10.5826/dpc.1301a8
Introduction: Malignant melanoma is one of the rarest but the most deadly form of skin cancer.
Objective: The objective of this paper was to analyze the epidemiological characteristics and trends of mortality from malignant melanoma of the population of Central Serbia in the period 1999-2015.
Methods: &nbsp;The study was designed as a retrospective descriptive epidemiological study. Standardized mortality rates were used in statistical data processing.&nbsp; A linear trend model and regression analysis were used to examine trends in malignant melanoma mortality.
Results: &nbsp;In Serbia, malignant melanoma mortality shows an increasing trend. The overall age-adjusted melanoma death rate was 2.6 per 100 000 with a higher death rate among men (3.03per 100 000) than among women (2.1 per 100 000). Malignant melanoma mortality rates increase with age in both sexes and are highest in the age group of 75 and older. The highest increase in mortality in men is recorded in the age group of 65-69 years, with an average percentage increase of 21.33 (95% CI, 8.40 - 51.05), while in women the largest increase in mortality was recorded in the age group 35-39 years, with an average percentage increase of 31.4 &nbsp;and in the age group of 70-74 years, 12.9 .
Conclusions: The trend of increasing mortality from malignant melanoma in Serbia is similar to those in most developed countries. Education and improvement of the awareness of the general population and among health professionals remain vital to reducing melanoma mortality in the future.
text/xml
2160-9381
2350
en
Snezana Radovanovic
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Serbia
Mortality Of Malignant Melanoma In Central Serbia, In The Period 1999-2015
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-01-28
2023-01-31
2023-02-27
e2023008
Dermatol Pract Concept
Introduction: Malignant melanoma is one of the rarest but the most deadly form of skin cancer.
Objective: The objective of this paper was to analyze the epidemiological characteristics and trends of mortality from malignant melanoma of the population of Central Serbia in the period 1999-2015.
Methods: &nbsp;The study was designed as a retrospective descriptive epidemiological study. Standardized mortality rates were used in statistical data processing.&nbsp; A linear trend model and regression analysis were used to examine trends in malignant melanoma mortality.
Results: &nbsp;In Serbia, malignant melanoma mortality shows an increasing trend. The overall age-adjusted melanoma death rate was 2.6 per 100 000 with a higher death rate among men (3.03per 100 000) than among women (2.1 per 100 000). Malignant melanoma mortality rates increase with age in both sexes and are highest in the age group of 75 and older. The highest increase in mortality in men is recorded in the age group of 65-69 years, with an average percentage increase of 21.33 (95% CI, 8.40 - 51.05), while in women the largest increase in mortality was recorded in the age group 35-39 years, with an average percentage increase of 31.4 &nbsp;and in the age group of 70-74 years, 12.9 .
Conclusions: The trend of increasing mortality from malignant melanoma in Serbia is similar to those in most developed countries. Education and improvement of the awareness of the general population and among health professionals remain vital to reducing melanoma mortality in the future.
Snezana Radovanovic
2023/01/31
10.5826/dpc.1301a8
e2023008
University of Kragujevac, Serbia, Faculty of Medical Sciences, Department of Social medicine 
2160-9381
Serbia
en
e2023008
Pfahlberg A, Kölmel KF, Gefeller O; Febim Study Group. Timing of excessive ultraviolet radiation and melanoma: epidemiology does not support the existence of a critical period of high susceptibility to solar ultraviolet radiation- induced melanoma. Br J Dermatol. 2001;144(3):471‐475. DOI: 10.1046/j.1365-2133.2001.04070.x PMID: 11260001
Mortality Of Malignant Melanoma In Central Serbia, In The Period 1999-2015
https://dpcj.org/index.php/dpc/article/download/2350/1930
          Mortality of Malignant Melanoma in Central
               Serbia, in the Period 1999-2015
             Milica Pantovic1, Ognjen Djordjevic2, Svetlana Radevic3, Dragic Bankovic4,
                         Katarina Parezanovic Ilic5, Snezana Radovanovic3


1 Clinical Hospital Center Zemun, Belgrade, Serbia
2 Department of Hygiene and Ecology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
3 Department of Social Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
4 Faculty of Science, University of Kragujevac, Kragujevac, Serbia
5 University of Kragujevac, Serbia, Faculty of Medical Sciences, Department of Physical medicine and rehabilitation



Key words: malignant melanoma, mortality, risk factors, Serbia
Citation: Pantovic M, Djordjevic O, Radevic S, Bankovic D, Parezanovic Ilic K, Radovanovic S. Mortality Of Malignant Melanoma In
Central Serbia, In The Period 1999-2015. Dermatol Pract Concept. 2023;13(1):e202308. DOI: https://doi.org/10.5826/dpc.1301a8
Accepted: June 20, 2022; Published: January 2023
Copyright: ©2023 Pantovic et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication
Corresponding Author: Svetlana Radevic, PhD, Department of Social Medicine, Faculty of Medical Sciences University of Kragujevac,
Svetozara Markovica 69, 34000 Kragujevac, Serbia. Tel: +381 34 306 800 ext 217 Fax: + 381 34 306 800 E-mail: cecaradevic@yahoo.com




  ABSTRACT             Introduction: Malignant melanoma is one of the rarest forms of skin cancer but it is the most deadly.
                       Objective: The objective of this paper was to analyze the epidemiological characteristics and trends
                       of mortality from malignant melanoma in the population of Central Serbia in the period 1999-2015.
                       Methods: The study was designed as a retrospective descriptive epidemiological study. Standardized
                       mortality rates were used in statistical data processing. A linear trend model and regression analysis
                       were used to examine trends in malignant melanoma mortality.
                       Results: In Serbia, malignant melanoma mortality shows an increasing trend. The overall age-adjusted
                       melanoma death rate was 2.6 per 100,000 with a higher death rate among men (3.03 per 100,000)
                       than among women (2.1 per 100,000). Malignant melanoma mortality rates increase with age in both
                       sexes and are highest in the age group of 75 and older. The highest increase in mortality in men is re-
                       corded in the 65-69 age group, with an average percentage increase of 21.33 (95% CI, 8.40 - 51.05),
                       while in women the largest increase in mortality was recorded in the 35-39 age group, with an average
                       percentage increase of 31.4 and in the 70-74 age group, 12.9.
                       Conclusions: The trend of increasing mortality from malignant melanoma in Serbia is similar to those
                       in most developed countries. Education and improvement of awareness in the general population and
                       among health professionals are vital to reducing melanoma mortality in the future.




Original Article | Dermatol Pract Concept. 2023;13(1):e202308                                                                       1
Introduction                                                       has lower mortality rates than the highest estimated in the
                                                                   world, it is in the group of countries with a higher risk of
Malignant melanoma accounts for 4% of all skin cancers             disease. Unless additional efforts in prevention are made, the
and 1,7% of all cancers [1]. Although it still accounts for less   number of melanoma cases is projected to increase in Ser-
than 5% of all skin malignancies, melanoma causes about            bia over the next 15 years, with a concomitant increase in
80% of skin cancer deaths [2]. The incidence of cutaneous          healthcare costs.
melanoma has increased sharply in recent years in all parts           The aim of the research is to analyze the epidemiolog-
of the world, with a steady increase in incidence among the        ical characteristics and trends of mortality from malignant
white population, while the mortality associated with it re-       melanoma in the population of Central Serbia in the period
mains stable [3-5]. It should also be noted that the incidence     1999-2015.
of melanoma has increased due to better education and im-
provement of awareness among patients and due to the de-
                                                                   Materials and Methods
velopment of dermatoscopy [6].
    According to Globocan data from 2018, the total num-           The study was designed as a retrospective descriptive epide-
ber of deaths from malignant melanoma in the world was             miological study. The research used data from the Cancer
60,712, which ranks it 22nd in the structure of mortality from     Registry of Central Serbia, formed on the basis of reports
malignant tumors of all localizations [7]. Mortality rates in      of malignant diseases for the period 1999-2015. The Pop-
different populations of the world multiple vary depending         ulation Register for Cancer was established in Serbia in
on the level of development, so mortality is almost 5 times        1970 and since 1998, the Cancer Registry of Central Serbia
higher in developed countries than in developing countries         has been admitted to the International (IACR) and Euro-
[8,9]. Worldwide, the highest mortality rates are registered in    pean Association of Cancer Registries (ENCR). In the reg-
regions such as North America, Northern Europe, Australia          isters, due to numerous data sources and the need for their
and New Zealand, while lower rates are commonly found              verification and analysis, the usual time period for data
in South American and African countries. For 2018, global          collection is two years, after which the report is published,
data on skin melanoma revealed age-standardized mortality          which is the reason why the last published data from 2015
rates of approximately 0.63 deaths per 100,000 inhabitants         will be used.
(0.78 deaths per 100,000 inhabitants for men and 0.50 for             Standardized mortality rates were used in statistical data
women) [7].                                                        processing. Mortality rates were calculated based on data on
    Epidemiological studies show that melanoma is more             deaths from malignant melanoma in the Cancer Registry of
common in older adults than in younger people and is more          Central Serbia. All reported melanoma deaths were coded
common in men than in women, but the ratio of these rates          according to the International Classification of Disease, 10th
between the sexes varies with age [10, 11]. For example, the       Revision (code S43.0). The cases were grouped by gender
incidence rate is three times higher in men aged 80 and older      into 5-year age groups. The size and composition of the pop-
than in women of the same age [12]. Although the incidence         ulation by age and sex were obtained by the 1991, 2002, and
of melanoma is lower in people under the age of 40, it is one      2011 Censuses. The population of Central Serbia by age and
of the most common cancers diagnosed among adolescents             sex in the years between the Censuses were estimated based
and young adults [13].                                             on natural increase and migration.
    Although the etiology of melanoma has not been fully              Age-adjusted mortality rates were calculated by direct
elucidated, the findings of studies indicate the importance        standardization, using the world’s population and pre-
of the interaction between genetic, biological, and envi-          sented per 100,000 inhabitants. A linear trend model and
ronmental factors. Several meta-analyses have identified           regression analysis were used to examine trends in malig-
key risk factors such as: family history of melanoma, age,         nant melanoma mortality. The percentage of the change in
history of sunburn and exposure to ultraviolet (UV) radia-         the mortality rate was calculated as the percentage of the
tion, fair-skinned people, increased number of nevi, dysplas-      difference between the adjusted rates for two consecutive
tic nevi, genetic factors (CDKN2A, CDK4, MC1R genes,               years, and then as the average value of these changes over
TYRP1) [14,15]. The most important and potentially mod-            the entire observation period. Confidence intervals (CI) for
ifying environmental risk factor for the development of ma-        average age-adjusted and age-specific mortality rates were
lignant melanoma is exposure to ultraviolet (UV) rays due to       estimated with 95% probability. Bilateral P values have
their genotoxic effects [10,16,17].                                been reported and are considered to show statistical signif-
    According to the latest IARC estimations (2018), the           icance if they are lesser than 0.05. Data were processed us-
estimated mortality rate in Serbia is 2.5 / 100,000 inhab-         ing the statistical package for social sciences, version 19.0
itants [18]. Compared to other countries, although Serbia          (SPSS Inc, Chicago, IL, USA).



2                                                                       Original Article | Dermatol Pract Concept. 2023;13(1):e202308
Results                                                          gradually maintained a slow increase. Over the last decade,
                                                                 the death rate has been growing steadily by 1.5% in the
In 2015, a total of 195 melanoma deaths occurred in Central      most of observed countries, such as New Zealand and Aus-
Serbia, which constitutes 1.3% of the total number of cancer     tralia [10].
deaths and ranks 17th in the structure of cancer mortality           Mortality rates in northern European countries (Nor-
of all localizations. During the 17-year observation period,     way, Sweden, Netherlands) are among the highest in the
there was a significant decrease in the total mortality of the   world. Thus, according to the latest data from Globocan,
population (y = -8,7001x + 582.67; p = 0.001; % change           in Norway in 2018, the total number of deaths from ma-
= - 8.83) (Figure 1), with a significant increase in mortality   lignant melanoma was 13.2% of cancer of all localizations,
from all malignant tumors in total (y = 0.6343x + 115.13;        which ranks it 7th in the structure of cancer mortality of all
p = 0.004; % change = + 0.27) and in both sexes (Figure 2).      localizations. For the same period, in Sweden, the number
    In the same period, mortality from malignant melanoma        of deaths from malignant melanoma accounted for 2.4% of
recorded an increasing trend (y = 0.0194x + 1.3682; p =          cancer deaths of all localizations, which ranks it 12th, the
0.009; % change = + 1.94). Observed by gender, there is a        standardized mortality rate is 2.5 per 100,000 inhabitants.
significant trend of increasing mortality in men (y = 0.0486x    The total number of deaths from malignant melanoma in the
+ 1.5494; p = 0.036; % change = + 6.26), while in women          Netherlands in 2018 presents 2.0%, of deaths from cancer
there is a trend of declining mortality from malignant mel-      of all localizations, which ranks it 17th in the structure of
anoma (y = -0, 0124x + 1.3282; p = 0.088; % change = +           cancer mortality of all localizations [7].
0.43. (Figure 3).                                                    Differences in skin type, length, and sun exposure pat-
    The overall age-adjusted melanoma death rate was 2.6         terns may partly explain the lowest mortality rates recorded
per 100,000 with a higher death rate among men (3.03 per         in some Middle Eastern countries (Qatar 0.04 per 100,000
100,000) than among women (2.1 per 100,000).                     inhabitants, Saudi Arabia 0.10 per 100,000 inhabitants, and
    Malignant melanoma mortality rates increase with age in      Yemen 0.11 per 100,000 inhabitants), Africa (Egypt 0.13
both sexes and are highest in the age group of 75 and older      per 100,000 inhabitants; Libya 0.14 per 100,000 inhabi-
(10.15 per 100,000 for men; 8.32 per 100,000 for women)          tants); Asian countries (India - 0.16 per 100,000 inhabitants,
(Table 1). Low mortality rates have been reported in men and     China - 0.18 per 100,000 inhabitants and Vietnam 0.08 per
women under the age of 30. The largest increase in mortality     100,000 inhabitants), some Central American countries
in men was recorded in the 65-69 age group, with an average      (Barbados 0.0 per 100,000 inhabitants and Haiti 0.16 per
percentage increase of 21.33 (95% CI, 8.40 - 51.05), while       100,000 inhabitants) and Europe (Albania 0.53 per 100,000
in women the largest increase in mortality was recorded in       inhabitants; Montenegro 0.89 per 100,000 inhabitants) [18].
the 35-39 age group, an average percentage increase of 31.4          The results of our study showed that mortality from ma-
(95% CI, 23.10 - 85.91) and in the 70-74 age group, 12.9         lignant melanoma is higher in men than in women, which
(95% CI, 14.41 - 40.14).                                         is in line with most published studies [11, 23]. The average
                                                                 standardized mortality rate for men in the world was 0.78
                                                                 per 100,000 in 2018, and 0.50 per 100,000 for women in
Discussion
                                                                 2018. In terms of the global distribution of malignant mela-
Mortality from malignant melanoma in Serbia records an           noma, the standardized malignant melanoma mortality rate
upward trend and mortality rates for malignant melanoma in       expressed on 100,000 inhabitants is higher for men than
Serbia remain among the highest in the world. Similar trends     for women in all regions of the world: Australia and New
are being observed around the world despite numerous ef-         Zealand (men 5.9; women 2.4); Northern Europe (men 2.5;
forts to improve primary prevention and early detection,         women 1.6), North America (men 2.6; women 1.2), West-
and these increasing rates are affecting public health and the   ern Europe (men 2; women 1.3). Less significant differences
economic burden of the disease [11, 19]. Melanoma mortal-        in mortality rates are present in less developed regions of
ity rates have increased marginally among fair-skinned pop-      the Caribbean (men 0.3, women 0.2), West Africa (men 0.5;
ulations. Mortality rates are highest in Australia and New       women 0.3); East Asia (men 0.4; women 0.3); Southeast Asia
Zealand (3.4 per 100,000) and Northern Europe (2.0 per           (men 0.3; women 0.2); North Africa (men 0.2; women 0.2),
100,000), while the lowest rates are recorded in South Cen-      Central Asia (men 0.2; women 0.1) [7].
tral Asia and Eastern Asia (0.19) [7].                               In Europe, the standardized mortality rate of malignant
    Trends in melanoma mortality are variable and are af-        melanoma for men is 3.2 per 100,000, and for women 1.9
fected by latitude, ethnicity, age, and gender [20-22]. In       per 100,000, with differences varying between regions of
high-risk regions, the mortality rate increased historically     Europe: Western Europe (3.3 men and 1.9 women) in Cen-
until the 1980s, peaking between 1988 and 1990, and then         tral and Eastern Europe (3.0 and 2.0) in Northern Europe



Original Article | Dermatol Pract Concept. 2023;13(1):e202308                                                                3
       Table 1. The average age-specific mortality rates and linear trend of Melanoma malignum in
                                      Central Serbia, in 1999–2015.
      Age       Age-specific rates*                                                        Average annual percentage
    (years)       (per 100,000)            Linear trend        R2            p                  change (95% CI)
 Male                                            †
 0-4                    0.00                     †
 5-9                    0.00                     †
 10-14                  0.00                     †
 15-19                  0.00                     †
 20-24                  0.27                     †
 25-29                  0.42                     †
 30-34                  1.07                     †
 35-39                  1.69                     †
 40-44                  2.03                     †
 45-49                  3.33                     †
 50-54                  4.95                     †
 55-59                  7.99                     †
 60-64                  4.15             y = 5,26 + 0.21·x    0.274        0.031                7,93 (-9.16 – 24.97)
 65-69                  4.85             y = 5.87 + 0.46·x    0.321        0.018               21.33 (-8,40 – 51,05)
 70-74                  7.68             y = -6.23 +0.56·x    0.620      < 0.0005              10.84 (-8.73 – 30.41)
 75+                   10.15             y = 7.16 + 0.83·x    0.669      < 0.0005              10,96 (-9.59 – 31.51)
 Female
 0-4                    0.00                     †
 5-9                    0.00                     †
 10-14                  0.00                     †
 15-19                  0.00                     †
 20-24                  0.16                     †
 25-29                  0.42                     †
 30-34                  0.88                     †
 35-39                  1.48             y = 2.28 - 0.10·x    0.273        0.032               31.41 (-23,10 – 85.91)
 40-44                  1.80                     †
 45-49                  2.34                     †
 50-54                  2.82                     †
 55-59                  3.56                     †
 60-64                  3.45                     †
 65-69                  3.42
 70-74                  5.42             y = 2.90 + 0.32·x    0.430        0.004               12.86 (-14.41 – 40.14)
 75+                    8.32                     †


(3.8 and 2.2) in Southern Europe (2.7 and 1.6). The esti-     Poland (4.0 and 2.4 per 100,000 inhabitants), Slovakia
mated standardized mortality rate for malignant melanoma      (4.8 and 3.2 per 100,000 inhabitants), Finland (4.4 and
for men and women in 2018 in Europe is the lowest in Al-      1.7 per 100,000 inhabitants), Norway (6.3 and 4.1 per
bania (0.8 and 0.6 per 100,000 inhabitants), Montenegro       100,000 inhabitants) and the Netherlands (4.6 and 3.1 per
(1.2 and 1.3 per 100,000 inhabitants), Romania (1.9 and 1.4   100,000 inhabitants) [24].
per 100,000 inhabitants), Spain (1.9 and 1.3 per 100,000            Men are approximately 1.5 times more likely to de-
inhabitants). On the other hand, the highest values for men   velop melanoma than women. The incidence of melanoma
and women are in Croatia (4.6 and 2.5 per 100,000 inhab-      is higher in women than in men until they reach the age of
itants), North Macedonia (4.0 and 2.2 per 100,000 inhab-      40, however, from the age of 75, the incidence is almost three
itants), Slovenia (4.8 and 3, 2 per 100,000 inhabitants),     times higher in men than in women [25]. Mortality from



4                                                                     Original Article | Dermatol Pract Concept. 2023;13(1):e202308
                                                600
                                                                                                                    y = -8.7001x + 582.67; р=0.001; %change=-8.83

        Age standardized rates (per 100.000)
                                                500


                                                400


                                                300


                                                200
                                                                                                                    y = 0.6341x + 115.13; p=0.004; %change=+0.27


                                                100
                                                                                                                    y = 0.0194x + 1.3682; p=0.375; %change=+197
                                                     0
                                                              1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

                                                                        All causes                 All malignant tumors                      Malignant melanoma

           Figure 1. Trends of age-adjusted mortality rates for all causes of death, all malignant tumors and malignant melanoma in
           Central Serbia in the period 1999-2015.




                                               180

                                                                                                   y = 0.4255x+ 144.37; p=0,04; % change = +0.51
                                               160
        Age standardized rates (per 100.000)




                                               140
                                                                                              y = 0.6342x + 115.13 p=0.004; % change=+0.27

                                               120

                                                                                              y = 0.2038x + 93.92; p=0.106; % change=+0.08
                                               100


                                               80


                                               60


                                               40
                                                           99      00      01     02     03     04        05     06      07      08     09     10     11     12     13     14     15
                                                         19      20      20     20     20     20      20       20      20      20     20     20     20     20     20     20     20

                                                                                                   both              males            females

           Figure 2. Trends of age-adjusted mortality rates all malignant tumors in Central Serbia by sex, in the period 1999-2015.




malignant melanoma begins to rise sharply in men aged 40-                                                                     When age is taken into account, adolescents and young
44 and is especially high in those over 60 years of age. In                                                            adult women are more susceptible to melanoma than men
women, a sharp increase was also observed at the age of                                                                [20]. This could be partly due to the widespread use of tan-
40-44, while the rate is especially high between the ages of                                                           ning beds among women, which is associated with an in-
55 and 59. In some countries, the increase in the standard-                                                            creased risk of melanoma [11]. However, after the age of 40,
ized mortality rate for those over the age of 85 is twenty                                                             the incidence rate of melanoma among men is higher than
times higher than for those at the age of 40-44 (Australia                                                             among women [25]. Some believe that this increased sen-
42.65 per 100,000 and 2.62 per 100,000) [18].                                                                          sitivity in men may be partly influenced by androgens [26].



Original Article | Dermatol Pract Concept. 2023;13(1):e202308                                                                                                                          5
                                               3.5

                                                3                    y = 0.0486x + 1.5494 ; p=0.036; % change = +6.26
        Age standardized rates (per 100.000)

                                               2.5

                                                2                        y = 0.0194x + 1.3682 ; p=0.009; % change=+1.94

                                               1.5

                                                1
                                                                         y = -0.0124x + 1.3282; P=0.088; % change=+0.43
                                               0.5

                                                0
                                                     19992000200120022003200420052006200720082009201020112012201320142015

                                                                        both       males          females
           Figure 3. Trends of age-adjusted malignant melanoma mortality rates in Central Serbia, by sex, in the period 1999-2015.




Higher survival rates in women are also attributed to bio-                                 Many authors state that melanoma is more common
logical differences such as oxidative stress response, sex hor-                        in the elderly [30,31]. The results of our study also con-
mones or vitamin D metabolism and other influencing factors                            firmed that age is a significant risk factor for malignant mel-
that have yet to be explored [27]. Speculation about the link                          anoma. Mortality rates are highest in people aged 75 and
between steroid hormones and melanoma arose when pop-                                  older in both sexes, with the highest percentage increase
ulation studies found that women had a higher survival rate                            in mortality recorded in the 35-39 age group in women,
than men, which was evident between 1973 and 1997 when                                 and in the oldest age groups in men (65-69, 70-74, and 75
men had a death rate from melanoma that was twice as high                              and older).
as in women [28]. Furthermore, the history of malignant                                    Similar to our results, a study conducted by Karimkhani
melanoma in women is rare before puberty and then in-                                  et al found that malignant melanoma mortality rates are
creases sharply during the reproductive period and decreases                           highest in the 75-79, 70-74, and 80 and older age groups
during the menopausal years, which implies the involvement                             [30]. In America, the percentage share of individual age
of estrogen. This phenomenon has led to the suggestion that                            groups in the total number of deaths shows the highest per-
hormones play an important role in melanoma. However,                                  centage (23.9%) in the 75-84 age group [32].
the results of epidemiological studies that assess the risk of                             Older adults have more cumulative sun exposure than
melanoma in relation to hormonal and reproductive factors,                             younger ones, and each additional decade of intense sun
such as the use of oral contraceptives, pregnancy and meno-                            exposure increases the risk of melanoma [33,34]. The re-
pause, are contradictory; some studies did not show a cause-                           sults of epidemiological research show that high sun ex-
and-effect relationship, while others found an increased risk                          posure in the first 10 years of life more than doubles the
of melanoma [26,29]. Thus, the existence of a link between                             risk of melanoma, while intense, occasional sun exposure
hormones and melanoma remains uncertain.                                               during each decade until the age of 29 increases the risk
    Other authors believe that these gender differences may be                         of melanoma by more than 1.5 times [35]. More than five
partly due to low rates of sun protection and more time spent                          sunburns double the risk of melanoma for both those un-
outdoors during life compared to women. In addition, men are                           der 15 and those over 15 years of age. However, other
less likely to use sunscreen compared to women and are less                            studies have found that the number of sunburns before
aware of the importance of preventive measures, so melanoma                            the age of 30 significantly increased the risk of melanoma,
is usually detected when the disease is present at an advanced                         and the positive connection with the risk of melanoma
stage, while women are more willing to seek medical help earlier                       is weaker in burns that occurred in those older than 30
and thus to detect changes in the earlier stage of the disease [5].                    years [36].




6                                                                                           Original Article | Dermatol Pract Concept. 2023;13(1):e202308
Conclusion                                                              7. GLOBOCAN 2020. Cancer Incidence and Mortality Worldwide.
                                                                           Accessed March 19, 2020. Available from: http:// https://gco.
The trend of increasing mortality from malignant melanoma                  iarc.fr/
                                                                        8. Boyers LN, Karimkhani C, Naghavi M, et al. Global mortal-
in Serbia is similar to those in most developed countries. Due
                                                                           ity from conditions with skin manifestations. J Am Acad Der-
to the high incidence of malignancies and their high mor-                  matol. 2014; 2. pii: S0190-9622(14)01869-6. DOI: https://doi.
tality rates, the prevention of malignant diseases has a huge              org/10.1016/j.jaad.2014.08.022
public health potential and represents the most effective ap-           9. Lin L, Yan L, Liu Y, Yuan F, Li H, Ni J. Incidence and death in
proach to the control of malignant diseases. Given the strong              29 cancer groups in 2017 and trend analysis from 1990 to 2017
and continuous trend of demographic aging and the grow-                    from the Global Burden of Disease Study. J Hematol Oncol.
                                                                           2019;12(1):96. DOI: 10.1186/s13045-019-0783-9
ing burden of the disease, it is estimated that a significant
                                                                       10. Sneyd MJ, Cox B. A comparison of trends in melanoma mor-
number of new cases of melanoma could be prevented by                      tality in New Zealand and Australia: the two countries with the
implementing effective prevention measures ranging from                    highest melanoma incidence and mortality in the world. BMC
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