Lack of Knowledge Continues to Influence Delayed Melanoma Diagnosis

Malignant cutaneous melanoma outcomes were investigated as they relate to diagnosis delay and potential influence from socioeconomic and demographic factors in Brazil, where skin cancer diagnoses represent 30% of all cancer diagnoses.

Education surrounding malignant cutaneous melanoma (MCM) and its initial symptoms was shown to be significantly inadequate among patients and health care professionals in Brazil, which study investigators implicated as a cause of delay in the cancer’s early diagnosis and treatment, as noted in Revista da Associação Médica Brasileira.

The study cohort consisted of 103 patient records from Hospital Universitário Evangélico Mackenzie for January 2015 through December 2020, with data derived on social, economic, demographic, and cultural factors and time from symptom onset to diagnosis. Most of these records (n = 89) had all necessary information; 14 lacked socioeconomic and demographic variables (ie, occupation, family income, employees living in same household, housing conditions, education). Mean (SD) patient age was 66.34 (13.5) years, and 55.3% were female patients. The most common MCM photoype was phototype III (55.3%).

“MCM is the most aggressive tumor, representing about 5% of malignant cutaneous tumors and being responsible for most skin cancer-related deaths,” the study authors wrote. “However, if diagnosed in its early stages, complete resection of the lesion is associated with favorable survival rates.” They added a sense of urgency to early diagnosis, noting MCM’s “high potential to produce metastasis.”

At study initiation, metastatic disease was seen in 5.82% of the patient cases and 76.7% of tumors with Breslow thickness of 1 cm or less. Approximately one-third of patients (31.06%) also had nonmelanoma skin cancers. In addition, 68.53% had a monthly income that was at least 1.5 times that of the minimum wage, 12.8% had completed higher education, 43.68% were housewives or retired, 80.9% lived in brick homes, and 83.1% had basic sanitation. The most common initial MCM symptom reported was lesion growth, although 39.8% of patients reported not observing any lesion changes.

The average time between patients observing their first symptoms and contacting a medical professional (time period 1) was 29.54 (range, 0-240) months and that between symptom onset and diagnosis (time period 2), 30.9 (range, 0-240) months. There was also variation among histological subtypes:

  • Superficial spreading melanoma:
    • Time period 1: 12 (range, 0-120) months
    • Time period 2: 0.03 (range, 0-12) months
  • Lentigo malignant melanoma:
    • Time period 1: 15 (range, 0-120)
    • Time period 2: 0.26 (range, 0-1) months
  • Acral lentiginous melanoma:
    • Time period 1: 5.1 (range, 3.0-7.2) months
    • Time period 2: 2.5 (range, 0.0-5.0)

Among the variables investigated for potential influence on the time it took a patient to make initial medical contact after noticing symptoms, significant associations were seen with these variables for longer time: tumor Breslow thickness of 1 cm or less (P = .024), stage 0 cancer (neoplasms in situ; P = .028), phototypes I and II (P = .024), and basic health care unit (BHU) search (P = .008). Perception of lesion growth and income range below 1.5 times the minimum wage, the 2 remaining variables investigated, did not have a negative impact on wait times.

For factors that may have caused a delay between first medical contact and definitive diagnosis with a reference service, only housing condition (living in a brick house) was shown to contribute (P = .043). Smoking status and household profession were shown to not affect this time period.

Further, factors that contributed to the longest delays from symptom onset to definitive diagnosis with the reference service were tumor Breslow thickness of 1 cm or less (P = .037), stage 0 tumors (in situ; P = .039), phototypes I and II (P = .021), and search for BHU before reference service arrival (P = .009). Income range below 1.5 times the minimum wage and living in a wooden house did not influence this time period (P = .036).

Principal reasons for the overall delay between symptom recognition and diagnosis of MCM posited by the study authors were that physicians and patients may only consider a potential skin cancer to be malignant when it starts to present with more advanced changes and MCMs that grow slowly, so that gradual changes are not noticed.

“All physicians involved in primary or secondary health care need to be aware of the possibility of melanoma, especially in those with a positive family history, report of long exposure to the sun, skin with photodamage, or other changes evidenced by the patient,” the study investigators concluded. “It is of great importance that strategies to raise awareness of patients and health professionals are implemented to reduce the time for diagnosing these tumors.”


Gilli IO, Zanoni AC, de Andrade DP, Andrade DAS. Cutaneous melanoma diagnosis delay: socioeconomic and demographic factors influence. Rev Assoc Med Bras. 2022;68(10):1405-1409. doi:10.1590/1806-9282.20220369

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