Skin Pharmacol Appl Skin Physiol 2001;14:280–290
Epidemiology of Cutaneous
Melanoma in Germany and Worldwide
Claus Garbe Andreas Blum
Department of Dermatology, University of Tübingen, Germany
Key Words
Melanoma W Epidemiology W Tumor
thickness W Prognosis
Abstract
Rising incidence rates of cutaneous melano-
ma have been observed during the last three
decades. At the beginning of the 1970s 3
cases and in the 1990s 9 cases per 100,000
inhabitants and year were reported by the
Saarland Cancer Registry in Germany. Other
incidence studies from Germany in the 1990s
even reported 10–12 cases per 100,000 inhab-
itants and year, which is more likely to be the
representative melanoma incidence in West-
ern Germany. In a worldwide comparison this
is a medium incidence rate as compared to
clearly higher incidence rates in the United
States (10–20 cases per 100,000 inhabitants
and year) and in Australia (40–60 cases per
100,000 inhabitants and year). In Europe the
highest incidence rates have been reported
from Scandinavia (about 15 cases per 100,000
inhabitants and year) and the lowest from the
© 2001 S. Karger AG, Basel
ABC 1422–2868/01/0145–0280$17.50/0
Fax + 41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/journals/sph
Mediterranean countries (about 5–7 cases per
100,000 inhabitants and year). Mortality rates
likewise increased in Germany between 1970
and 1995 in males from 1.7 to 3.2 cases and in
females from 1.6 to 2.0 cases per 100,000
inhabitants and year. In the 1990s, in Germa-
ny and in many other countries a leveling off
of mortality rates was observed. 48,928 mela-
noma patients have been recorded by the
Central Malignant Melanoma Registry from
the German-speaking countries in the time
period from 1983 to September 2000, and
clinico-epidemiological analysis of cutaneous
melanoma is based on this data material.
While 2/3 of all melanoma patients in Germa-
ny were females in the 1970s, there is now a
more balanced gender distribution with more
than 45% of patients being males. Age distri-
bution does not significantly change during
the last three decades. Most melanomas are
diagnosed in the age group between 50 and
60 years, 22% of all melanomas are diag-
nosed before the 40th year of age. A clear
decrease of Breslow’s tumor thickness was
found from the beginning of the 1980s to the
Claus Garbe, MD
Department of Dermatology, University of Tübingen
Liebermeisterstrasse 25, D–72076 Tübingen (Germany)
Tel. +49 7071 298 7110, Fax +49 7071 29 5187
E-Mail claus.garbe@med.uni-tuebingen.de
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Fig. 1. Age standardized incidence
rates of the Saarland Cancer Regis-
try from 1970 until 1996 (stan-
dardized for the German popula-
tion 1989).
mid-1990s with the median thickness de-
creasing from 1.3 to 0.8 mm. Lower Breslow’s
tumor thickness at first diagnosis of cuta-
neous melanoma has only been reported
from Australia. This development indicates
improved early recognition of cutaneous
melanoma which is presently the main factor
for a more favorable prognosis.
Copyright © 2001 S. Karger AG, Basel
Introduction
Cutaneous melanoma has shown increas-
ing incidence during the last decades and has
developed from a very rare disease entity to a
cancer with growing importance from the
medical point of view. Cutaneous melanoma
is a skin cancer mainly developing in Cauca-
sian populations, whereas its incidence re-
mains very low in the darker pigmented popu-
lations of African or Asian origin. This in-
crease of melanoma incidence is related to
changing attitudes of leisure time behavior
and of sun exposure. Increasing incidences
were mainly reported from industrial coun-
tries with Caucasian populations with the
highest incidence rates in Australia and the
southern states of the USA. Incidence rates in
Epidemiology of Cutaneous Melanoma
the European countries were found to be
clearly lower. In the following, recent develop-
ments of melanoma epidemiology in Germa-
ny and in Caucasian populations worldwide
are summarized.
Incidence
Cutaneous melanoma belongs in Germany
with 1.5–2% of all malignant neoplasias not
to the frequent cancers, but an increasing inci-
dence has been reported during the last de-
cades [1–3]. Data of the Saarland Cancer
Registry show a clear increase of incidence
rates since the beginning of the 1970s from
about 3 cases per 100,000 inhabitants and
year to 8–9 cases in the mid-1990s (fig. 1).
Already in the mid-1980s higher incidence
rates have been reported from regional areas
in Germany. Between 10 and 12 cases per
100,000 inhabitants and years were registered
in Central Hesse and between 8 and 10 cases
per 100,000 inhabitants and year in West Ber-
lin [4, 5]. Probably, incidence rates in West-
ern Germany were somewhat higher than the
data from the Saarland Cancer Registry sug-
gest and were more likely to reach 10–12 cases
per 100,000 inhabitants and year in the mid-
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1990s. In Germany, presently about 10,000
new cases of cutaneous melanoma are ex-
pected to be diagnosed every year.
In Europe the highest incidence rates have
been reported from Scandinavia where up to
15 cases per 100,000 inhabitants and year
have been registered [6–8]. The figures from
Germany are representative for middle Eu-
rope and similar incidence rates have been
registered in England, Scotland and Italy [9–
11]. Lower incidence rates where found in the
Mediterranean countries. Therefore, in Eu-
rope we see a gradient in incidence rates with
the highest rates in the northern and dropping
incidence rates towards the southern coun-
tries. This has been explained by the more
intensively pigmented complexion of the Eu-
ropean populations living in the Mediterra-
nean countries and by the very fair com-
plexion of the northern European populations
offering less protection against UV radiation.
In the USA, the incidence of cutaneous
melanoma reached the magnitude of 10–20
cases per 100,000 inhabitants and years in the
1980s [6, 12–14]. Much higher incidence rates
have been reported from Australia. At the end
of the 1980s an average incidence rate of 30
cases per 100,000 inhabitants and year for
males and 24 cases for females has been calcu-
lated in Australia [15]. Data for West Austra-
lia showed these magnitude already for the
early 1980s and even higher incidence rates
have been reported from Queensland with 43
cases for females and 56 cases for males [16,
17]. Similar incidence rates were registered in
South Wales in Australia with 43 cases for
females and 53 cases for males per 100,000
inhabitants and year [18]. Cutaneous melano-
ma developed into one of the most frequent
cancers in Australia. Altogether, there is still a
further increase in incidence rates in Austra-
lia, but in the younger birth cohorts stabiliza-
tion of incidence rates can be seen and even a
slight decrease has been found [19].
282 Skin Pharmacol Appl Skin Physiol
2001;14:280–290
Mortality
Mortality rates of cutaneous melanoma are
far higher than mortality rates for all other
skin cancers together. The analysis of data of
the official mortality statistics for Western
Germany showed an increase of case numbers
from about 900 per year at the beginning of
the 1970s to about 1,600 cases in the mid-
1990s. Likewise, age-standardized mortality
rates in Western Germany (standardized for
the German population of 1989) were increas-
ing between 1970 and 1995 for males from 2.2
to 3.0 cases and for females from 1.6 to 2.0
cases for 100,000 inhabitants and years
(fig. 2). The increase in incidence rates and its
absolute numbers were found to be clearly
higher in males than in females. This is also
true for Eastern Germany, where data were
reported from the 1970s and 1980s [20].
Mortality rates in Switzerland and Scandi-
navia have been reported to be higher than in
Germany and for these countries likewise an
increase in mortality rates was registered [21,
22]. Increasing mortality rates have also been
found in the USA where an annual increase in
incidence rates of 2% has been reported [23].
An analysis of birth cohorts showed a chang-
ing trend with a stabilization of mortality
rates particularly in males born after the
1950s and in females born after the 1930s
[24]. In Australia, a clear increase in mortality
rates has been observed until the mid-1980s
which developed on a higher level as com-
pared to Europe and the USA [25]. The an-
nual increase was reported to be 2.5% in
males and 1.1% in females in Australia. Since
1985, the development of a plateau in mortal-
ity rates has been observed [19].
Thus, similar trends were observed in Eu-
rope, the USA and Australia: Clear increases
in mortality rates were particularly found un-
til the mid-1980s, thereafter in different geo-
graphic areas slowing down and reaching a
Garbe/Blum
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Fig. 2. Age standardized mortality
rates reported by the Official Ger-
man Mortality Statistics 1968–
1997 (standardized for the German
population 1989).
plateau phase. Increases in mortality rates
have been less distinct as compared to inci-
dence rates. Probably, improvement in the
early detection of melanoma with more favor-
able prognosis have contributed to slow down
the mortality rates at a time point when still
clearly increasing incidence rates have been
registered.
Clinical Epidemiology
The present data of the clinical epidemiol-
ogy of cutaneous melanoma derived from the
Central Malignant Melanoma Registry of the
German Dermatological Society to which
more than 60 Departments of Dermatology
contributed within the German-speaking
countries [1]. From 1983 to September 2000,
48,928 cutaneous melanomas have been re-
gistered within this multicenter project. In
Germany, about half of all melanoma cases
are registered by the Central Malignant Mela-
noma Registry and the data are fairly repre-
sentative for the development of the epidemi-
ological development of cutaneous melano-
ma. The Central Malignant Melanoma Regis-
try has been initiated by C.E. Orfanos and C.
Garbe in 1983 and has been continuously
Epidemiology of Cutaneous Melanoma
working until today, presently registering
about 5,000 new melanomas per year.
Gender and Age
The percentage of females among all mela-
noma patients was more than 60% during the
1970s and 1980s in Germany, until the 1990s
an increasing percentage of males has been
observed with a nearly balanced proportion
between males and females at the end of the
1990s [26, 27]. In the mid-1990s, the percent-
age of males exceeded 45%. In the worldwide
comparison, a higher percentage of females
has been reported from areas with low mela-
noma incidence like England, whereas the
gender relation is more balanced in countries
with higher incidence rates [10, 28]. In Aus-
tralia where the highest incidence rates have
been found the percentage of males exceeds
that of females [15–17].
Based on the data of the Central Malignant
Melanoma Registry most melanoma cases
were diagnosed in the middle of life [3, 29].
The highest percentage of diagnoses is made
between the 50th and 60th year of age (23%).
More than 40% of all diagnoses are already
made before the 50th year of age and 22% are
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Fig. 3. Age distribution at the time
of first diagnosis reported by the
Central Malignant Melanoma Re-
gistry 1983–2000.

Table 1. Clinico-pathologic subtypes of cutaneous melanoma and median

age at time of diagnosis (Data of the Central Malignant Melanoma Regis-
try of the German Dermatological Society, 48,928 cases, 1983–2000)

Type Percentage Median

age, years

Superficial spreading melanoma 57.4 51

Nodular melanoma 21.4 56
Lentigo-maligna melanoma 8.8 68
Acral lentiginous melanoma 4.0 63
Unclassified melanoma 3.5 54
Others 4.9 54

already diagnosed before completion of the
40th year of age (fig. 3). Based on the mortali-
ty statistics of the USA, a loss of 17 life years
has been calculated for every death case
caused by cutaneous melanoma [30].
The age at time of diagnosis is nearly the
same in males and females. However, there
was a clear variation of age according to the
different histologic subtypes of cutaneous
melanoma. Superficial spreading melanoma
was diagnosed at the earliest age of 51 years
(median age), followed by nodular melanoma
with a median age of 56 years. Lentigo-malig-
na melanoma is diagnosed clearly later at a
median age of 68 years.
Histological Subtypes
In the data of the Central Malignant Mela-
noma Registry 57.4% of all melanomas are
superficial spreading melanomas (table 1).
The second most common tumor subtype is
nodular melanoma with a percentage of

284 Skin Pharmacol Appl Skin Physiol Garbe/Blum

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 Table 2. Anatomical localization of cutaneous melanomas and median age at first diagnosis
(Data of the Central Malignant Melanoma Registry of the German Dermatological Society,
48,928 cases, 1983–2000)

Anatomical Male Female

localization
percentage median age percentage median age

Face 8.1 65 10.0 69

Scalp 4.6 61 1.9 60
Neck 2.2 56 1.8 54
Breast 12.4 53 4.4 45
Back 38.1 54 14.8 48
Lower abdomen 3.5 52 2.6 46
Buttock 1.0 52 1.4 44
Genito-anal region 0.3 56 0.7 61
Upper arms 7.7 53 11.9 55
Lower arms 3.2 53 5.3 56
Hands 0.9 58 1.1 64
Thighs 6.3 47 10.2 44
Lower legs 6.2 50 25.4 54
Feet 4.0 58 7.2 58
Unknown primary 1.3 54 0.8 57
Mucosal 0.2 64 0.2 64
Total 100 54 100 53

21.4%, followed by lentigo-maligna melano- likewise observed in other industrialized na-

ma with 8.8% and acral lentiginous melano-
ma with 4.0%. A similar distribution is re-
ported in an incidence analysis from the USA
[31].
Anatomical Localization
The anatomical localization of cutaneous
melanoma is different for both genders. In
males most melanomas are diagnosed on the
upper trunk, whereas in females most melano-
mas are found on the lower extremities. More
than 40% of all melanomas occur in these
anatomical regions. Second most frequent in
males are melanomas on the lower extremities
and in females on the upper trunk. This is fol-
lowed by the head and neck region (table 2).
This pattern of anatomical distribution is
tions with Caucasian populations. Similar
distributions have been reported from Swit-
zerland, from Northern America and from
Australia [32–34]. Anatomical distribution of
cutaneous melanoma matched well with ana-
tomical distribution of melanocytic nevi ac-
cording to gender [35–37]. Other explana-
tions of anatomical distribution like melano-
cyte density or the localization specific prone-
ness for malignant transformation have like-
wise been discussed [38].
Tumor Thickness
Breslow’s vertical tumor thickness is the
most important prognostic factor in primary
melanoma. Thus, vertical tumor thickness at
the time of melanoma diagnosis is the most

Epidemiology of Cutaneous Melanoma Skin Pharmacol Appl Skin Physiol 285

2001;14:280–290
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Fig. 4. Mean and median values of
Breslow’s tumor thickness at first
diagnosis of cutaneous melanoma
reported by the Central Malignant
Melanoma Registry 1984–2000.
important indicator for the evaluation of early
melanoma recognition. In Western Germany,
a clear decrease of tumor thickness was recog-
nizable in the eighties. The average tumor
thickness dropped from 2 to 1.5 mm and the
median tumor thickness from 1.3 to 0.8 mm
(fig. 4). An analysis of this development dur-
ing the 1990s still revealed a slightly recogniz-
able decrease of tumor thickness. In Eastern
Germany, a similar trend of decreasing tumor
thickness was observed with initial higher tu-
mor thickness as compared to Western Ger-
many. In Eastern Germany the trend to de-
creasing tumor thickness continued likewise
during the 1990s. However, the average tu-
mor thickness values were found to be higher
in Eastern Germany as compared to Western
Germany until the mid-1990s.
A clear decrease of tumor thickness at first
diagnosis was also reported from other coun-
tries. Between 1960 and 1990 tumor thickness
decreased in Australia from a median of 2.5 to
1.1 mm and in Alabama from 3.3 to 1.4 mm
[39]. Similar developments have been re-
ported from Great Britain, Italy and Scandi-
navia with clearly decreasing tumor thickness
at first diagnosis [6, 10, 40, 41]. This develop-
ment has been interpreted that the rapid de-
crease in melanoma incidence is mainly due
286 Skin Pharmacol Appl Skin Physiol
2001;14:280–290
to an increase in the frequency of the type of
non-metastasizing melanoma [42]. In fact, cu-
taneous melanoma is increasingly diagnosed
in its horizontal growth phase having not yet
developed the capacity for metastasis. This
has most frequently been observed in Austra-
lia. In this country, the lowest median tumor
thickness at first diagnosis has been reported.
In Western Australia median tumor thickness
dropped from 1.9 to 0.77 mm from 1975/76
to 1980/81 [43]. Similar values have in Ger-
many only been reported since the mid-1990s
in its western part.
Tumor Spread and Prognostic
Factors
In the data of the Central Malignant Mela-
noma Registry, 90% of males and 93% of
females were diagnosed with primary cuta-
neous melanoma alone without recognizable
metastases. In 8% of males and 6% of females
loco-regional metastasis was present and in
1.6% of males and 1.1% of females already
distant metastasis was present at first diagno-
sis (table 3). Unfortunately, comparable eval-
uations of the tumor spread at first diagnosis
have not been reported from larger collectives
Garbe/Blum
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in other countries. In the western industrial-
ized countries, however, cutaneous melano-
mas are diagnosed mainly in the stage of the
primary tumor. This is the reason why numer-
ous studies have been performed on prognos-
tic factors in primary cutaneous melanoma. A
study on prognostic factors performed in
more than 5,000 patients from 4 Departments
of Dermatology in Germany identified Bres-
low’s tumor thickness, Clark’s level of inva-
sion, gender, anatomical localization, histo-
logical subtype and age as independent prog-
nostic factors [44]. In this study, ulceration
has not been included into the analysis.
The most important prognostic factor in
primary melanoma is Breslow’s tumor thick-
ness. With increasing tumor thickness until a
magnitude of 6 mm a linear increase of the
risk of death is observed [45]. Recent evalua-
tions of the Central Malignant Melanoma
Registry showed that ulceration of the prima-
ry melanoma is the second most important
prognostic factor. Ulceration is defined as ab-
sence of the epidermis covering the tumor in
the histological slide. The American Joint
Committee on Cancer (AJCC) suggested to
include ulceration into the TNM staging clas-
sification of primary melanoma [39]. Clark’s
level of invasion is seemingly only relevant for
classification of thin tumors particularly with
the difference of level of invasion II versus 6
III, the further classification in levels of inva-
sion III, IV, V does not gain statistical signifi-
cance when tumor thickness is taken into con-
sideration [45]. Gender is a significant prog-
nostic factor with a clearly more favorable
prognosis for females than for males even if
other prognostic factors like tumor thickness
are in the same range. Anatomical localiza-
tion is another highly significant prognostic
factor with the highest differences for dicho-
tomic classification taking together localiza-
tion with high and low risk of metastasis [46].
Based on the data material of the Central
Epidemiology of Cutaneous Melanoma
Table 3. Tumor spread (clinical TNM stage) at first
diagnosis of cutaneous melanoma (Data of the Central
Malignant Melanoma Registry of the German Derma-
tological Society, 48,928 cases, 1983–2000)
Tumor stage Males Females
% %
Primary tumor 90.3 93.2
Satellite and intransit metastasis 3.1 3.0
Regional lymph node metastasis 5.1 2.7
Distant metastasis 1.6 1.1
Malignant Melanoma Registry TANS local-
ization have been suggested to be the high risk
localization comprising upper trunk, upper
arms, neck and scalp. The histological sub-
type gained only marginal statistical signifi-
cance [44]. Age has been likewise identified as
a prognostic factor and older persons were
found to have a more unfavorable prognosis
[44, 47]. Taking all these factors into consider-
ation, an individual estimation of the progno-
sis can be calculated by a mathematical model
according to the data of an individual patient
(table 4) [44].
Conclusions
Rising incidence rates of cutaneous mela-
noma are observed in Germany and likewise
in other industrial countries with Caucasian
populations. In Germany and in most other
countries there is still a trend towards a fur-
ther increase of the incidence rates. In the
countries with the highest incidence rates a
trend towards leveling-off of incidence rates
has been observed in younger birth cohorts.
The increase in mortality rates is less distinct
as compared to incidence rates. Since the
1990s a plateau phase has been reached in
many countries. The main factor for stabiliza-
tion of mortality rates simultaneously to fur-
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Table 4. Prognostic factors in
primary cutaneous melanomas Prognostic factor p value Relative 95% CI
based on an analysis of follow-up risk of death
data from 5,093 patients with
primary melanoma [44] Breslow’s tumor thickness
1 1 mm vs. ^1.00 mm ! 0.0001 2.6 1.8; 3.8
1 2 mm vs. 1.01–2.00 mm ! 0.0001 2.7 2.2; 3.4
1 4 mm vs. 2.01–4.00 mm ! 0.0001 1.6 1.4; 2.0
Clark’s level of invasion 6III vs. II ! 0.0001 4.0 2.0; 8.1
Gender male vs. female ! 0.0001 1.5 1.3; 1.8
Anatomical localization
TANS vs. non-TANS ! 0.0001 1.6 1.4; 1.8
Histologic subtypes
ALM vs. SSM/LMM ! 0.01 1.7 1.2; 2.3
NM vs. SSM/LMM ! 0.05 1.2 1.0; 1.4
Age1 1 60 years vs. ^60 years ! 0.05 1.2 1.0; 1.4

TANS = Upper Trunk, upper Arms, Neck and Scalp; SSM = superficial
spreading melanoma; NM = nodular melanoma; LMM = lentigo-maligna
melanoma; ALM = acral lentiginous melanoma.
1 Classification of age: ^30; 31 – 60; 1 60 years.

ther increasing incidence rates is due to earlier
recognition of cutaneous melanoma with
many tumors diagnosed at a time point when
the potential for the development of a metas-
tasis had still not been gained. Earlier recogni-
tion of melanoma is the main factor for the
improvement of the prognosis in cutaneous
melanoma.
All efforts to improve primary prevention,
however, and keeping people out of the sun
have not yet resulted in decreasing frequen-
cies of this highly malignant tumor. Improve-
ment of the public awareness of melanoma
and skin cancer is still a major goal for derma-
tologists and public health workers.

References

1 Garbe C, Bertz J, Orfanos CE: Ma-
lignes Melanom: Zunahme von Inzi-
denz und Mortalität in der Bundes-
republik Deutschland. Z Hautkr
1986;61:1751–1764.
2 Garbe C, Orfanos CE: Epidemiolo-
gie des malignen Melanoms in der
Bundesrepublik Deutschland im in-
ternationalen Vergleich. Onkologie
1989;12:253–262.
3 Garbe C, Orfanos CE: Epidemiolo-
gy of malignant melanoma in central
Europe: Risk factors and prognostic
predictors. Results of the Central
Malignant Melanoma Registry of
the German Dermatologicalal Soci-
ety. Pigment Cell Res Suppl 1992;2:
285–294.
4 Rauh M, Paul E, Illig L: Incidence of
malignant melanoma in Central
Hesse, Germany. Anticancer Res
1987;7:447–448.
5 Garbe C, Thiess S, Nürnberger F,
Ehlers G, Albrecht G, Lindlar F,
Bertz J: Incidence and mortality of
malignant melanoma in Berlin
(West) from 1980 to 1986. Acta
Derm Venereol 1991;71:506–511.
6 Armstrong BK, Kricker A: Cuta-
neous melanoma. Cancer Surv
1994;19–20:219–240.
7 Osterlind A, Hou Jensen K, Moller
Jensen O: Incidence of cutaneous
malignant melanoma in Denmark
1978–1982. Anatomic site distribu-
tion, histologic types, and compari-
son with non-melanoma skin can-
cer. Br J Cancer 1988;58:385–391.
8 Thorn M, Bergstrom R, Adami HO,
Ringborg U: Trends in the incidence
of malignant melanoma in Sweden,
by anatomic site, 1960–1984. Am J
Epidemiol 1990;132:1066–1077.

288 Skin Pharmacol Appl Skin Physiol Garbe/Blum

2001;14:280–290
141.213.236.110 - 7/27/2013 12:34:32 PM
Univ. of Michigan, Taubman Med.Lib.
Downloaded by:
 9 Carli P, Borgognoni L, Biggeri A,
Carli S, Reali UM, Giannotti B: In-
cidence of cutaneous melanoma in
the centre of Italy: Anatomic site
distribution, histologic types and
thickness of tumour invasion in a
registry-based study. Melanoma Res
1994;4:385–390.
10 MacKie R, Hunter JA, Aitchison
TC, Hole D, Mclaren K, Rankin R,
Blessing K, Evans AT, Hutcheon
AW, Jones DH: Cutaneous malig-
nant melanoma, Scotland, 1979–89.
The Scottish Melanoma Group.
Lancet 1992;339:971–975.
11 MacKie RM, Watt D, Doherty V,
Aitchison T: Malignant melanoma
occurring in those aged under 30 in
the west of Scotland 1979–1986: A
study of incidence, clinical features,
pathological features and survival.
Br J Dermatol 1991;124:560–564.
12 Lee JA, Scotto J: Melanoma: Linked
temporal and latitude changes in the
United States. Cancer Causes Con-
trol 1993;4:413–418.
13 Lyon JL, Gardner K, Gress RE:
Cancer incidence among Mormons
and non-Mormons in Utah (USA)
1971–85. Cancer Causes Control
1994;5:149–156.
14 Newell GR, Sider JG, Bergfelt L,
Kripke ML: Incidence of cutaneous
melanoma in the United States by
histology with special reference to
the face. Cancer Res 1988;48:5036–
5041.
15 Jelfs PL, Giles G, Shugg D, Coates
M, Durling G, Fitzgerald P, Ring I:
Cutaneous malignant melanoma in
Australia, 1989. Med J Aust 1994;
161:182–187.
16 English DR, Heenan PJ, Holman
CD, Armstrong BK, Blackwell JB,
Kelsall GR, Matz LR, Singh A, ten
Seldam RE: Melanoma in Western
Australia 1975–76 to 1980–81:
Trends in demographic and patho-
logical characteristics. Int J Cancer
1986;37:209–215.
17 MacLennan R, Green AC, McLeod
GR, Martin NG: Increasing inci-
dence of cutaneous melanoma in
Queensland, Australia. J Natl Can-
cer Inst 1992;84:1427–1432.
18 Burton RC, Coates MS, Hersey P,
Roberts G, Chetty MP, Chen S,
Hayes MH, Howe CG, Armstrong
BK: An analysis of a melanoma epi-
demic. Int J Cancer 1993;55:765–
770.
Epidemiology of Cutaneous Melanoma
19 Giles GG, Armstrong BK, Burton
RC, Staples MP, Thursfield VJ: Has
mortality from melanoma stopped
rising in Australia? Analysis of
trends between 1931 and 1994. BMJ
1996;312:1121–1125.
20 Jung HD: Epidemiologie des mali-
gnen Melanoms in der Deutschen
Demokratischen Republik. II. Mit-
teilung. Mortalität, Verhältnis Mor-
talität/Inzidenz, Überlebensraten,
Verlust an Arbeitsjahren. Dermatol
Monatsschr 1988;174:73–79.
21 Angst E, Bisig B, Tschopp A, Sigg C,
Schuler G, Gutzwiller F, Schnyder
UW: Die Melanommortalität in der
Schweiz 1970–1986. Schweiz Med
Wochenschr 1989;119:1591–1598.
22 Lindegard B: Mortality and fatality
of cutaneous malignant melanoma
in Sweden, 1982–1986. Biomed
Pharmacother 1990;44:495–501.
23 Anonymus: Deaths from melanoma
– United States, 1973–1992. Morb
Mortal Wkly Rep 1995;44:337,
343–347.
24 Roush GC, McKay L, Holford TR:
A reversal in the long-term increase
in deaths attributable to malignant
melanoma. Cancer 1992;69:1714–
1720.
25 Jones ME, Shugg D, Dwyer T,
Young B, Bonett A: Interstate differ-
ences in incidence and mortality
from melanoma: A re-examination
of the latitudinal gradient. Med J
Aust 1992;157:373–378.
26 Garbe C, Büttner P, Ellwanger U,
Bröcker EB, Jung EG, Orfanos CE,
Rassner G, Wolff HH: Das Zentral-
register Malignes Melanom der
Deutschen Dermatologischen Ge-
sellschaft in den Jahren 1983–1993.
Epidemiologische Entwicklungen
und aktuelle therapeutische Versor-
gung des malignen Melanoms der
Haut. Hautarzt 1995;46:683–692.
27 Garbe C, Wiebelt H, Orfanos CE:
Change of epidemiological charac-
teristics of malignant melanoma
during the years 1962–1972 and
1983–1986 in the Federal Republic
of Germany. Dermatologica 1989;
178:131–135.
28 Roberts DL: Malignant melanoma
in West Glamorgan – Increasing in-
cidence and improving prognosis,
1986–88. Clin Exp Dermatol 1990;
15:406–409.
Skin Pharmacol Appl Skin Physiol
2001;14:280–290
29 Garbe C, Büttner P, Ellwanger U,
Bröcker EB, Jung EG, Orfanos CE,
Rassner G, Wolff HH: Das Zentral-
register Malignes Melanom der
Deutschen Dermatologischen Ge-
sellschaft in den Jahren 1983–1993.
Epidemiologische Entwicklungen
und aktuelle therapeutische Versor-
gung des malignen Melanoms der
Haut. Hautarzt 1995;46:683–692.
30 Albert VA, Koh HK, Geller AC,
Miller DR, Prout MN, Lew RA:
Years of potential life lost: Another
indicator of the impact of cutaneous
malignant melanoma on society. J
Am Acad Dermatol 1990;23:308–
310.
31 Newell GR, Sider JG, Bergfelt L,
Kripke ML: Incidence of cutaneous
melanoma in the United States by
histology with special reference to
the face. Cancer Res 1988;48:5036–
5041.
32 Elwood JM, Gallagher RP: Site dis-
tribution of malignant melanoma.
Can Med Assoc J 1983;128:1400–
1404.
33 Green A, MacLennan R, Youl P,
Martin N: Site distribution of cuta-
neous melanoma in Queensland. Int
J Cancer 1993;53:232–236.
34 Levi F, La Vecchia C, Te VC, Mez-
zanotte G: Descriptive epidemiolo-
gy of skin cancer in the Swiss Can-
ton of Vaud. Int J Cancer 1988;42:
811–816.
35 Gallagher RP, McLean DI, Yang
CP, Coldman AJ, Silver HK, Spinel-
li JJ, Beagrie M: Anatomic distribu-
tion of acquired melanocytic nevi in
white children. A comparison with
melanoma: The Vancouver Mole
Study. Arch Dermatol 1990;126:
466–471.
36 Kelly JW, Holly EA, Shpall SN, Ahn
DK: The distribution of melanocyt-
ic naevi in melanoma patients and
control subjects. Austr J Dermatol
1989;30:1–8.
37 Stierner U, Augustsson A, Rosdahl
I, Suurkula M: Regional distribution
of common and dysplastic naevi in
relation to melanoma site and sun
exposure: A case-control study. Mel-
anoma Res 1992;1:367–375.
38 Green A: A theory of site distribu-
tion of melanomas: Queensland,
Australia. Cancer Causes Control
1992;3:513–516.
289
141.213.236.110 - 7/27/2013 12:34:32 PM
Univ. of Michigan, Taubman Med.Lib.
Downloaded by:
39 Balch CM, Buzaid AC, Atkins MB,
Cascinelli N, Coit DG, Fleming ID,
Houghton A, Kirkwood JM, Mihm
MF, Morton DL, Reintgen D, Ross
MI, Sober A, Soong SJ, Thompson
JA, Thompson JF, Gershenwald JE,
McMasters KM: A new American
Joint Committee on Cancer staging
system for cutaneous melanoma.
Cancer 2000;88:1484–1491.
40 Cavalieri R, Macchini V, Mostac-
cioli S, Sonego G, Ferranti G, Coro-
na R, Fucci M, Marzolini F, Ros-
mini F, Pasquini P: Time trends in
features of cutaneous melanoma at
diagnosis: Central-south Italy,
1962–1991. Ann Ist Super Sanità
1993;29:469–472.
41 Thorn M, Ponten F, Bergstrom R,
Sparen P, Adami HO: Trends in tu-
mour characteristics and survival of
malignant melanoma 1960–84: A
population-based study in Sweden.
Br J Cancer 1994;70:743–748.
290 Skin Pharmacol Appl Skin Physiol
2001;14:280–290
42 Burton RC, Armstrong BK: Current
melanoma epidemic: A nonmetasta-
sizing form of melanoma? World J
Surg 1995;19:330–333.
43 Heenan PJ, English DR, Holman
CD, Armstrong BK: Survival among
patients with clinical stage I cuta-
neous malignant melanoma diag-
nosed in Western Australia in 1975/
1976 and 1980/1981. Cancer 1991;
68:2079–2087.
44 Garbe C, Büttner P, Bertz J, Burg G,
d’Hoedt B, Drepper H, Guggen-
moos Holzmann I, Lechner W, Lip-
pold A, Orfanos CE, et al: Primary
cutaneous melanoma: Identification
of prognostic groups and estimation
of individual prognosis for 5093 pa-
tients. Cancer 1995;75:2484–2491.
45 Büttner P, Garbe C, Bertz J, Burg G,
d’Hoedt B, Drepper H, Guggen-
moos Holzmann I, Lechner W, Lip-
pold A, Orfanos CE, et al: Primary
cutaneous melanoma. Optimized
cutoff points of tumor thickness and
importance of Clark’s level for prog-
nostic classification. Cancer 1995;
75:2499–2506.
46 Garbe C, Büttner P, Bertz J, Burg G,
d’Hoedt B, Drepper H, Guggen-
moos Holzmann I, Lechner W, Lip-
pold A, Orfanos CE, et al: Primary
cutaneous melanoma: Prognostic
classification of anatomic location.
Cancer 1995;75:2492–2498.
47 Austin PF, Cruse CW, Lyman G,
Schroer K, Glass F, Reintgen DS:
Age as a prognostic factor in the ma-
lignant melanoma population. Ann
Surg Oncol 1994;1:487–494.
Garbe/Blum
141.213.236.110 - 7/27/2013 12:34:32 PM
Univ. of Michigan, Taubman Med.Lib.
Downloaded by: