Melanoma risk is twice as high in Parkinson's: A call to counsel every person at every visit
By Michael S. Okun
This is a really terrific article in everydayhealth.com discussing skin cancers and the importance of making the diagnosis and initiating appropriate treatment.
Does it surprise you that if you happen to have Parkinson’s disease, you are at twice the risk for the development of a skin cancer called melanoma? In this month’s blog, we will take a closer look at the data and ask the question, ‘why don’t we counsel folks about this risk at ‘every clinical visit’ to the doctor or advanced practice provider?’ Melanoma is devastating but potentially preventable.
This is one of many similar representative pictures from Google Images and Wikipedia showing cases of biopsy confirmed melanoma.
When it comes to the science required to determine a risk or association of a particular cancer to another disease, progress takes time; and is usually ‘painfully’ slow. Many studies in the literature have however documented the excessive melanoma risk in Parkinson’s. The first large meta-style analysis combining all available studies was by performed by Liu and colleagues in the journal Neurology in 2011. The pooled results revealed the risk was over 2 times higher for folks with Parkinson’s to also receive a diagnosis of melanoma.
Additionally, a seminal study on melanoma risk in the setting of Parkinson’s disease was published in 2010 by John Bertoni and colleagues (JAMA Neurology). The data from the Bertoni study was drawn from the large scale effort of the North American Parkinson's and Melanoma Survey Group and in my mind it has reshaped the way we approach melanoma risk and Parkinson’s.
John Bertoni and colleagues published an important study on melanoma and Parkinson’s in 2010 in the Archives of Neurology which later became JAMA Neurology.
What are the most important summary details from the Bertoni Parkinson’s melanoma study?
Thirty-one centers examined folks with Parkinson’s disease.
At the fist visit, a neurologist obtained a medical history.
At the second visit, a dermatologist recorded melanoma risk factors, performed a whole-body examination, and performed a biopsy of lesions suggestive of melanoma for evaluation by a central dermatopathology laboratory.
Over 2000 folks completed the study.
There were 20 in situ melanomas (0.9%) and 4 invasive melanomas (0.2%).
In the folks enrolled in this study there were also 68 prior melanomas (3.2%); meaning a past history of melanoma but no current disease.
Malignant melanoma was 2.24-fold higher in the Parkinson’s cohort when compared to the general population.
This was the first comprehensive paper which appeared in the literature in 2011 by Liu and colleagues in Neurology and it showed a moderate risk of melanoma in Parkinson’s disease. The methods included 8 studies in a meta analysis. These authors did not find an increased risk for other cancers in Parkinson’s disease.
In 2015 a followup meta analysis and review article the data largely confirmed the Liu study. This study was performed by Huang and it appeared in the journal Translational Neurodegeneration.
Zhang and colleagues in 2021 again confirmed the ~2 fold risk increase of melanoma in Parkinson’s disease by using a sample of data drawn from 17 million cancer cases. Also, this group of authors confirmed that there was not an increased risk of ‘other cancers’ in Parkinson’s disease.
Zhang and colleagues in the British Medical Journal (2021) looked at 17 million folks for relationships of Parkinson’s to melanoma and other cancers. This study found a ~2 fold increased risk of melanoma in Parkinson’s.
What exactly is melanoma?
Melanoma is a skin cancer. It occurs in the pigment producing cells of the skin called melanoctytes. Melanoma is both higher than expected in Parkinson’s disease and the occurrence of PD is higher than expected in those with melanoma.
The first word melanoma is derived from the Greek word ‘melas’ which means dark and the word ‘oma’ which means tumor. Hippocrates and Rufus of Eupheses both used this word.
Do you know the 4 main types of melanoma?
This is a great summary picture from molemap showing the 4 types of melanoma.
1. Superficial spreading melanoma
Grows out from the skin instead of inward.
Most common ~60-70% of cases.
Most common age groups are 30 and 50.
Men: most common on the trunk.
Women: Most common on the leg(s).
2. Nodular melanoma
Grows down and deep into the skin.
Fast growing.
Look for a raised area.
15-30% of cases.
Common age group 50’s.
3. Lentigo maligna melanoma
There are slow growing colored skin patches (lentigo maligna or Hutchinson's melanotic freckles) and this type of melanoma grows from that lesion.
Flat and stays in the surface skin layers.
Slow growing and can change shape and color.
Transformation to lentigo maligna means it can grow deeper and create nodules.
5-15% of cases.
Age group is usually more than 60.
Tend to occur in areas with a lot of sun exposure.
4. ‘Amelanotic’ melanoma
Red or skin colored (no dark black melanin)
Rare, 8% of cases.
Most likely to be mistaken as another skin lesion.
What are the ABCDE’s of recognizing a melanoma?
Look for these features when performing a self examination:
A: Asymmetry (not a perfect symmetric shape)
B: Border
C: Color
D: Diameter (measure side to side)
E: Evolving (changes over time)
This is a great picture from the Skin Care Network showing how to spot a melanoma and showing the comparison to normal skin.
What can you do to protect your skin from the sun?
The best way to address melanoma in Parkinson’s disease is to ‘prevent it.’ Do not be fooled or acquire a ‘false’ sense of ‘overprotection’ if you are using high SPF sunscreens. Most organizations recommend a sunscreen with at least a ‘SPF of 30,’ and that you should be generous in lathering it onto all ‘sun exposed’ areas of your body and most importantly it needs to be reapplied every two hours if you remain in the sun .
Other tips for sun safety to protect against melanoma:
Wear a broad hat
Wear sunglasses
Wear protective clothing
Avoid sun between the hours of 11AM-3PM
Use sunscreen
Drink lots of water
Be cautious of the sun reflecting off other surfaces
Seek shade; avoid direct sunlight
Prevention of melanoma is crucial and the key element is safety in the sun. This is great summary picture on sun safety from molecheck.
Apply generously and every 2 hours…
A recent article ‘opined’ about the ‘best spray on sunscreens of 2023.’ Do not be fooled as to whether you use a spray or lotion; lather generously and reapply every 2 hours. A minimum sunscreen with SPF of ~30 is recommended; most folks use something ‘higher.’
The NY Post had a 2023 piece on the best spray on sunscreens, and this raises the important point of what to consider when choosing any sunscreen whether spray on or lotion.
Do tanning beds increase the risk of melanoma?
You bet tanning beds increase the risk of melanoma; some estimates are as high as ~75% increased risk.
Tanning beds increase the risk of melanoma by 75% according to melanoma.org.
What are the current recommendations for skin cancer screening?
Recently, the American Family physician journal summarized the key findings from the USPSTF for skin cancer screening and this summary is provided below:
Does levodopa or dopamine replacement therapy increase the risk of melanoma?
The short answer is NO. A series of ‘misleading single case reports and series’ were published in the 1970’s. One paper which appeared in 1974 even questioned ‘causation’ and warned about generalization of these ‘anecdotes.’ Much has been documented and published on the topic in the subsequent 30+ years, and there is currently no solid evidence that dopamine replacement therapies cause melanoma or will worsen melanoma even in those with a previous skin cancer diagnosis.
Based on this data, I without hesitation, recommend dopamine replacement therapies including levodopa in Parkinson’s folks with a history of melanoma and also those undergoing current treatment for their cancer.
What are my recommendations for Parkinson’s disease and reducing the melanoma risk?
My strong feeling is that the ‘double’ melanoma risk is sufficiently high that primary care doctors and neurologists should be discussing mandatory full body skin examinations by a dermatologist at a minimum once a year.
Here is my bottomline:
Mandatory brief discussion of melanoma at every follow-up visit.
A full body skin examination should be performed by a dermatologist once a year; and potentially sooner if any ‘new or changing lesions’ are identified by ‘self examination’ or by a care-partner.
Be aggressive to avoid excessive sun exposure.
Use a high SPF sunscreen and liberally apply and reapply every 2 hours.
Folks, if you think my recommendation for mandatory brief discussions on melanoma at every Parkinson’s disease doctor or nurse practitioner visit I would remind you of the huge impact this could have in preventing a serious and life-threatening form of cancer.
Michael Okun is the parkinsonsecrets.com co-editor and also professor and author of many books and articles on Parkinson’s disease.
Jonny Acheson is the parkinsonsecrets.com artist, a physician and a person with Parkinson’s.
Selected References for Articles on Melanoma and Parkinson’s Disease:
Bertoni JM, Arlette JP, Fernandez HH, Fitzer-Attas C, Frei K, Hassan MN, Isaacson SH, Lew MF, Molho E, Ondo WG, Phillips TJ, Singer C, Sutton JP, Wolf JE Jr; North American Parkinson's and Melanoma Survey Investigators. Increased melanoma risk in Parkinson disease: a prospective clinicopathological study. Arch Neurol. 2010 Mar;67(3):347-52. doi: 10.1001/archneurol.2010.1. PMID: 20212233.
Ascherio A, Schwarzschild MA. The epidemiology of Parkinson's disease: risk factors and prevention. Lancet Neurol. 2016 Nov;15(12):1257-1272. doi: 10.1016/S1474-4422(16)30230-7. Epub 2016 Oct 11. PMID: 27751556.
Niemann N, Billnitzer A, Jankovic J. Parkinson's disease and skin. Parkinsonism Relat Disord. 2021 Jan;82:61-76. doi: 10.1016/j.parkreldis.2020.11.017. Epub 2020 Nov 20. PMID: 33248395.
Bose A, Petsko GA, Eliezer D. Parkinson's Disease and Melanoma: Co-Occurrence and Mechanisms. J Parkinsons Dis. 2018;8(3):385-398. doi: 10.3233/JPD-171263. PMID: 29991141; PMCID: PMC6130416.
Weiner WJ, Singer C, Sanchez-Ramos JR, Goldenberg JN. Levodopa, melanoma, and Parkinson's disease. Neurology. 1993 Apr;43(4):674-7. doi: 10.1212/wnl.43.4.674. PMID: 8469320.
Liu R, Gao X, Lu Y, Chen H. Meta-analysis of the relationship between Parkinson disease and melanoma. Neurology. 2011 Jun 7;76(23):2002-9. doi: 10.1212/WNL.0b013e31821e554e. PMID: 21646627; PMCID: PMC3116643.
Ye Q, Wen Y, Al-Kuwari N, Chen X. Association Between Parkinson's Disease and Melanoma: Putting the Pieces Together. Front Aging Neurosci. 2020 Mar 10;12:60. doi: 10.3389/fnagi.2020.00060. PMID: 32210791; PMCID: PMC7076116.
Dalvin LA, Damento GM, Yawn BP, Abbott BA, Hodge DO, Pulido JS. Parkinson Disease and Melanoma: Confirming and Reexamining an Association. Mayo Clin Proc. 2017 Jul;92(7):1070-1079. doi: 10.1016/j.mayocp.2017.03.014. PMID: 28688464; PMCID: PMC5682925.
Vermeij JD, Winogrodzka A, Trip J, Weber WE. Parkinson's disease, levodopa-use and the risk of melanoma. Parkinsonism Relat Disord. 2009 Sep;15(8):551-3. doi: 10.1016/j.parkreldis.2009.05.002. Epub 2009 Jun 5. PMID: 19501540.