Malignant melanoma is a relatively common malignancy in the United States and is responsible for the majority of skin cancer deaths. Approximately 70,230 cases of melanoma were diagnosed, and approximately 8,790 people died from melanoma in the United States in 2011 [
We identified patients using the SEER 9 registries, which encompass nine geographic regions in the United States (Atlanta, Connecticut, Detroit, Hawaii, Iowa, New Mexico, San Francisco-Oakland, Seattle-Puget Sound, and Utah) and include approximately 9.5% of the US population. The SEER 9 population accurately represents the US population in most regards [
All data was obtained using SEER*Stat version 7.0.9, and statistical analysis was performed with SPSS Version 19 (IBM Corporation, Armonk, NY, USA), and Joinpoint Regression Program version 3.5.3 [
We identified 452 cases of MMHN in the SEER 9 registry between 1987 and 2009. Of these patients, 237 (52.4%) were female, and 215 (47.6%) were male. The cohort included 383 white patients (84.7%), 24 black patients (5.3%), 44 patients (9.7%) classified as “other” (including American Indian/Alaska Native and Asian/Pacific Islander), and one patient (0.2%) with unknown race. By comparison, the racial distribution of the general US population is 75.1% white, 12.3% black, and 12.5% other races (including American Indian/Alaska Native, Asian, Hawaiian/Pacific Islander, other race, and two or more races) [
Characteristics of patients with mucosal melanoma of the head and neck identified in SEER 9 from 1987 to 2009.
# of patients | % of total | |
---|---|---|
Sex | ||
Male | 215 | 47.6% |
Female | 237 | 52.4% |
Race | ||
White | 383 | 84.7% |
Black | 24 | 5.3% |
Other* | 44 | 9.7% |
Unknown | 1 | 0.2% |
Age | ||
0–19 | 0 | 0.0% |
20–39 | 22 | 4.9% |
40–54 | 50 | 11.1% |
55–69 | 125 | 27.7% |
70–84 | 190 | 42.0% |
85+ | 65 | 14.4% |
Site | ||
Nasal cavity | 237 | 52.4% |
Paranasal sinuses | 89 | 19.7% |
Middle ear | 2 | 0.4% |
|
328 | 72.6% |
Oral cavity | 78 | 17.3% |
Oropharynx | 13 | 2.9% |
Nasopharynx | 20 | 4.4% |
Parotid gland | 13 | 2.9% |
|
124 | 27.4% |
| ||
Total | 452 |
*Includes American Indian/Alaska Native and Asian/Pacific Islander.
The age-adjusted incidence of MMHN in the United States has increased over time. From 1987 to 2009, the total PC in the age-adjusted IR for all patients with MMHN was 50.0%, and the APC was 2.4% (
Age-adjusted incidence rates (in cases per million persons per year) with Joinpoint regression trendlines for all patients with MMHN in SEER 9 registries from 1987 to 2009. The APC over this time period was 2.4%.
Details of the total PC and APC in age-adjusted IRs for MMHN by subgroup from 1987 to 2009 are shown in Table
Total percent change (PC) and annual percent change (APC) for subgroups of patients with MMHN identified in SEER 9 registries from 1987 to 2009.
PC (%) | APC (%) |
|
|
---|---|---|---|
Site | |||
Sinonasal | 135.3 | 2.7 | <0.01 |
Nasal cavity | 102.9 | 2.7 | <0.01 |
Paranasal sinuses | 286.6 | 2.3 | 0.19 |
Non-Sinonasal | −40.3 | 1.1 | 0.40 |
Sex | |||
Male | 35.2 | 1.0 | 0.30 |
Female | 45.5 | 3.4 | <0.01 |
Age | |||
20–54 | −42.1 | — | — |
55–84 | 184.4 | 2.9 | <0.01 |
85+ | −34.4 | — | — |
Sex and Race | |||
White male | 12.6 | 0.6 | 0.52 |
White female | 25.6 | 3.4 | <0.01 |
White Females by Age | |||
Age 20–54 | −80.2 | — | — |
Age 55–84 | 306.3 | 5.1 | <0.01 |
Age 85+ | −44.1 | — | — |
Blank fields indicate that the statistic could not be calculated due to insufficient patient numbers in the respective subgroup.
‡
Age-adjusted incidence rates (in cases per million persons per year) with Joinpoint regression trendline for patients with melanoma of the nasal cavity in SEER 9 registries from 1987 to 2009. The APC over this time period was 2.7%.
There were also differences in age-adjusted IR trends between various age groups. For patients of ages 55 to 84 there was a significant trend demonstrating higher age-adjusted IRs over time, with a total PC of 184.4% and an APC of 2.9% from 1987 to 2009. For patients ages 20–54 and ≥85, there were insufficient patient numbers to determine an APC; however, the PC in age-adjusted IRs between 1987 and 2009 for these subgroups were −42.1% and −34.4%, respectively. The specific subset of patients that had the highest total PC and APC in the age-adjusted IR for MMHN from 1987 to 2009 were white females ages 55 to 84. In this cohort, the total PC in age-adjusted incidence of MMHN was 306.3%, and the APC was 5.1% over the study period (
Age-adjusted incidence rates (in cases per million persons per year) with Joinpoint regression trendline for white female patients ages 55 to 84 with MMHN in SEER 9 registries from 1987 to 2009. The APC over this time period was 5.1%.
MMHN is a rare malignancy that makes up less than one percent of all melanomas. Outcomes for patients with MMHN are generally poor, with reported five-year overall survival (OS) rates for all stages ranging from 20 to 48% [
It is firmly established that the incidence of cutaneous melanoma is increasing over time [
Risk factors for the development of cutaneous melanoma are well understood and include exposure to ultraviolet radiation, family history of melanoma, and multiple benign or atypical nevi [
A possible explanation for our findings is that advances in endoscopy and imaging may have improved detection of this disease over the last 25 years. However, given the infrequency of screening mucosal surfaces of the head and neck in asymptomatic patients and the inherent difficulty in identifying many of these lesions on physical exam, it is unlikely that improved screening would be singularly responsible for such a pronounced increase in incidence over time. Additionally, this explanation would not account for the differences in the rates of increase in IRs between gender, racial, and age-based subgroups.
One of the notable findings of our study was the fact that MMHN incidence is rising in nasal cavity lesions, but the age-adjusted IR for tumors outside of the nasal cavity has remained stable. This finding suggests that there is a specific etiologic agent contributing to nasal cavity melanomas that is either not present or does not have the same carcinogenic effects in other subsites. In a separate recently published SEER analysis, Jethanamest et al. demonstrated that nasal cavity melanomas are associated with superior survival compared to mucosal melanomas in other head and neck subsites, which lends further support to the hypothesis that nasal cavity melanomas are somehow biologically distinct from other MMHNs [
Of the patients identified in our SEER analysis from 1987 to 2009, patients with MMHN (
Our study has several strengths. Primarily, the SEER data is population-based and is therefore highly generalizable. Second, by using the SEER data, we were able to identify patients diagnosed with MMHN over a long period of time who were diagnosed in multiple geographic regions of the United States. Limitations of our study include the potential for underreporting of minority data in the SEER registries, possible mistakes in coding, possible inconsistencies of coding across registries, and the relatively low number of cases. Additionally, the SEER data is limited in its ability to identify specific patient and disease factors that may contribute to the development of MMHN. These include (but are not limited to) family history, sun exposure history, occupational exposures, smoking history, and comorbid illnesses. Finally, as MMHN is often misclassified pathologically [
In summary, MMHN is a rare and often fatal malignancy that is increasing rapidly in incidence in the United States. The most profound increasing incidence is primarily in patients with nasal cavity tumors and in white women, with the most significant increases in incidence observed in white women ages 55 to 84. While MMHN and cutaneous melanoma do not appear to have a common etiologic basis, the rates of increase in the incidence of these diseases are similar. Further research on MMHN is needed, and we hope that our hypothesis-generating study will help to form a basis for future investigation that may elucidate the etiology and epidemiology of this aggressive disease.
J. J. Beitler and T. K. Owonikoko are Georgia Cancer Coalition Distinguished Scholars.