This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lange, J. R. Articles by Balch, C. M. Search for Related Content PubMed PubMed Citation Articles by Lange, J. R. Articles by Balch, C. M.

Melanoma in Children and Teenagers: An Analysis of Patients From the National Cancer Data Base

Julie R. Lange, Bryan E. Palis, David C. Chang, Seng-Jaw Soong, Charles M. Balch

From the Department of Surgery, Johns Hopkins Medicine, Baltimore, MD; The National Cancer Data Base, American College of Surgeons, Chicago, IL; and the Biostatistics and Bioinformatics Unit, University of Alabama School of Medicine, Birmingham, AL

Address reprint requests to Julie R. Lange, MD, ScM, 600 N Wolfe St, Carnegie 681, Baltimore, MD 21287; e-mail: jlange{at}jhmi.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
Purpose: This study examines the demographics, presentation, and outcomes of children and teenagers with melanoma using a US hospital-based oncology database.

Patients and Methods: Data from the National Cancer Data Base from 1985 through 2003 were examined for demographics, presentation, and survival of patients aged 1 to 19 years, as well as a comparison group of patients aged 20 to 24 years. Two-sided linear and Pearson ² tests were calculated to examine associations. Proportions were compared using two-sided z tests. Five-year overall observed survival was evaluated using the Kaplan-Meier method and the log-rank test. Cox proportional hazards regression was used to estimate risk of mortality.

Results: Of 3,158 patients aged 1 to 19 years, 96.3% had cutaneous melanoma, 3.0% had ocular melanoma, and 0.7% had an unknown primary tumor. Cutaneous melanoma in patients aged 1 to 19 years was more common in girls (55.5%) and patients older than 10 years (90.5%). The demographics and presentation of cutaneous melanoma were age related; younger children were significantly more likely to be nonwhite and male and more likely to present with a head and neck primary tumors and with regional or distant metastases (linear ², P < .001 for sex, race, and extent of disease). Poorer survival was associated with higher stage and younger age. In contrast to patients aged 20 to 24 years, survival was not related to thickness in patients aged 1 to 19 years with localized invasive melanoma.

Conclusion: Melanoma in children and teenagers differs from melanoma in young adults in demographics, presentation, and survival. Further investigation is warranted to elucidate possible biologic correlates of the unique aspects of melanoma in children and teenagers.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
Melanoma is a significant public health problem in the United States, with an estimated 62,190 new cases of invasive melanoma and 7,910 deaths attributable to melanoma in 2006.¹ Melanoma is uncommon in teenagers and rare in younger children. The Centers for Disease Control and Prevention estimated 475 new cases of melanoma in the United States in 2002 for persons 19 years of age and only 47 new cases in children less than 10 years old.² The incidence of melanoma grew rapidly in adults over the past several decades.³ The incidence of melanoma in adolescents has also been reported to be increasing in both the United States and Sweden.^4,5 A recent report from the Surveillance, Epidemiology, and End Results (SEER) database confirms an increase in the incidence of melanoma in children of approximately 2.9% per year from 1973 to 2001.⁶

In adults, the demographics and presentation of melanoma are known to be age related; older melanoma patients are more likely to be male, have head and neck primary tumors, and lentigo maligna histology.^3,7-9 It is not well understood whether children with melanoma differ from adults in presentation or outcomes, and it is unclear whether older children differ substantially from younger children. Melanoma in children may differ from melanoma in adults in etiology, natural history, and prognosis. The National Cancer Data Base (NCDB), a large hospital-based cancer database maintained by the American College of Surgeons in collaboration with the American Cancer Society, collects data on incident cancer patients from tumor registries of hospitals approved by the American College of Surgeons Commission on Cancer. The primary goal of this study is to describe the demographics and clinical presentation of children with melanoma; treatment and outcomes are described as well.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
The NCDB serves as a comprehensive clinical surveillance resource for cancer care in the United States. Data are submitted annually from the cancer registries of hospitals with cancer programs approved by the American College of Surgeons Commission on Cancer. The NCDB currently contains information on approximately 75% of newly diagnosed cancer patients in the United States from approximately 1,430 hospitals in 49 states. Of all patients with melanoma reported to the NCDB from 1985 through 2003, 0.7% were aged 1 to 19 years.

The NCDB was queried for analytic melanoma cases reported in persons 1 to 24 years old diagnosed between the years 1985 and 2003, and information on race/ethnicity, sex, type of melanoma, and anatomic site of cutaneous melanoma was obtained. The diagnosis was designated by the pathologist at the treating facility; there was no central pathology review. Data were abstracted according to histology using standard International Classification of Diseases–O2/3 melanoma codes (M8720-8790).

Pediatric patients were identified as being aged 1 to 19 years, and a comparison group of young adults was aged 20 to 24 years. Neonatal patients were excluded by omitting patients designated as age 0. For analysis of age-related parameters, the Centers for Disease Control and Prevention–defined age groups (1 to 4, 5 to 9, 10 to 14, 15 to 19, and 20 to 24 years) were used; for some analyses, ages 1 to 9 or 1 to 19 years were combined because of small numbers. Racial designations were reported as non-Hispanic white or nonwhite, which encompasses all other specific designations, including African American, Asian/Pacific Islander, and Native American. The American Joint Committee on Cancer staging system is not formally observed for children 15 years old, and therefore, a SEER general summary stage was used to classify cancer as in situ, localized invasive, regional, or distant disease. Treatment and outcomes were also examined. Sentinel node biopsy was reported beginning in 1998. Use of biologic therapies is reported, although the database does not specify type of biologic therapy such as interferon, vaccine therapy, or other biologic response modifier. Localized invasive melanomas were analyzed from patients diagnosed from 1985 through 2002 for uniformity of T-stage grouping. Primary tumors were grouped as 1.5 mm or more than 1.5 mm for one survival analysis.

Two-sided linear and Pearson ² tests were calculated to examine significance of age, sex, race, site, T stage, and extent of disease associations. Proportions were compared using two-sided z tests. Outcomes were reported as observed overall survival rather than disease-specific survival because of the expectation of excellent overall survival in the absence of disease. Five-year overall observed survival was evaluated using the Kaplan-Meier method and log-rank test. Cox proportional hazards regression was used to estimate risk of mortality for patients with localized invasive melanoma aged 1 to 19 years and for those aged 20 to 24 years. Models included thickness, sex, and primary site. All calculations were performed using SPSS 14.0 (SPSS Inc, Chicago, IL).

	RESULTS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
Distribution of Melanoma Type and Sex
Of the 3,158 patients aged 1 to 19 years, 96.3% had cutaneous melanoma, with only a small minority of patients designated as having ocular melanoma (3.0%) or an unknown primary site (0.7%). Only one patient with mucosal melanoma was reported (Table 1). Overall, melanoma was more common in girls (55%) than in boys.

View larger version (21K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 1. (A) Distribution of cutaneous melanoma patients by age and sex. (B) Distribution of cutaneous melanoma patients by age, sex, and primary site. Lower extremity (LE) sex comparison: two-sided z test, P < .05 for age groups 5 to 9, 10 to 14, 15 to 19, and 20 to 24 years. Head and neck (H/N) sex comparison: two-sided z test, P < .001 for age groups 10 to 14, 15 to 19, and 20 to 24 years.

Cutaneous Melanoma: Extent of Disease
Using reported TNM stage when available and reported general summary stage when TNM stage was not reported, 91.5% of patients had designated stage. Three fourths of children aged 1 to 19 years presented with localized disease, either in situ melanoma (13.4%) or localized invasive melanoma (62.3%). With increasing age, the percentage of patients with localized invasive melanoma increased from 48.0% in patients aged 1 to 4 years to 75.3% in patients aged 20 to 24 years, whereas the percentage of patients with regional disease decreased from 25.5% in patients aged 1 to 4 years to 9.1% of patients aged 20 to 24 years. The percentage of patients presenting with distant disease decreased with age from 14.3% in patients aged 1 to 4 years to 3.0% in patients aged 20 to 24 years (Linear ², P < .001; Table 2). Sex differences were also noted. Boys aged 10 years and older were significantly less likely to present with localized invasive disease and significantly more likely to present with regional disease (both P < .01, data not shown). Both sexes at ages 1 to 19 years were equally likely to present with distant disease, but young men aged 20 to 24 years were more likely to present with distant disease than were young women (P < .001, data not shown).

Localized Cutaneous Melanoma: Thickness Distribution
Of children aged 1 to 19 years with localized invasive melanoma, 71.7% had known T stage. For children with known T stage, most melanomas were 1.5 mm. Young adults and older teenagers were more likely to have thinner lesions than were children aged 1 to 14 years; localized invasive melanoma was 1.5 mm in 58.9% of patients aged 1 to 14 years, 69.5% of patients aged 15 to 19 years, and 74.0% of patients aged 20 to 24 years (Pearson ², P < .001; Table 3).

Outcomes
Median follow-up time was 59 months for patients aged 1 to 19 years with cutaneous melanoma. Overall 5-year observed survival was strongly associated with initial summary stage (98.7% ± 0.9% for in situ disease, 93.6% ± 0.9% for localized invasive disease, 68.0% ± 4.2% for regionally metastatic disease, and 11.8% ± 6.4% for distant disease; P < .05 for all comparisons; Fig 2) Survival analysis for all patients with cutaneous melanoma (excluding in situ) demonstrated that age groups of 10 to 14, 15 to 19, and 20 to 24 years had similar 5-year overall observed survival rates (88.0% ± 2.5%, 87.5% ± 1.3%, and 87.7% ± 0.8%, respectively). However, children aged 1 to 9 years had significantly poorer 5-year overall observed survival (77.0% ± 4.5%) compared with other age groups (P < .05, data not shown).

View larger version (13K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 2. Observed survival curves of cutaneous melanoma by stage for patients aged 1 to 19 years.

View larger version (20K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 3. (A) Observed 5-year survival of patients with all stages (excluding in situ) of cutaneous melanoma by age and sex. Age comparison: P < .05 for ages 1 to 9 and 10 to 19 years and for ages 1 to 9 and 20 to 24 years. Sex comparison: P < .001 for ages 10 to 19 and 20 to 24 years. All other comparisons were not significant. (B) Observed 5-year survival of patients with localized cutaneous melanoma by thickness and age. Age comparison: P < .05 for thickness 1.5 mm, and P < .01 for thickness more than 1.5 mm. Thickness comparison: P = .413 for ages 1 to 19 years, and P < .001 for ages 20 to 24 years.

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
As in adults, most reported cases of melanoma in children are cutaneous, with far fewer noncutaneous cases reported. Melanoma occurs far more frequently in older versus younger children.^4,10 The demographics, site distribution, stage, and outcomes of children and teenagers with melanoma differ from those of young adults, and younger children differ from older children as well. Our data are consistent with previous reports showing that the overall pediatric melanoma population is predominantly female.^6,11,12 However, our study shows that, in patients aged 1 to 9 years, there is a male predominance that is striking and most prominent in the youngest patients. The higher percentage of nonwhite patients in the younger children compared with older children and young adults has been described in SEER data and is seen in the current data set as well.^4,6

In adults, the presentation of cutaneous melanoma is known to be associated with both age and sex.^3,7-9,13 The current study shows that children present with a different primary site distribution than young adults and that younger children are more likely to present with higher stage disease, similar to the SEER data.⁶ In our data set, children less than 15 years old with localized invasive melanoma had thicker primary tumors compared with older teenagers and young adults. Girls older than age 4 had a higher percentage of lower extremity melanoma, and boys 10 years old had a higher percentage of head and neck melanomas. The percentage of boys and girls younger than 10 years old with regional metastases at presentation is similar, but with increasing age, this percentage decreases sooner and to a greater extent in girls than in boys and remains lower in females into young adulthood. The demographics, site distribution, and stage distribution of cutaneous melanoma in children changes with increasing age.

The mainstay of management of stage 0 through III cutaneous melanoma is surgery, which is reflected in the current data. Sentinel node biopsy has been integrated into surgical management of primary melanoma in children, as it has been in adults. In the literature, sentinel node biopsy in children seems to be associated with a 25% to 40% rate of node positivity, consistent with the observation in adults that younger adults have a higher chance of being node positive compared with older adults.^14-17 The use of high-dose interferon alfa-2b has been described in children with resected, high-risk melanoma and seems to be tolerated well.^18,19 The current study documents frequent use of biologic response modifiers in children and teenagers with regionally metastatic melanoma, although the use of these therapies remains controversial.

Survival of children with melanoma is clearly related to extent of disease. Observed overall survival of all stages together (excluding in situ disease) is significantly worse for children aged 1 to 9 years than for persons aged 10 to 24 years. In children less than 10 years old, overall observed survival is similar in males and in females, whereas males aged 10 to 24 years have worse outcomes than females, consistent with the findings in adults. This contrasts to the reported SEER data, where all children 19 years old are reported as a single group and show poorer survival for males.⁶ Among the patients with localized invasive melanoma, it is notable that, in the group aged 1 to 19 years, survival was not associated with primary tumor thickness, and it was also notable that patients aged 1 to 19 years with thicker melanomas had far better survival compared with the young adults with thicker melanoma. This may suggest an inherently different biology and natural history in children with melanoma because tumor thickness is the single most important prognostic factor in all other age groups but does not seem to be a prognostic factor in children.

Among patients with invasive melanoma aged 1 to 9 years, there was a striking trend towards a higher percentage of patients with regional or distant disease at initial presentation, and younger patients diagnosed with localized invasive cutaneous melanoma are more likely to present with thicker tumors. Possible reasons include delayed diagnosis or age-related differences in biologic behavior that are not yet understood. The clinical and pathologic characteristics of melanoma in children can make diagnosis difficult.^20-23 Although the most common presentation of melanoma in children is a change in a mole, some melanocytic lesions in children have atypical appearance.^24,25 Because they may not clinically look like adult melanoma and because this rare diagnosis is sometimes not considered in young children, the diagnosis can be missed or delayed.^24-26 Some melanocytic lesions in childhood and adolescence are hard to classify pathologically as benign or malignant; it is possible that some malignant lesions are misclassified as benign and only recognized as malignant when they recur, and it is possible that some benign lesions are misclassified as malignant when they, in fact, have no malignant potential.

Registry data do not include whether individual patients may have had a delayed diagnosis or a false-positive diagnosis. The data presented here are hospital based and include only patients who have been given a diagnosis of melanoma; it is possible that this database over-represents patients with higher severity of disease. Cancer registry data have no information on whether any of the patients were originally diagnosed with an atypical lesion and subsequently diagnosed with metastases; in cancer registry data, such individuals would appear to be diagnosed with metastatic disease at initial presentation. This database also has no information on comorbidities, second neoplasms, family history, or many predisposing factors. However, we believe this to be by far the largest reported series on pediatric melanoma. It has sufficient detail on demographics, presentation, and outcomes to convincingly describe some of the unique features of melanoma in this population.

It is not well understood why the incidence of melanoma seems to be increasing in teenagers; given the consistency of the increase over many years and in reports from more than one country, it is probably not an artifact of more complete reporting to tumor registries. In adults, the risk of melanoma is epidemiologically strongly related to UV exposure, and there may be plausible mechanisms to account for UV as an etiologic agent.^27,28 The SEER data report that melanoma incidence in teenagers is higher in areas of the United States with greater sun exposure.⁶ The use of artificial tanning facilities has been reported to be high in American teenagers, with as much as 47% of girls aged 17 to 18 years using tanning facilities at least three times.^29,30 UV exposure as an etiologic agent in young children seems less likely because most childhood exposure occurs in the teen years, and the youngest patients simply have not been alive long enough to have a plausible interval from exposure to diagnosis.

These data raise the possibility that melanoma, or at least some melanomas, may be biologically different in children compared with adults. In addition to the differences in demographics and presentation, perhaps more compelling is the apparent lack of prognostic value of tumor thickness in children with localized invasive melanoma. Melanoma in children and teenagers may have unique biologic features and a different natural history than melanoma in adults. Comparative genomic hybridization has shown that adult melanoma differs from benign nevi in the presence of frequent chromosomal aberrations; more research in the molecular genetics of pediatric melanoma is needed. A better understanding of the molecular and genetic aspects of this disease may help resolve the diagnostic dilemmas posed by cases that are pathologically ambiguous and may lead to targeted therapies for children with melanoma.

	AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
The authors indicated no potential conflicts of interest.

	AUTHOR CONTRIBUTIONS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
Conception and design: Julie R. Lange, Seng-Jaw Soong, Charles M. Balch

Administrative support: Bryan E. Palis, David C. Chang

Provision of study materials or patients: Bryan E. Palis

Collection and assembly of data: Julie R. Lange, Bryan E. Palis, David C. Chang

Data analysis and interpretation: Julie R. Lange, Bryan E. Palis, David C. Chang, Seng-Jaw Soong

Manuscript writing: Julie R. Lange, Bryan E. Palis, David C. Chang, Charles M. Balch

Final approval of manuscript: Julie R. Lange, Bryan E. Palis, David C. Chang, Seng-Jaw Soong, Charles M. Balch

	NOTES

 
Presented in part at the 6th World Melanoma Congress, September 6-10, 2005, Vancouver, British Columbia, Canada.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

	REFERENCES

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
1. American Cancer Society: Cancer Facts and Figures 2006. Atlanta, GA, American Cancer Society, 2006

2. US Cancer Statistics Working Group: United States Cancer statistics: 1999-2002 incidence and mortality web-based report. http://www.cdc.gov/cancer/npcr/uscs/

3. Desmond RA, Soong SJ: Epidemiology of malignant melanoma. Surg Clin North Am 83:1-29, 2003[CrossRef][Medline]

4. Hamre MR, Chuba P, Bakhshi S, et al: Cutaneous melanoma in childhood and adolescence. Pediatr Hematol Oncol 19:309-317, 2002[CrossRef][Medline]

5. Karlsson P, Boeryd B, Sander B, et al: Increasing incidence of cutaneous malignant melanoma in children and adolescents 12-19 years of age in Sweden 1973-92. Acta Derm Venereol 78:289-292, 1998[CrossRef][Medline]

6. Strouse JJ, Fears TR, Tucker MA, et al: Pediatric melanoma: Risk factor and survival analysis of the surveillance, epidemiology and end results database. J Clin Oncol 23:4735-4741, 2005[Abstract/Free Full Text]

7. Elwood JM, Gallagher RP: Body site distribution of cutaneous malignant melanoma in relationship to patterns of sun exposure. Int J Cancer 78:276-280, 1998[CrossRef][Medline]

8. Bulliard JL, Cox B: Cutaneous malignant melanoma in New Zealand: Trends by anatomical site, 1969-1993. Int J Epidemiol 29:416-423, 2000[Abstract/Free Full Text]

9. Gillgren P, Mansson-Brahme E, Frisell J, et al: Epidemiological characteristics of cutaneous malignant melanoma of the head and neck: A population-based study. Acta Oncol 38:1069-1074, 1999[CrossRef][Medline]

10. Whiteman D, Valery P, McWhirter W, et al: Incidence of cutaneous childhood melanoma in Queensland, Australia. Int J Cancer 63:765-768, 1995[Medline]

11. Pappo AS: Melanoma in children and adolescents. Eur J Cancer 39:2651-2661, 2003[CrossRef][Medline]

12. Conti EM, Cercato MC, Gatta G, et al: Childhood melanoma in Europe since 1978: A population-based survival study. Eur J Cancer 37:780-784, 2001[CrossRef][Medline]

13. Stang A, Stabenow R, Eisinger B, et al: Site- and gender-specific time trend analyses of the incidence of skin melanomas in the former German democratic republic (GDR) including 19351 cases. Eur J Cancer 39:1610-1618, 2003[CrossRef][Medline]

14. Toro J, Ranieri JM, Havlik RJ, et al: Sentinel lymph node biopsy in children and adolescents with malignant melanoma. J Pediatr Surg 38:1063-1065, 2003[CrossRef][Medline]

15. Roaten JB, Partrick DA, Pearlman N, et al: Sentinel lymph node biopsy for melanoma and other melanocytic tumors in adolescents. J Pediatr Surg 40:232-235, 2005[CrossRef][Medline]

16. Chao C, Martin RC II, Ross MI, et al: Correlation between prognostic factors and increasing age in melanoma. Ann Surg Oncol 11:259-264, 2004[Abstract/Free Full Text]

17. Sondak VK, Taylor JM, Sabel MS, et al: Mitotic rate and younger age are predictors of sentinel lymph node positivity: Lessons learned from the generation of a probabilistic model. Ann Surg Oncol 11:247-258, 2004[Abstract/Free Full Text]

18. Chao MM, Schwartz JL, Wechsler DS, et al: High-risk surgically resected pediatric melanoma and adjuvant interferon therapy. Pediatr Blood Cancer 44:441-448, 2005[CrossRef][Medline]

19. Navid F, Furman WL, Fleming M, et al: The feasibility of adjuvant interferon alpha-2b in children with high-risk melanoma. Cancer 103:780-787, 2005[CrossRef][Medline]

20. Wechsler J, Bastuji-Garin S, Spatz A, et al: Reliability of the histopathologic diagnosis of malignant melanoma in childhood. Arch Dermatol 138:625-628, 2002[Abstract/Free Full Text]

21. Barnhill RL, Flotte TJ, Fleischli M, et al: Cutaneous melanoma and atypical spitz tumors in childhood. Cancer 76:1833-1845, 1995[CrossRef][Medline]

22. Milton GW, Shaw HM, Thompson JF, et al: Cutaneous melanoma in childhood: Incidence and prognosis. Australas J Dermatol 38:S44-S48, 1997 (suppl 1)[CrossRef][Medline]

23. Spatz A, Ruiter D, Hardmeier T, et al: Melanoma in childhood: An EORTC-MCG multicenter study on the clinico-pathological aspects. Int J Cancer 68:317-324, 1996[CrossRef][Medline]

24. Saenz NC, Saenz-Badillos J, Busam K, et al: Childhood melanoma survival. Cancer 85:750-754, 1999[CrossRef][Medline]

25. Boddie AW Jr, Smith JL Jr, McBride CM: Malignant melanoma in children and young adults: Effect of diagnostic criteria on staging and end results. South Med J 71:1074-1078, 1978[Medline]

26. Melnik MK, Urdaneta LF, Al-Jurf AS, et al: Malignant melanoma in childhood and adolescence. Am Surg 52:142-147, 1986[Medline]

27. Fears TR, Bird CC, Guerry D IV, et al: Average midrange ultraviolet radiation flux and time outdoors predict melanoma risk. Cancer Res 62:3992-3996, 2002[Abstract/Free Full Text]

28. Gilchrest BA, Eller MS, Geller AC, et al: The pathogenesis of melanoma induced by ultraviolet radiation. N Engl J Med 340:1341-1348, 1999[Free Full Text]

29. Demko CA, Borawski EA, Debanne SM, et al: Use of indoor tanning facilities by white adolescents in the United States. Arch Pediatr Adolesc Med 157:854-860, 2003[Abstract/Free Full Text]

30. Cokkinides VE, Weinstock MA, O'Connell MC, et al: Use of indoor tanning sunlamps by US youth, ages 11-18 years, and by their parent or guardian caregivers: Prevalence and correlates. Pediatrics 109:1124-1130, 2002[Abstract/Free Full Text]

Submitted August 18, 2006; accepted January 12, 2007.

This article has been cited by other articles:

				K. Y. Bilimoria, A. K. Stewart, D. P. Winchester, and C. Y. Ko The National Cancer Data Base: A Powerful Initiative to Improve Cancer Care in the United States Ann. Surg. Oncol., March 1, 2008; 15(3): 683 - 690. [Full Text] [PDF]

				J. R. Lange Pediatric Melanoma ASCO Educational Book, January 1, 2008; 2008(1): 436 - 440. [Abstract] [Full Text] [PDF]

				Melanoma in Children Journal Watch Dermatology, May 18, 2007; 2007(518): 1 - 1. [Full Text]

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lange, J. R. Articles by Balch, C. M. Search for Related Content PubMed PubMed Citation Articles by Lange, J. R. Articles by Balch, C. M.