To the Editor: Janda and colleagues’ survey of skin screening by general practitioners in regional Queensland1 demonstrated that only 20% of participants had undergone a total-body skin examination in the previous 3 years and that examination rates were slightly lower for patients 50 years of age and older. They conclude that those at greatest risk (older people, especially men) will need to be targeted if screening programs are to reduce melanoma mortality.

In the same issue of the Journal, a study by English and colleagues of excisional biopsies of pigmented lesions by Perth GPs showed that the excision rate for patients under the age of 50 years (62%) is nearly twice that for patients over 50 years (38%), and that in the younger cohort this is primarily harvesting benign naevi.2 They conclude by encouraging GPs to increase their suspicion and lower their biopsy threshold in older patients in order to detect more melanomas.

These studies serve to remind us that it is predominantly older people (and especially men) who are at greatest risk of thick (and potentially lethal) melanoma.3 The evidence provided by these studies of mismatch between skin cancer risk and resource allocation to surveillance and excisional surgery might help explain why recent advances in early detection seem to have bypassed elderly men. It is of continuing concern that despite the fact that melanomas are currently diagnosed at an earlier stage when compared with 20 or 30 years ago, the background incidence of thick melanoma has remained stable, both in Australia and around the world.

In a recent study conducted in Victoria,4 we found that thick melanomas (≥ 3 mm) were predominantly nodular melanomas, primarily affecting people over 50 years of age and especially men. This elusive subtype frequently fails to fulfil the “ABCD” (asymmetry, border, colour, diameter) diagnostic criteria in that they are more often uniform in colour, symmetric in shape and predominantly amelanotic.5 A possible aide-mémoire that we have suggested elsewhere for identifying nodular melanoma is the addition of “EFG” (“elevated, firm, growing for more than 1 month”) criteria.6

The observation that nodular melanomas grow quickly, leading to deep invasion within a few months, poses a significant obstacle to the potential success of community-based screening programs.1 It is likely that many nodular melanomas will escape early detection by such programs, as they will evolve significantly in the interval between screening examinations.4,5 It is important that all clinicians recognise this subtype if we hope to reduce melanoma mortality in Australia.