

    View details for DOI 10.1038/jid.2008.423

    View details for Web of Science ID 000267270300013

    View details for PubMedID 19131946

  • Lymphatic invasion in cutaneous melanoma is associated with sentinel lymph node metastasis JOURNAL OF CUTANEOUS PATHOLOGY Doeden, K., Ma, Z., Narasimhan, B., Swetter, S. M., Detmar, M., Dadras, S. S. 2009; 36 (7): 772-780


    Sentinel lymph node (SLN) metastasis is a major determinant for staging, prognostication and clinical management of patients with cutaneous melanoma. However, the role of lymphatic vs. vascular invasion (VI) for SLN spread remains unclear.We compared the frequency of lymphatic invasion (LI) vs. VI in melanoma sections from 94 patients with a mean three-year clinical follow up using immunostains for the lymphatic endothelial markers D2-40 (podoplanin) and LYVE-1 and the panvascular marker CD31.LI occurred more frequently than VI (16 vs. 3%, respectively, p = 0.001) and correlated with higher American Joint Committee on Cancer stage at diagnosis (p = 0.0004). In a univariate analysis, LI was strongly associated with SLN metastasis (p = 0.008), independent of tumor thickness. In a multivariate analysis, LI was not a significant risk factor for SLN metastasis. The presence of intratumoral lymphatics (ITLs) was associated with distant metastasis, whereas VI was rare and did not correlate with SLN or distant metastasis. A combination of LI and ITL had higher positive and negative predictive values for the risk of developing SLN metastasis compared with routine histology and VI.Detection of LI in the primary tumor may aid in identifying melanoma patients with the propensity to develop SLN metastasis.

    View details for DOI 10.1111/j.1600-0560.2008.01166.x

    View details for Web of Science ID 000266490200008

    View details for PubMedID 19032379

  • Impaired interferon signaling is a common immune defect in human cancer PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Critchley-Thorne, R. J., Simons, D. L., Yan, N., Miyahira, A. K., Dirbas, F. M., Johnson, D. L., Swetter, S. M., Carlson, R. W., Fisher, G. A., Koong, A., Holmes, S., Lee, P. P. 2009; 106 (22): 9010-9015


    Immune dysfunction develops in patients with many cancer types and may contribute to tumor progression and failure of immunotherapy. Mechanisms underlying cancer-associated immune dysfunction are not fully understood. Efficient IFN signaling is critical to lymphocyte function; animals rendered deficient in IFN signaling develop cancer at higher rates. We hypothesized that altered IFN signaling may be a key mechanism of immune dysfunction common to cancer. To address this, we assessed the functional responses to IFN in peripheral blood lymphocytes from patients with 3 major cancers: breast cancer, melanoma, and gastrointestinal cancer. Type-I IFN (IFN-alpha)-induced signaling was reduced in T cells and B cells from all 3 cancer-patient groups compared to healthy controls. Type-II IFN (IFN-gamma)-induced signaling was reduced in B cells from all 3 cancer patient groups, but not in T cells or natural killer cells. Impaired-IFN signaling was equally evident in stage II, III, and IV breast cancer patients, and downstream functional defects in T cell activation were identified. Taken together, these findings indicate that defects in lymphocyte IFN signaling arise in patients with breast cancer, melanoma, and gastrointestinal cancer, and these defects may represent a common cancer-associated mechanism of immune dysfunction.

    View details for DOI 10.1073/pnas.0901329106

    View details for Web of Science ID 000266580500043

    View details for PubMedID 19451644

  • Melanoma in Middle-aged and Older Men A Multi-institutional Survey Study of Factors Related to Tumor Thickness ARCHIVES OF DERMATOLOGY Swetter, S. M., Johnson, T. M., Miller, D. R., Layton, C. J., Brooks, K. R., Geller, A. C. 2009; 145 (4): 397-404


    To identify factors related to the detection of melanoma and to determine those that differ between thinner vs thicker tumors in middle-aged and older men.Survey.Three institutional melanoma clinics.Men 40 years or older who had newly diagnosed invasive melanoma.Differences in melanoma awareness, skin examination practices, discovery patterns, and social/medical care factors relative to tumor thickness.Two hundred twenty-seven men completed surveys within 3 months of melanoma diagnosis; 57 (25.1%) had thicker tumors (>2.00 mm). Thicker tumors were associated with nodular histologic features (43.9%), a lack of atypical nevi, having less than a high school education, and patient vs physician (dermatologist or nondermatologist) detection. Knowledge of melanoma (P = .007), attention to skin cancer detection information (P = .02), an interest in health topics (P = .003), and knowing the importance of physician skin examination (P = .05) were more common in those with thin tumors. Tumor thickness did not correlate with age, anatomic location, marital/cohabitation status, prior skin cancer, or sun sensitivity. Overall patient awareness of melanoma warning signs, skin self-examination practices, and Internet use were poor (<20%, <50%, and <14%, respectively).Physician discovery, the patient's higher level of education and detection-promoting awareness and attitudes, and the presence of clinically atypical nevi were related to thinner melanomas. Innovative outreach strategies and novel educational campaigns incorporating these factors, coupled with sharper messages regarding the importance of physician screening, are needed to improve early detection in middle-aged and older men.

    View details for Web of Science ID 000265411100004

    View details for PubMedID 19380661

  • Factors Associated With Physician Discovery of Early Melanoma in Middle-aged and Older Men ARCHIVES OF DERMATOLOGY Geller, A. C., Johnson, T. M., Miller, D. R., Brooks, K. R., Layton, C. J., Swetter, S. M. 2009; 145 (4): 409-414


    To determine factors associated with physician discovery of early melanoma in middle-aged and older men.Survey.Three institutional melanoma clinics.A total of 227 male participants (aged > or =40 years) with invasive melanoma who completed surveys within 3 months of diagnosis. Intervention Survey.Factors associated with physician-detected thin melanoma.Patients with physician-detected melanoma were older, 57% were 65 years or older compared with 34% for other-detected (odds ratio [OR], 2.57; 95% confidence interval [CI], 1.19-5.55) and 42% for patient-detected melanoma (P = .07). Physician-detected melanoma in the oldest patients (aged > or =65 years) had tumor thickness equal to that of self-detected melanoma or melanoma detected by other means in younger patients. Back lesions composed 46% of all physician-detected melanoma, 57% of those detected by other means, and 16% of self-detected lesions (physician- vs self-detected: OR, 4.25; 95% CI, 1.96-9.23). Ninety-two percent of all physician-detected back-of-the-body melanomas were smaller than 2 mm compared with 63% of self-detected lesions (P = .004) and 76% of lesions detected by other means (P = .07).Skin screenings of at-risk middle-aged and older American men can be integrated into the routine physical examination, with particular emphasis on hard-to-see areas, such as the back of the body. "Watch your back" professional education campaigns should be promoted by skin cancer advocacy organizations.

    View details for Web of Science ID 000265411100005

    View details for PubMedID 19380662

  • Gender Differences in Melanoma Awareness and Detection Practices Between Middle-aged and Older Men With Melanoma and Their Female Spouses ARCHIVES OF DERMATOLOGY Swetter, S. M., Layton, C. J., Johnson, T. M., Brooks, K. R., Miller, D. R., Geller, A. C. 2009; 145 (4): 488-490

    View details for Web of Science ID 000265411100022

    View details for PubMedID 19380679

  • Factors Related to the Presentation of Thin and Thick Nodular Melanoma From a Population-based Cancer Registry in Queensland Australia CANCER Geller, A. C., Elwood, M., Swetter, S. M., Brooks, D. R., Aitken, J., Youl, P. H., Demierre, M., Baade, P. D. 2009; 115 (6): 1318-1327


    Worldwide, the incidence of thick melanoma has not declined, and the nodular melanoma (NM) subtype accounts for nearly 40% of newly diagnosed thick melanoma. To assess differences between patients with thin (or=2.01 mm) nodular melanoma, the authors evaluated factors such as demographics, melanoma detection patterns, tumor visibility, and physician screening for NM alone and compared clinical presentation and anatomic location of NM with superficial spreading melanoma (SSM).The authors used data from a large population-based study of Queensland (Australia) residents diagnosed with melanoma. Queensland residents aged 20 to 75 years with histologically confirmed first primary invasive cutaneous melanoma were eligible for the study, and all questionnaires were conducted by telephone (response rate, 77.9%).During this 4-year period, 369 patients with nodular melanoma were interviewed, of whom 56.7% were diagnosed with tumors 2.00 mm).Awareness of factors related to earlier detection of potentially fatal nodular melanomas, including the benefits of a physician examination, should be useful in enhancing public and professional education strategies. Particular awareness of clinical warning signs associated with thin nodular melanoma should allow for more prompt diagnosis and treatment of this subtype.

    View details for DOI 10.1002/cncr.24162

    View details for Web of Science ID 000264148300022

    View details for PubMedID 19189368

  • Melanoma JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Coit, D. G., Andtbacka, R., Bichakjian, C. K., Dilawari, R. A., Dimaio, D., Guild, V., Halpern, A. C., Hodi, F. S., Kashani-Sabet, M., Lange, J. R., Lind, A., Martin, L., Martini, M. C., Pruitt, S. K., Ross, M. I., Sener, S. F., Swetter, S. M., Tanabe, K. K., Thompson, J. A., Trisal, V., Urist, M. M., Weber, J., Wong, M. K. 2009; 7 (3): 250-275

    View details for Web of Science ID 000270264600004

    View details for PubMedID 19401060

  • High-molecular-weight keratin stain as a complement to Melan A stain JOURNAL OF CUTANEOUS PATHOLOGY Egbert, B. M., Rouse, R. V., Swetter, S. M. 2008; 35 (12): 1159-1159

    View details for Web of Science ID 000260536400016

    View details for PubMedID 18976405

  • Melanoma underreporting: Why does it happen, how big is the problem, and how do we fix it? JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Cockburn, M., Swetter, S. M., Peng, D., Keegan, T. H., Deapen, D., Clarke, C. A. 2008; 59 (6): 1081-1085

    View details for DOI 10.1016/j.jaad.2008.08.007

    View details for Web of Science ID 000261141600026

    View details for PubMedID 19022107

  • California medicaid Enrollment and melanoma stage at diagnosis - A population-based study AMERICAN JOURNAL OF PREVENTIVE MEDICINE Pollitt, R. A., Clarke, C. A., Shema, S. J., Swetter, S. M. 2008; 35 (1): 7-13


    Insurance status and SES are associated with the stage of melanoma at diagnosis. However, the influence of Medicaid enrollment on melanoma stage has not been studied in detail. This study examined the effect of Medicaid enrollment status and duration on melanoma stage at diagnosis in a large, multi-ethnic California population.California Cancer Registry records were linked with statewide Medicaid enrollment files to identify 4558 men and women diagnosed with invasive cutaneous and metastatic melanoma during 1998-1999. Multivariate logistic regression was used to evaluate the association between prediagnosis Medicaid enrollment status and late-stage diagnosis and tumor depth at diagnosis.Late-stage disease was diagnosed in 27% of Medicaid and 9% of non-Medicaid melanoma patients. Those enrolled in Medicaid at diagnosis and those enrolled intermittently during the year prior to diagnosis had significantly greater covariate-adjusted odds of late-stage cancer than those not enrolled in Medicaid (OR 13.64, 95% CI=4.43, 41.98, and OR 2.77, 95% CI=1.28, 5.99, respectively). Participants continuously enrolled during the previous year were not at increased odds for late-stage disease. An increased likelihood of late-stage melanoma was also associated with low SES (p<0.05) and non-Hispanic black race/ethnicity (p<0.10) after covariate adjustment.Men and women intermittently enrolled in Medicaid or not enrolled until the month of diagnosis had a significantly increased likelihood of late-stage melanoma. Greater education and outreach, particularly in low-SES areas, are needed to improve melanoma awareness and access to screening.

    View details for DOI 10.1016/j.amepre.2008.03.026

    View details for Web of Science ID 000256996900002

    View details for PubMedID 18482824

  • Primary dermal melanoma ARCHIVES OF DERMATOLOGY Cassarino, D. S., Cabral, E. S., Kartha, R. V., Swetter, S. M. 2008; 144 (1): 49-56


    To provide an updated and expanded analysis of clinical outcome and immunohistochemical (IHC) findings unique to primary dermal melanoma (PDM) that may be used to differentiate this entity from primary nodular melanoma (PNM) and cutaneous metastatic melanoma (MM).Cohort analysis and extensive IHC panel comparing PDM with PNM and cutaneous MM.Melanoma clinics and pathology departments of academic and VA medical centers.Thirteen patients with a solitary dermal or subcutaneous nodule of histologically proven melanoma, prospectively followed through April 30, 2007.Clinical, pathologic, and IHC assessment of patients diagnosed as having PDM.Long-term clinical outcome and determination of unique clinical and IHC features in the study cohort compared with other melanoma subtypes.Histologically, there was no evidence of an overlying in situ component, ulceration, or regression, and there was no associated nevus in any cases. Clinical history and findings from workup, including imaging studies, skin examination, and sentinel lymph node biopsy, were negative for evidence of melanoma elsewhere. The mean Breslow depth was 9.6 mm. Two patients developed satellite or in-transit recurrences, 1 developed pulmonary metastasis, and another died of liver metastases. Overall, the cohort showed a 92% melanoma-specific survival rate at a mean duration of follow-up of 44 months. The IHC findings showed that PDM exhibited lower levels of staining for the antigens p53 (P = .02), Ki-67 (Mib-1) (P = .002), cyclin D1 (P = .001), and podoplanin (recognized by D2-40 antibody) lymphovascular staining (P <.001) compared with MM and PNM. All other markers were comparable.Patients with PDM have remarkably prolonged survival compared with patients with MM or PNM of similar thickness. Preliminary results suggest that PDM may be characterized by lower levels of p53, Ki-67, cyclin D1, and D2-40 compared with histologically similar MM and PNM.

    View details for Web of Science ID 000252439200006

    View details for PubMedID 18209168

  • Screening, early detection, and trends for melanoma: Current status (2000-2006) and future directions JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Geller, A. C., Swetter, S. M., Brooks, K., Demierre, M., Yaroch, A. L. 2007; 57 (4): 555-572


    In the past 5 years, there have been notable strides toward the earlier recognition and discovery of melanoma, including new technologies to complement and augment the clinical examination and new insights to help clinicians recognize early melanoma. However, incidence and mortality rates throughout most of the developed world have risen over the past 25 years, while education and screening, potentially the best means for reducing the disease, continue to be severely underutilized. Much progress needs to be made to reach middle-aged and older men and persons of lower socioeconomic status who suffer a disproportionate burden of death from melanoma. Worldwide melanoma control must also be a priority, and comprehensive educational and screening programs should be directed to Northern Ireland and a number of Eastern European nations, whose 5-year survival rates range between 53% and 60%, mirroring those of the United States and Australia more than 40 years ago.After completing this learning activity, participants should be aware of the most recent melanoma epidemiologic data, both in the United States and internationally; worldwide early detection and screening programs; clinical strategies to recognize and improve the detection of early melanoma; the latest technologies for early detection of melanoma; and public and professional education programs designed to enhance early detection.

    View details for DOI 10.1016/j.jaad.2007.06.032

    View details for Web of Science ID 000249695600001

    View details for PubMedID 17870429

  • Evaluation of digital dermoscopy in a pigmented lesion clinic: Clinician versus computer assessment of malignancy risk JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Boldrick, J. C., Layton, C. J., Nguyen, J., Swetter, S. M. 2007; 56 (3): 417-421


    Digital dermoscopy systems employ computer-based algorithms to quantitate features of pigmented skin lesions (PSLs) and provide an assessment of malignancy risk. We evaluated interobserver concordance of PSL malignancy risk between a pigmented lesion specialist and an artificial neural network (ANN)-based automated digital dermoscopy system. While digital dermoscopy provides a reliable means of image capture, storage, and comparison of PSLs over time, the ANN algorithm requires further training and validation before the malignancy risk assessment feature can be widely used in clinical practice.

    View details for DOI 10.1016/j.jaad.2006.08.033

    View details for Web of Science ID 000244612700009

    View details for PubMedID 17109995

  • Effect of health care delivery models on melanoma thickness and stage in a university-based referral center - An observational pilot study ARCHIVES OF DERMATOLOGY Swetter, S. M., Soon, S., Harrington, C. R., Chen, S. C. 2007; 143 (1): 30-36


    To compare the effect of differing health care delivery models, specifically, gatekeeper (GK) vs direct access (DA) routes, on melanoma outcome as measured by tumor thickness and cancer stage at diagnosis.Retrospective medical record review of patients previously diagnosed as having cutaneous melanoma who were referred to a university-based clinic from January 1, 1996, through December 31, 2000.Stanford Pigmented Lesion and Cutaneous Melanoma Clinic, Stanford, Calif. Patients Two hundred thirty-four patients with primary melanoma stratified according to health care access route (GK or DA).Differences in Breslow thickness, American Joint Committee on Cancer stage, histologic features, patient delay in seeking medical attention, and physician delay in diagnosis (time between initial physician visit and diagnostic biopsy procedure).Of 234 patients, 168 (72%) were referred through the DA route and 66 (28%) through the GK route. A significant association was found between physician delay and access route; patients in the DA group underwent biopsy sooner (< or =3 months vs >3 months) than those in the GK group (P<.001). No significant difference was observed in stage at diagnosis (predominantly stage IA), proportion of nodular melanoma (DA 4% vs GK 2%), patient delay, or median tumor thickness between DA and GK routes (0.42 mm vs 0.50 mm, respectively). A trend toward a greater proportion of histologically ulcerated melanoma was observed in the DA group compared with the GK group (12% vs 5%, respectively; P = .06).This pilot study demonstrated no difference in outcome between GK and DA routes as measured by melanoma thickness and stage, although patients in the DA group underwent diagnostic biopsy sooner than those in the GK group. The potential effect of health care models on melanoma outcomes merits further study.

    View details for Web of Science ID 000243509100004

    View details for PubMedID 17224539

  • Crafting a melanoma educational campaign to reach middle-aged and older men JOURNAL OF CUTANEOUS MEDICINE AND SURGERY Geller, J., Swetter, S. M., Leyson, J., Miller, D. R., Brooks, K., Geller, A. C. 2006; 10 (6): 259-268


    From 1973 through 2002, melanoma mortality rates have risen steeply in middle-aged and older men. Men's higher mortality rate from melanoma is hardly an isolated example of the ways in which men's health lags behind women's health. Given the significantly higher melanoma mortality rates of men compared with women, there is now a need for a melanoma education program targeted to middle-aged and older men and their closest contacts, including spouses, significant others, and health care professionals.In this article, we discuss the theoretical and practical foundations for such a program. Then, taking into account factors such as socioeconomic status, health literacy, and residence, we present suggestions for creating such a campaign.Planners for a new educational campaign must understand the target audience's motivations for and perceived barriers to behavioral change. Future studies should examine what motivates certain men to conduct skin self-examinations, ask their physicians about melanoma, and attend melanoma screenings, whereas other men with similar risk factors are less prevention conscious. Issues of health literacy and understandability of our messages must be further explored.

    View details for DOI 10.2310/7750.2006.00066

    View details for Web of Science ID 000248050200001

    View details for PubMedID 17241595

  • Facial resurfacing for nonmelanoma skin cancer prophylaxis ARCHIVES OF DERMATOLOGY Hantash, B. M., Stewart, D. B., Cooper, Z. A., Rehmus, W. E., Koch, R. J., Swetter, S. M. 2006; 142 (8): 976-982


    To determine the effect of facial skin resurfacing for treatment of actinic keratoses (AKs) and prophylaxis against new primary basal and squamous cell carcinomas in individuals with previous nonmelanoma skin cancer (NMSC) or severe photodamage.Randomized, prospective 5-year trial.Dermatology and otolaryngology clinics of a Veterans Affairs hospital.Thirty-four patients with a history of facial or scalp AKs or basal or squamous cell carcinoma were enrolled. Five of 7 eligible patients who declined study-related treatment were used as controls. Twenty-seven patients were randomized to 3 treatment arms; 3 patients were discontinued from the study.Carbon dioxide laser resurfacing, 30% trichloroacetic acid peel, or 5% fluorouracil cream applied twice daily for 3 weeks.Reduction in the number of AKs was measured 3 months after treatment. The incidence of new NMSC in treated areas was assessed between January 1, 2001, and June 30, 2005. Times from baseline to diagnosis of first skin cancer were compared between the treatment and control groups.Treatment with fluorouracil, trichloroacetic acid, or carbon dioxide laser resulted in an 83% to 92% reduction in AKs (P< or =.03), a lower incidence of NMSC compared with the control group (P<.001), and a trend toward longer time to development of new skin cancer compared with the control group (P=.07). However, no significant differences were noted among the treatment groups.All 3 modalities demonstrated benefit for AK reduction and skin cancer prophylaxis compared with controls and warrant further study in a larger trial.

    View details for Web of Science ID 000239762700003

    View details for PubMedID 16924046

  • Slow-growing nodule on the thigh - Solitary fibrous tumor (SFT) ARCHIVES OF DERMATOLOGY Stewart, D. B., Egbert, B. M., Rouse, R. V., Swetter, S. M. 2006; 142 (7): 923-?
  • Use of artificial tanning products among young adults JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Brooks, K., Brooks, D., Dajani, Z., Swetter, S. M., Powers, E., Pagoto, S., Geller, A. C. 2006; 54 (6): 1060-1066


    Neither the prevalence of sunless tanner use nor its impact on sunburning and tanning bed use has been evaluated in the United States.We surveyed young adults in greater Boston to measure use of artificial tanning products, as well as recent history of sunburns and tanning bed use.In July 2004, 448 individuals 18 to 30 years of age completed a brief questionnaire at universities, shopping venues, and parks.Twenty-two percent of respondents used sunless tanning lotions in the preceding 12 months, and another 22% had not used them but would consider doing so in the coming year. Sunless tanning users were more likely to be female, younger, and more likely to report being severe burners. Both users and potential users were more likely to have sunburned during the summer and to have used tanning beds than those who neither used nor intended to use sunless tanning lotions, even after controlling for skin type.The study was based on a non-randomly selected sample in one city and was cross-sectional in nature.Our study raises the possibility that sunless tanning products do not decrease rates of sunburning or use of tanning beds. While safe alternatives to ultraviolet exposure are desirable, the potential risks of widely endorsing artificial tanning products must be considered.

    View details for DOI 10.1016/j.jaad.2006.01.014

    View details for Web of Science ID 000237908900014

    View details for PubMedID 16713463

  • Sun care advertising in popular US magazines AMERICAN JOURNAL OF HEALTH PROMOTION Lee, E. T., O'Riordan, D., Swetter, S. M., Demierre, M., Brooks, K., Geller, A. C. 2006; 20 (5): 349-352


    We assessed the placement of magazine advertising for sun care products to lay the groundwork for broader promotion to more diverse and high-risk demographic groups.We reviewed 579 issues of 24 magazines published between the months of May and September from 1997 to 2002. We conducted a cover-to-cover review of top-selling magazines for men, women, teens, parents, travelers, and outdoor recreation users. We determined if there were any advertisements for the following sun care products: sun tanning lotions containing sun protection factor (SPF), sunless tanners without SPF, sunscreen with SPF, moisturizers with SPF, or cosmetics with SPF (which include sunless tanners containing SPF.Sun care products, including sunscreens, were advertised primarily in women's magazines (77%). Nearly two thirds of all sun care products advertised were either for cosmetics (38%) or moisturizers (26%) containing SPF, followed by ads for sunscreen sold as a stand-alone product (19%). None of the ads contained all of the recommendations for safe use of sunscreen: a minimum SPF of 15, both UVA and UVB protection, reapplication instructions, and an adequate application coverage of 2 milligrams per square centimeter.Magazine advertising to men, travelers, outdoor recreation users, and parents/families (totaling a circulation of 41 million readers) during this six-year period were far fewer than those for women, despite high rates of excessive sun exposure in these groups.

    View details for Web of Science ID 000237487100008

    View details for PubMedID 16706006

  • A call for the development and implementation of a targeted national melanoma screening program ARCHIVES OF DERMATOLOGY Geller, A. C., Miller, D. R., Swetter, S. M., Demierre, M. F., Gilchrest, B. A. 2006; 142 (4): 504-507

    View details for Web of Science ID 000236854700014

    View details for PubMedID 16618872

  • Sun protection factor content and warning statements for sunless tanning products: An examination of retail outlets and the Internet JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Dajani, Z., Swetter, S. M., Demierre, M. F., Geller, A. C. 2005; 53 (5): 919-920

    View details for DOI 10.1016/j.jaad.2005.06.002

    View details for Web of Science ID 000232898000046

    View details for PubMedID 16243168

  • Increasing incidence of lentigo maligna melanoma subtypes: Northern California and national trends 1990-2000 JOURNAL OF INVESTIGATIVE DERMATOLOGY Swetter, S. M., Boldrick, J. C., Jung, S. Y., Egbert, B. M., Harvell, J. D. 2005; 125 (4): 685-691


    Worldwide, lentigo maligna melanoma (LMM) comprises 4%-15% of cutaneous melanoma and occurs less commonly than superficial spreading or nodular subtypes. We assessed the incidence of melanoma subtypes in regional and national Surveillance, Epidemiology, and End Results (SEER) cancer registry data from 1990 to 2000. Because 30%-50% of SEER data were not classified by histogenetic type, we compared the observed SEER trends with an age-matched population of 1024 cases from Stanford University Medical Center (SUMC) (1995-2000). SEER data revealed lentigo maligna (LM) as the most prevalent in situ subtype (79%-83%), and that LMM has been increasing at a higher rate compared with other subtypes and to all invasive melanoma combined for patients aged 45-64 and > or =65 y. The SUMC data demonstrated LM and LMM as the only subtypes increasing in incidence over the study period. In both groups, LM comprised > or =75% of in situ melanoma and LMM > or =27% of invasive melanoma in men 65 y and older. Regional and national SEER data suggest an increasing incidence of LM and LMM, particularly in men > or =age 65. An increased incidence of LM subtypes should direct melanoma screening to heavily sun-exposed sites, where these subtypes predominate.

    View details for DOI 10.1111/j.0022-202X.2005.23852.x

    View details for Web of Science ID 000232556700011

    View details for PubMedID 16185266

  • Sentinel lymph node biopsy for cutaneous melanoma - The Stanford experience, 1997-2004 ARCHIVES OF DERMATOLOGY Berk, D. R., Johnson, D. L., Uzieblo, A., Kiernan, M., Swetter, S. M. 2005; 141 (8): 1016-1022


    To review sentinel lymph node (SLN) data from Stanford University Medical Center from January 1, 1997, to January 1, 2004, including rates of SLN positivity according to 2002 American Joint Committee on Cancer (AJCC) tumor classification, relation to other clinical and pathologic prognostic factors, and rates and sites of melanoma recurrence.Retrospective case series.Stanford University Medical Center and Stanford melanoma clinics.A total of 274 consecutive patients with primary melanoma who underwent SLN biopsy (SLNB) between January 1, 1997, and January 1, 2004, or who were referred to the Stanford melanoma clinics after SLNB and were followed up through March 2005.All patients underwent standard wide local excision of their primary tumors and SLNB with intradermal injection of isosulfan blue dye and/or technetium sulfur colloid.Rates of SLN positivity per 2002 AJCC tumor classification, relation to other clinical and pathologic prognostic factors, and rates and sites of melanoma recurrence in node-negative and node-positive patients.Positive SLNs were detected in 39 (15%) of 260 cases, including 0 (0%) of 45 for cutaneous melanomas 1.0 mm thick or less (T1), 21 (18%) of 115 for melanomas 1.01 to 2.0 mm thick (T2), 12 (19%) of 64 for melanomas 2.01 to 4.0 mm thick (T3), and 5 (16%) of 32 for melanomas thicker than 4.0 mm (T4). Median Breslow depths were 1.89 mm for SLN-positive biopsy specimens and 1.50 mm for SLN-negative biopsy specimens (P = .07). The recurrence rate was 46% among SLN-positive patients, with a median time to recurrence of 8 months. Bivariate analysis revealed SLN positivity to be associated with AJCC tumor classification (P = .02), location on the trunk (P = .03), and presence of ulceration (P = .03). By multivariate logistic regression, ulceration (P = .01) was predictive of SLN positivity, whereas SLN status (P< .001), ulceration (P = .02), and location (P = .03) were predictive of recurrent disease.Data from the past 8 years confirm the accuracy and prognostic value of SLNB in cutaneous melanoma and the low rate of regional nodal recurrence for SLN-negative patients.

    View details for Web of Science ID 000231072100011

    View details for PubMedID 16103331

  • Histologic similarities between lentigo maligna and dysplastic nevus: importance of clinicopathologic distinction JOURNAL OF CUTANEOUS PATHOLOGY Farrahi, F., Egbert, B. M., Swetter, S. M. 2005; 32 (6): 405-412


    Lentigo maligna (LM) can histologically simulate dysplastic nevus (DN). Partial biopsy of LM may lead to misdiagnosis.One hundred and fourteen cases of LM and LM melanoma (LMM) were diagnosed at the Veterans Affairs Palo Alto Health Care System (1993-2002). Biopsy and excision specimens for 68 in situ and 28 invasive melanomas were classified as having predominant classical LM features, predominant DN-like morphology, or a mixed pattern.Biopsy specimens demonstrated a predominant classical pattern in 38% (25/65) LM and 36% (10/28) LMM, predominant DN-like features in 43% (28/65) LM and 25% (7/28) LMM, and mixed pattern in 15% (10/65) LM and 29% (8/28) LMM. Most LM and LMM biopsies were partial. Significant DN-like features were present in 51% LM and 57% LMM excision specimens. Median age was 72 years for LM and 73 years for LMM, mean lesion diameters were 1.3 and 1.7 cm for LM and LMM, respectively, and 85% of LM and 75% of LMM cases were located on heavily sun-exposed sites.Misdiagnosis of LM or LMM as DN could have devastating results. Large pigmented lesions on sun-damaged skin in elderly individuals should warrant consideration of LM/LMM diagnosis, even in the setting of DN-like features histologically. Excisional biopsy may help to avoid misdiagnosis.

    View details for Web of Science ID 000229637200003

    View details for PubMedID 15953373

  • Malignant Melanoma eMedicine Journal [serial online]. Available at: Swetter SM 2005
  • Vaccine therapy of melanoma: an update. Current Cancer Therapy Reviews Demierre M-F, Swetter SM, Sondak VK 2005; 1: 115-25
  • Prevention and detection of melanoma in the primary care setting. J Clin Outcomes Management Swetter SM, Geller AC 2005; 12: 523-34
  • Melanoma in the older person ONCOLOGY-NEW YORK Swetter, S. M., Geller, A. C., Kirkwood, J. M. 2004; 18 (9): 1187-1196


    Melanoma accounts for the majority of skin cancer deaths worldwide and has dramatically increased in incidence over the past half-century. Despite recent trends showing improved survival, and stabilization of incidence rates in younger Americans, melanoma incidence and mortality continue to rise unabated in older individuals, particularly in men over age 65. Efforts at early clinical detection of melanoma in older individuals should take into account the differences in melanoma subtypes in older individuals, potentially reduced access to medical specialists in this population, as well as comorbidities that may affect ability to undergo treatment for advanced disease. Secondary melanoma prevention should be focused on targeted education to older men and their spouses for early detection and reduction of mortality in this extremely high-risk group.

    View details for Web of Science ID 000238211600017

    View details for PubMedID 15471201

  • Extraocular sebaceous carcinoma in a patient with Muir-Torre syndrome DERMATOLOGIC SURGERY Harrington, C. R., Egbert, B. M., Swetter, S. M. 2004; 30 (5): 817-819


    Sebaceous carcinoma is a rare, aggressive neoplasm that arises from the adnexal epithelium of sebaceous glands and is commonly associated with Muir-Torre syndrome.The metastatic potential of extraocular sebaceous carcinoma warrants a thorough evaluation to establish the extent of disease.We describe a 55-year-old man who presented with an asymptomatic abdominal wall mass 3 years after definitive diagnosis of Muir-Torre syndrome.A biopsy of the surgical specimen revealed sebaceous carcinoma.Dermatologists are crucial to the early recognition and diagnosis of extraocular sebaceous carcinoma. In our patient with documented Muir-Torre syndrome, continued surveillance allowed for prompt recognition and treatment of this associated cutaneous malignancy.

    View details for Web of Science ID 000220940700025

    View details for PubMedID 15099333

  • Diffuse verrucous, vascular nodules on the extremities and trunk ARCHIVES OF DERMATOLOGY Nguyen, J., Egbert, B. M., Swetter, S. M. 2004; 140 (3): 353-?

    View details for Web of Science ID 000220118300013

    View details for PubMedID 15023783

  • Muir-Torre syndrome: Confirmation of diagnosis by immunohistochemical analysis of cutaneous lesions JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Fiorentino, D. F., Nguyen, J. C., Egbert, B. M., Swetter, S. M. 2004; 50 (3): 476-478

    View details for DOI 10.1016/j.jaad.2003.07.027

    View details for Web of Science ID 000220080500026

    View details for PubMedID 14988697

  • Kinetics and specificity of Fas ligand induction in toxic epidermal necrolysis ARCHIVES OF DERMATOLOGY Chang, H. Y., Cooper, Z. A., Swetter, S. A., Marinkovich, M. P. 2004; 140 (2): 242-244

    View details for Web of Science ID 000188877100024

    View details for PubMedID 14967808

  • Primary dermal melanoma - A distinct subtype of melanoma ARCHIVES OF DERMATOLOGY Swetter, S. M., Ecker, P. M., Johnson, D. L., Harvell, J. D. 2004; 140 (1): 99-103


    The term primary dermal melanoma has been used to describe a subtype of melanoma confined to the dermis and/or subcutaneous fat that histologically simulates metastasis but is associated with an unexpectedly prolonged survival. We report 7 cases of primary dermal melanoma diagnosed from 1998 to 2002 with no identifiable junctional or epidermal component or nevoid precursor. Histopathologic and immunohistochemical features were compared with known cases of cutaneous metastasis and nodular melanoma in an attempt to differentiate this entity from clinical and pathologic mimics.Seven patients had a single dermal and/or subcutaneous focus of melanoma. Metastatic staging workup findings were negative, including results from sentinel node and imaging studies. Mean Breslow depth was 7.0 mm, and mean maximum tumor diameter was 6.2 mm. The study cohort showed 100% survival at mean follow-up of 41 months (range, 10-64 months). Immunohistochemical analysis with S100, HMB-45, Ki-67, CD34, and p75 antibodies showed no significant staining patterns compared with metastatic and nodular melanomas.Primary dermal melanoma appears to be a distinct subtype of melanoma based on the excellent prognosis associated with this case series and others. Additional research focusing on cause, appropriate staging, and outcome of previously identified solitary dermal metastasis is warranted to further delineate this entity.

    View details for Web of Science ID 000188060200013

    View details for PubMedID 14732666

  • Challenge. Epithelioid cell histiocytoma. American Journal of dermatopathology Stewart, D. B., Egbert, B. M., Swetter, S. M. 2003; 25 (5): 430-?

    View details for PubMedID 14501293

  • Malignant melanoma JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Kanzler, M. H., Swetter, S. M. 2003; 48 (5): 780-783

    View details for DOI 10.1067/mjd.2003.284

    View details for Web of Science ID 000182977200018

    View details for PubMedID 12734509

  • Current management of melanoma: Benefits of surgical staging and adjuvant therapy JOURNAL OF SURGICAL ONCOLOGY McMasters, K. M., Swetter, S. M. 2003; 82 (3): 209-216


    Issues regarding appropriate management of stage I to III melanoma are addressed. Accurate surgical staging is critical to identifying patients who can benefit from therapeutic lymph node dissection and adjuvant therapy. Patients with primary tumors > or = 1 mm thick are appropriate candidates for sentinel lymph node biopsy, and node-positive patients benefit from therapeutic lymphadenectomy. Although the overall survival benefit of high-dose interferon has been questioned, the weight of evidence supports the use of adjuvant therapy in patients with stage IIB and III disease.

    View details for DOI 10.1002/jso.10216

    View details for Web of Science ID 000181294400013

    View details for PubMedID 12619066

  • Dermatological perspectives of malignant melanoma SURGICAL CLINICS OF NORTH AMERICA Swetter, S. M. 2003; 83 (1): 77-?


    Early recognition and treatment of thin cutaneous melanoma have contributed to a decreased case-fatality rate over the past 60 years. The only known preventive measure for melanoma is sun protection in childhood, which directly affects the number of melanocytic nevi developing as an adult. Additional melanoma risk factors, clinical features, and malignant potential of precursor lesions are discussed. The four major clinicopathologic subtypes of melanoma are described, with recommendations for appropriate biopsy techniques for suspected melanoma. Nationwide skin cancer screenings by dermatologists and greater public awareness of the warning signs of melanoma have enhanced detection of early melanoma, and promoted chances for cure.

    View details for Web of Science ID 000181917900005

    View details for PubMedID 12691451

  • Increased effectiveness of targeted skin cancer screening in the Veterans Affairs population of Northern California PREVENTIVE MEDICINE Swetter, S. M., Waddell, B. L., Vazquez, B. D., Khosravi, V. S. 2003; 36 (2): 164-171


    Skin cancer screening in populations at increased risk may be more useful than mass screening. We assessed the effectiveness of screening a targeted population in the Veterans Affairs Palo Alto Health Care System (VAPAHCS) for skin cancer/precancer detection and follow-up.We studied the demographics, presumptive diagnoses, and outcome of 374 participants in free screening clinics conducted over a 3-year period in multiple northern California sites. The number of attendees with presumptive actinic keratosis (AK), basal cell carcinoma (BCC), squamous cell carcinoma (SCC), dysplastic nevus (DN), and melanoma was noted.Three hundred sixty-two males and 12 females were screened (mean age 63.4 years); 74% were Caucasian. Two hundred three individuals (54%) had a positive screen including 139 (52%) with presumptive AK, 41 (11%) with BCC, 9 (2%) with SCC, and 14 (4%) with DN versus potential melanoma. One hundred one (50%) of referred individuals were subsequently evaluated by VAPAHCS dermatologists. Biopsy was performed in 34/36 cases (94%), with a positive predictive value of 62% in patients with suspected BCC, 43% for SCC, 37.5% for DN and 12.5% for melanoma.Targeting a predominantly elderly Caucasian population with minimal to no prior dermatologic care yielded high rates of detection for precancers, skin cancer, and atypical nevi, and resulted in an increased percentage of pathologically confirmed nonmelanoma skin cancer, particularly BCC, compared to prior screening studies and population-based cancer registries.

    View details for DOI 10.1016/S0091-7435(02)00027-0

    View details for Web of Science ID 000181261700005

    View details for PubMedID 12590991

  • Effects of biopsy-induced wound healing on residual basal cell and squamous cell carcinomas: rate of tumor regression in excisional specimens JOURNAL OF CUTANEOUS PATHOLOGY Swetter, S. M., Boldrick, J. C., Pierre, P., Wong, P., Egbert, B. M. 2003; 30 (2): 139-146


    Wound healing following a partial biopsy of basal cell (BCC) and squamous cell carcinomas (SCC) may induce tumor regression.Nonmelanoma skin cancer (NMSC) biopsy and re-excision specimens from 1994 to 2001 were reviewed for histologic evidence of scar vs. presence of residual tumor in excision specimens. Regressed and non-regressed tumors were analyzed to assess the influence of anatomic location, biopsy technique (punch vs. shave), histologic subtype of BCC or SCC, time interval between biopsy and excision, and patient age.Nine hundred and ten excisions were performed for transected BCC or SCC, 217 (24%) of which showed scar with no residual tumor. Logistic regression analysis revealed significant differences in the regressed vs. non-regressed subsets. SCCs were more likely to regress than BCCs (40% vs. 20%, respectively, p < 0.00001). Independent of the NMSC type, tumors regressed more often following shave rather than punch biopsy (34% vs. 15%, respectively, p < 0.00001), as did tumors on the trunk and extremities compared with head and neck cases (31% vs. 21%, respectively, p < 0.01).In our series, 24% of NMSCs transected on the initial biopsy showed no residual tumor in the excision specimens, implying that some event in the interval between biopsy and excision may lead to the eradication of residual tumor. The exact mechanism is unclear, but wound healing likely plays an important role.

    View details for Web of Science ID 000181633300008

    View details for PubMedID 12641794

  • Positron emission tomography is superior to computed tomography for metastatic detection in melanoma patients ANNALS OF SURGICAL ONCOLOGY Swetter, S. M., Carroll, L. A., Johnson, D. L., Segall, G. A. 2002; 9 (7): 646-653


    Whole-body positron emission tomography (PET) provides diagnostic information not currently available with traditional imaging and may improve the accuracy of staging melanoma patients.A retrospective cohort review was performed of 104 patients with primary or recurrent melanoma who underwent PET to determine sensitivity/specificity for metastatic detection compared with body computed tomography (CT). One hundred fifty-seven PET and 70 CT scans were analyzed, with a median patient follow-up of 24 months. Metastases were confirmed with positive histology (87.5%) or documented disease progression (12.5%). Fifty-three patients prospectively underwent consecutive studies within a mean 3-week interval for direct comparative analysis.PET demonstrated 84% sensitivity (95% confidence interval [CI],.78 to.89) and 97% specificity (95% CI,.91 to.99), whereas CT showed 58% sensitivity (95% CI,.49 to.66) and 70% specificity (95% CI,.51 to.84). Exclusion of areas not evaluated on CT (head, neck/supraclavicular, extremities) increased CT sensitivity to 69% (95% CI,.59 to.77). Sixty-six consecutive PET and CT scans were performed with 81% and 57% of metastases detected, respectively.PET is more sensitive and specific than CT for detection of melanoma metastasis and should be considered the primary staging study for recurrent disease. PET shows greater ability to detect soft tissue, small-bowel, and lymph node metastasis that do not meet criteria designated as abnormal by CT. PET is superior to CT even when sites not routinely evaluated by CT are excluded from comparative analysis.

    View details for Web of Science ID 000177327500008

    View details for PubMedID 12167578

  • Interstitial mycosis fungoides, a variant of mycosis fungoides resembling granuloma annulare and inflammatory morphea JOURNAL OF CUTANEOUS PATHOLOGY Su, L. D., Kim, Y. H., LeBoit, P. E., Swetter, S. M., Kohler, S. 2002; 29 (3): 135-141


    Interstitial mycosis fungoides (IMF) is a rare variant of mycosis fungoides that resembles the interstitial form of granuloma annulare and inflammatory morphea. IMF has received little attention in the literature.Clinical, histological, immunophenotypical, and genotypical findings of five cases of IMF were reviewed. The histological and immunophenotypical findings were compared with those of eight cases of interstitial granuloma annulare and six cases of inflammatory morphea.Five patients with IMF presented with non-indurated, erythematous macules; ill-defined erythematous plaques with slight scale; and nodules on the trunk and proximal limbs. Two of five patients had a prior diagnosis of mycosis fungoides. Skin biopsies revealed a striking dermal interstitial infiltrate of lymphocytes with rare histiocytes that resembled the interstitial form of granuloma annulare or inflammatory morphea. Epidermotropic lymphocytes were present at least focally in all cases. A band-like lymphocytic infiltrate was observed in two of five cases. In contrast, many plasma cells and histiocytes were observed in cases of inflammatory morphea and interstitial granuloma annulare, respectively. With Movat-pentachrome stains, increased dermal mucin deposition was observed in two of five IMF cases, in all cases of interstitial granuloma annulare, and in one of six cases of inflammatory morphea. There was focal loss of elastic fibers in all cases of inflammatory morphea. Immunohistochemical studies of IMF highlighted a dominant population of T cells (CD3+) in the dermis and epidermis. In contrast, moderate numbers of B cells (CD20+) were admixed with T cells and plasma cells in inflammatory morphea. Almost equal numbers of histiocytes (CD68+) and T cells comprised the infiltrate of interstitial granuloma annulare. In two of five IMF cases, a clonal T-cell population was detected by PCR T-cell gamma gene rearrangement analysis.Mycosis fungoides occasionally presents as an interstitial lymphocytic infiltrate that mimics granuloma annulare and inflammatory morphea. Hematoxylin & eosin (H&E) findings alone can sometimes distinguish the three disorders. Immunophenotyping and genotyping may be helpful in difficult cases.

    View details for Web of Science ID 000175587800002

    View details for PubMedID 11972709

  • Developing indications for the use of sentinel lymph node biopsy and adjuvant high-dose interferon alfa-2b in melanoma ARCHIVES OF DERMATOLOGY Dubois, R. W., Vetter, S. M., Atkins, M., McMasters, K., Halbert, R., Miller, S. J., Shiell, R., Kirkwood, J. 2001; 137 (9): 1217-1224


    To convene a multidisciplinary panel of dermatologists, surgical oncologists, and medical oncologists to formally review available data on the sentinel lymph node (SLN) biopsy procedure and high-dose adjuvant interferon alfa-2b therapy for patients with melanoma and to rate the "appropriateness," "inappropriateness," or "uncertainty" of the procedure and therapy to guide clinical decision making in practice.The panel comprised 13 specialists (4 dermatologists, 4 oncologists, and 5 surgeons) from geographically diverse areas who practiced in community-based settings (n = 8) and academic institutions (n = 5). Participants were chosen based on recommendations from the relevant specialty organizations.A formal literature review was conducted by investigators at Protocare Sciences Inc, Santa Monica, Calif, on the risks and benefits of performing an SLN biopsy in patients with stage I or II melanoma and adjuvant interferon alfa-2b therapy in patients with stage II or III disease. The MEDLINE database was searched from 1966 through July 2000, and supplemental information was obtained from various cancer societies and cancer research groups. Panel participants were queried on additional sources of relevant information. Unpublished, presented data were included in abstract form on 1 recently closed clinical trial.The RAND/UCLA Appropriateness Method was used to review and rate multiple clinical scenarios for the use of SLN biopsy and interferon alfa-2b therapy. The consensus method did not force agreement.The panel rated 104 clinical scenarios and concluded that the SLN biopsy procedure was appropriate for primary melanomas deeper than 1.0 mm and for tumors 1 mm or less when histologic ulceration was present and/or classified as Clark level 4 or higher. The SLN biopsy was deemed inappropriate for nonulcerated Clark level 2 or 3 melanomas 0.75 mm or less in depth and uncertain in tumors 0.76 to 1.0 mm deep unless they were ulcerated or Clark level 4 or higher. Interferon alfa-2b therapy was deemed appropriate for patients with regional nodal and/or in-transit metastasis and for node-negative patients with primary melanomas deeper than 4 mm. The panel considered the use of interferon alfa-2b therapy uncertain in patients with ulcerated intermediate primary tumors (2.01-4.0 mm in depth) and inappropriate for node-negative patients with nonulcerated tumors less than 4.0 mm deep. Specialty-specific ratings were conducted as well.

    View details for Web of Science ID 000170942600011

    View details for PubMedID 11559220

  • The rationale behind the 2002 AJCC Melanoma Staging Committee recommendations The Melanoma Letter Swetter SM, Ross MI 2001; 19 (4): 1-4
  • Characterization of circulating T cells specific for tumor-associated antigens in melanoma patients NATURE MEDICINE Lee, P. P., Yee, C., Savage, P. A., Fong, L., Brockstedt, D., Weber, J. S., Johnson, D., Swetter, S., Thompson, J., Greenberg, P. D., Roederer, M., DAVIS, M. M. 1999; 5 (6): 677-685


    We identified circulating CD8+ T-cell populations specific for the tumor-associated antigens (TAAs) MART-1 (27-35) or tyrosinase (368-376) in six of eleven patients with metastatic melanoma using peptide/HLA-A*0201 tetramers. These TAA-specific populations were of two phenotypically distinct types: one, typical for memory/effector T cells; the other, a previously undescribed phenotype expressing both naive and effector cell markers. This latter type represented more than 2% of the total CD8+ T cells in one patient, permitting detailed phenotypic and functional analysis. Although these cells have many of the hallmarks of effector T cells, they were functionally unresponsive, unable to directly lyse melanoma target cells or produce cytokines in response to mitogens. In contrast, CD8+ T cells from the same patient were able to lyse EBV-pulsed target cells and showed robust allogeneic responses. Thus, the clonally expanded TAA-specific population seems to have been selectively rendered anergic in vivo. Peptide stimulation of the TAA-specific T-cell populations in other patients failed to induce substantial upregulation of CD69 expression, indicating that these cells may also have functional defects, leading to blunted activation responses. These data demonstrate that systemic TAA-specific T-cell responses can develop de novo in cancer patients, but that antigen-specific unresponsiveness may explain why such cells are unable to control tumor growth.

    View details for Web of Science ID 000080823300037

    View details for PubMedID 10371507

  • Hereditary ochronosis: Hyperpigmented skin overlying cartilaginous structures CUTIS Garcia, S. F., Egbert, B., Swetter, S. M. 1999; 63 (6): 337-338


    Hereditary ochronosis, or alkaptonuria, results from deficiency of homogentisic acid oxidase. It is an autosomal recessive condition found in geographically isolated populations. The excess homogentisic acid deposits in collagenous structures, leading to unusual pigmentation of the skin overlying cartilaginous structures, but on occasion pigment is also seen in the sclera, in sweat after oxidation, and classically, in urine when left standing at room temperature. This case report highlights the pathogenesis and expression of this rare disorder.

    View details for Web of Science ID 000080885500009

    View details for PubMedID 10388955

  • Infiltrative basal cell carcinoma occurring in sites of biopsy-proven nodular basal cell carcinoma JOURNAL OF CUTANEOUS PATHOLOGY Swetter, S. M., Yaghmai, D., Egbert, B. M. 1998; 25 (8): 420-425


    Over 200 basal cell carcinomas (BCCs) are biopsied and subsequently excised each year at the Veterans Affairs Palo Alto Health Care System (VAPAHCS). A focal infiltrative pattern developed in the region of the biopsy scar in the re-excision specimens of 20 cases out of approximately 400 BCCs (< 5%) examined histopathologically over a 2-year period. The patient population included predominantly male, elderly Caucasians (mean age 71), and all tumors fulfilled clinical and histologic criteria for nodular BCC at the time of initial punch or shave biopsy. No patient showed recurrence of tumor following simple re-excision with 2-3 mm surgical margins, with a mean follow up of 25.4 months after excisional surgery. These neoplasms had a more benign clinical course, possibly related to scar formation in healing sites of previously biopsied nodular BCC, rather than true aggressive-growth BCC. The authors conclude that a focal infiltrative pattern in a re-excision specimen may occur histologically as a scar-induced pattern which mimics an aggressive-growth BCC, but does not appear to have the same prognosis. We believe this is an important histologic observation, as recognition of biopsy scar changes in an excisional specimen of BCC may help to distinguish it from true aggressive-growth BCC.

    View details for Web of Science ID 000076432400004

    View details for PubMedID 9826167

  • Chronic vulvar ulceration in an immunocompetent woman due to acyclovir-resistant, thymidine kinase-deficient herpes simplex virus JOURNAL OF INFECTIOUS DISEASES Swetter, S. M., HILL, E. L., Kern, E. R., Koelle, D. M., Posavad, C. M., LAWRENCE, W., Safrin, S. 1998; 177 (3): 543-550


    A 34-year-old healthy woman presented with a 15-month history of persistent, nonhealing vulvar ulcerations due to herpes simplex virus (HSV) type 2. Extensive dermatologic workup and serial skin biopsies failed to reveal an underlying vulvar dermatosis or autoimmune bullous disorder. Virologic studies revealed resistance to acyclovir in vitro due to deficiency in thymidine kinase activity. Serum antibody to human immunodeficiency virus was negative on two occasions, separated by 1 year. Immunologic evaluation showed normal HSV-specific proliferative and CD8 cytotoxic T lymphocyte responses as well as normal NK cell function. Vulvar lesions failed to heal in association with trials of topical trifluorothymidine and oral valacyclovir but resolved completely with the application of 1% foscarnet cream. No recurrence of HSV has been observed in 24 months of follow-up to date.

    View details for Web of Science ID 000072159900004

    View details for PubMedID 9498430

  • Dopamine-associated symmetric peripheral gangrene ARCHIVES OF DERMATOLOGY Park, J. Y., KANZLER, M., Swetter, S. M. 1997; 133 (2): 247-249

    View details for Web of Science ID A1997WH06700026

    View details for PubMedID 9041849

  • Increased proportion of aggressive-growth basal cell carcinoma in the Veterans Affairs population of Palo Alto, California JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Wrone, D. A., Swetter, S. M., Egbert, B. M., SMOLLER, B. R., Khavari, P. A. 1996; 35 (6): 907-910


    We have noted a high frequency of aggressive-growth basal cell carcinomas (BCCS) in our patient population. Subtypes observed with increased frequency include morpheaform, infiltrative, and micronodular.Our purpose was to examine the frequency of histologic subtypes of all BCCs seen in the dermatology clinics in the Veterans Affairs Palo Alto Health Care System in an 18-month period.We reviewed 432 consecutive primary BCC biopsy specimens taken from 252 patients.Aggressive-growth BCC was observed in 20.7% of biopsy specimens, including 13.4% morpheaform, 5.7% infiltrative, and 1.6% micronodular subtypes. The mean age of the patient population was 70 years, with a standard deviation of 9.1 years.Our observed percentage of aggressive-growth BCC is substantially higher than in most other large studies. A high frequency of aggressive-growth BCC coupled with the increasing incidence of nonmelanoma skin cancer may have significant implications for future health care resource allocation.

    View details for Web of Science ID A1996VY37700005

    View details for PubMedID 8959949

  • Malignant melanoma from the dermatologic perspective SURGICAL CLINICS OF NORTH AMERICA Swetter, S. M. 1996; 76 (6): 1287-?


    Early recognition and treatment of thin cutaneous melanomas (stages Ia and Ib) have contributed to a decreased case-fatality rate during the past several decades. The only known preventable risk factor for melanoma is sun protection in childhood, which directly affects the number of melanocytic nevi developing in an adult. Additional risk factors, clinical features, and the malignant potential of precursor lesions are discussed. The four major clinicopathologic subtypes of melanoma are described with recommendations for appropriate biopsy techniques for suspected melanoma. Nationwide skin cancer screenings by dermatologists and greater public awareness of the warning signs of melanoma have enhanced detection of early melanoma and have promoted chances for a cure.

    View details for Web of Science ID A1996WA77200006

    View details for PubMedID 8977551

  • Surgical margins for malignant melanoma: Another point of view JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY Kanzler, M. H., Swetter, S. M. 1996; 35 (6): 1014-1015

    View details for Web of Science ID A1996VY37700031

    View details for PubMedID 8959975

  • Cutaneous myiasis following travel to Belize INTERNATIONAL JOURNAL OF DERMATOLOGY Swetter, S. M., Stewart, M. I., SMOLLER, B. R. 1996; 35 (2): 118-120

    View details for Web of Science ID A1996TT73200011

    View details for PubMedID 8850041



    Scleredema is a rare connective disease which must be differentiated from scleroderma in childhood. Scleredema is characterized by thickening of the dermis of the neck, head, and upper trunk. We report a case of scleredema in an 8-year-old boy with coincident streptococcal colonization. The patient report demonstrates many of the common features of scleredema, including an associated streptococcal infection, a relatively benign presentation of illness, and the characteristic mucopolysaccharide intradermal staining on skin biopsy. The literature on scleredema is reviewed, focusing on the disease course, differential diagnosis, and an overview of the proposed three subgroups of scleredema. The association of scleredema to a prior streptococcal infection is explored, and a proposed autoimmune pathophysiology of the disease, as it relates to streptococcal infection, is presented.

    View details for Web of Science ID A1994PM02600006

    View details for PubMedID 7813140



    A 30-year-old immunocompromised man with known pulmonary Mycobacterium chelonae colonization developed a systemic infection with cutaneous manifestations. The eruption consisted of multiple, nontender, subcutaneous nodules on the extremities. A diagnosis of disseminated M. chelonae was made on the basis of recovery of M. chelonae subspecies abscessus from blood and bronchoalveolar lavage fluid and histologic evidence of acid-fast bacilli in a skin biopsy specimen. We believe this is the first reported case of disseminated M. chelonae infection in an immunocompromised host in whom a primary source of the infection was identified.

    View details for Web of Science ID A1993KL57000020

    View details for PubMedID 8436657

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