We read with interest the Review article by Tsai and colleagues (Epidemiology and treatment of melanoma in elderly patients. Nat. Rev. Clin. Oncol. 7, 148–152; 2010)1 that offered a good overview on the issues regarding melanomas among the elderly. We would like to add a few comments, specifically concerning melanomas in elderly men, especially with respect to observations made in Europe. Compared with in the USA, differences in incidence and mortality according to age in European countries, such as The Netherlands, are less pronounced, and the difference in incidence between men and women of all ages is less dramatic (Figure 1). For example, in The Netherlands, the total number of newly diagnosed melanoma cases in 2007 was 3,722, 58% of which were in patients aged <60 years at diagnosis. By contrast, the number of melanoma deaths in 2007 was 661, 40% of which were in patients aged <60 years at diagnosis.2 As Tsai et al.1 mention, mortality rates in recent years had decreased in the USA, whereas in numerous European countries the rates increased,3,4 especially among elderly men.

Figure 1
figure 1

Age-specific melanoma incidence and mortality in The Netherlands in 2007.

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In addition to the relatively high melanoma incidence and poor survival rates owing to their older age, elderly men with melanoma are also at greater risk of dying of melanoma than their female counterparts. Research indicates that the known melanoma survival disadvantage in men persists at older age, and is independent of prognostic factors such as age, body site, ulceration or tumor thickness,5,6,7 and even mitotic rate.8 The prognostic effect of age on survival might be largely dependent on the patient's gender.6 Interestingly, tumor behavior or tumor–host interaction may actually be different in elderly men compared with women, as these patients are more often than women diagnosed with rapid growing primary tumors.9

Summarizing the evidence, it is unlikely that delayed presentation or age alone can explain this phenomenon of poor survival in men with melanoma. Consequently, future screening campaigns should focus on men—especially older men. Unfortunately, most campaigns for early detection usually attract young women; for example, melanoma awareness, screening days or campaigns that aim to improve awareness on the risks of skin cancer and the need to inspect the skin for suspicious lesions in other ways. However, a study published in 2009 of the Belgian Euromelanoma campaign, in which the Belgian former Prime Minister featured prominently, showed that it is possible to attract elderly men to these campaigns.10

We feel that the public, physicians and researchers need to be aware of the substantial disadvantage in terms of melanoma survival in men at all ages. Elderly men deserve particular attention, as the combined disadvantages of being male, older and the relative high incidence of melanoma in this subgroup lead to high mortality rates. This heightened attention should be translated into more specifically targeted instructions to improve early detection among elderly men as well as to promote research into the mechanisms behind these survival disadvantages.