ORIGINAL CONTRIBUTION

Increased Melanoma Risk in Parkinson Disease

A Prospective Clinicopathological Study
John M. Bertoni, MD, PhD; John Philip Arlette, MD, FRCPC; Hubert H. Fernandez, MD; Cheryl Fitzer-Attas, PhD;
Karen Frei, MD; Mohamed N. Hassan, MD, PhD; Stuart H. Isaacson, MD; Mark F. Lew, MD; Eric Molho, MD;
William G. Ondo, MD; Tania J. Phillips, MD; Carlos Singer, MD; James P. Sutton, MD; John E. Wolf Jr, MD;
for the North American Parkinson’s and Melanoma Survey Investigators

Objective: To evaluate the possible association of Par-
kinson disease (PD) and melanoma in North America.
Design, Setting, and Patients: Thirty-one centers
enrolled patients with idiopathic PD. At visit 1, a neu-
rologist obtained a medical history. At visit 2, a derma-
tologist recorded melanoma risk factors, performed a
whole-body examination, and performed a biopsy of le-
sions suggestive of melanoma for evaluation by a cen-
tral dermatopathology laboratory. We compared overall
prevalence of melanoma with prevalence calculated from
the US Surveillance Epidemiology and End Results (SEER)
cancer database and the American Academy of Derma-
tology skin cancer screening programs.
Results: A total of 2106 patients (mean [SD] age, 68.6
[10.6] years; duration of PD, 7.1 [5.7] years) completed
the study. Most (84.8%) had received levodopa. Derma-
tology examinations revealed 346 pigmented lesions; der-
matopathological findings confirmed 20 in situ melano-
mas (0.9%) and 4 invasive melanomas (0.2%). In addition,
histories revealed 68 prior melanomas (3.2%). Preva-
lence (5-year limited duration) of invasive malignant mela-
noma in the US cohort of patients with PD (n=1692) was
2.24-fold higher (95% confidence interval, 1.21-4.17) than
expected in age- and sex-matched populations in the US
SEER database. Age- or sex-adjusted relative risk of any
melanoma for US patients was more than 7 times that
expected from confirmed cases in American Academy of
Dermatology skin cancer screening programs.
Conclusions: Melanoma prevalence appears to be higher
in patients with PD than in the general population. De-
spite difficulties in comparing other databases with this
study population, the study supports increased mela-
noma screening in patients with PD.
Arch Neurol. 2010;67(3):347-352

Author Affiliations are listed at
the end of this article.
Group Information: The North
American Parkinson’s and
Melanoma Survey Investigators
are listed on page 352.
A
N ASSOCIATION BETWEEN
Parkinson disease (PD)
and melanoma has long
been suspected, but
whether the association is
with the dopaminergic treatments or with
the disease itself remains a question. The
introduction of levodopa therapy for PD
in 1970 was followed 2 years later by a case
report suggesting that the drug might pre-
cipitate recurrence of malignant mela-
noma.1 In the intervening years, no con-
trolled study has assessed the possible
relationship of levodopa and melanoma,2
and the strength of the association has been
debated. As of 1999, the manufacturer had
reported 50 drug safety reports of malig-
nant melanoma possibly associated with
carbidopa/levodopa therapy.3 More than
35 articles have been published, but the
largest series presented only 11 new cases.4
The total number of cases is relatively
small, considering that more than 200 000
cases of melanoma are identified in the
United States within any given 5-year pe-
riod, and more than 1 million Americans
are taking levodopa.4,5
Some hypothesize that PD itself might
be associated with melanoma. A Danish
retrospective medical record review of
hospitalized patients revealed twice the
risk of melanoma among patients with
PD than in the age-matched general
population. 6 More recently, the inci-
dence of PD was reported to be more
than twice as high in patients with malig-
nant melanoma than in age- and sex-
matched control subjects.7 A retrospec-
tive analysis of the Deprenyl and
Tocopherol Antioxidative Therapy of
Parkinsonism (DATATOP) trial likewise
found a higher than expected incidence
of malignant melanoma.8
The present 31-center study was de-
signed to evaluate the possibility of an as-
sociation between PD and melanoma in
North America. The study prospectively
screened patients with PD to establish the
prevalence of melanoma, other skin can-
cers, and premalignant skin lesions. We

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 (SEER) US Cancer Statistics Review of 1975 to 2002,5 an ongoing
Table 1. Demographics of 2106 Patients With Idiopathic epidemiologic survey conducted by the National Cancer Institute;
Parkinson Disease (PD) and (2) clinical screening data were compared with the American
Academy of Dermatology (AAD) skin cancer screening programs
Characteristic Data a from1985to1999,9,10 withfollow-upforconfirmedmelanomacases
Sex from 1992 to 1994.11 In the present survey, written documenta-
Female 669 (31.8) tion was obtained for 70% and 100% of cases in the SEER and AAD
Male 1437 (68.2) analyses, respectively. For both, the ratios of observed to expected
Race cases were adjusted to the age and sex of the survey population.
White 1957 (92.9)
Asian 58 (2.8)
Other 91 (4.3) RESULTS
Age, y
ⱖ65 1383 (65.7)
Mean (SD) 68.6 (10.6) PATIENT DEMOGRAPHICS
Tobacco use b AND DISEASE HISTORY
Never 1199 (57.0)
Former 834 (39.7)
Current 69 (3.3)
Of 2295 PD patients recruited by neurologists, 2106 com-
Duration of PD, mean (SD), y 7.1 (5.7) pleted the study according to the protocol (Table 1), 414
Hoehn and Yahr stage, mean (SD) c 2.2 (0.7) in Canada and 1692 in the United States. Numbers of pa-
Use of dopaminergic drugs (past and current) tients recruited per site varied from 8 to 131. The main rea-
Any prior use 2035 (96.6)
Levodopa 1786 (84.8)
sons for early terminations (189 [8.2%]) were patient re-
Pramipexole dihydrochloride 704 (33.4) fusal to undergo the dermatologic examination and patient
Amantadine hydrochloride 446 (21.2) withdrawal of consent. The mean age of enrolled patients
Entacapone 405 (19.2) was 68.6 (range, 31-100) years. The mean duration of PD
Ropinirole hydrochloride 335 (15.9)
Selegiline hydrochloride 317 (15.1)
was 7.1 (range, 0-48) years. The Hoehn and Yahr stage
Pergolide mesylate 225 (10.7) ranged from 2.0 to 3.0 (mean, 2.2) (Table 1).
Tolcapone 45 (2.1) Nearly all of the patients (96.6%) were taking or had
Bromocriptine 25 (1.2) taken a dopaminergic agent (Table 1), most commonly
No dopaminergic agent 71 (3.4)
levodopa (84.8% of the patients). The distribution of do-
a Unless otherwise indicated, data are expressed as number (percentage) paminergic agents matched the clinical use of these agents
of patients. at the time of this study (US data from the 2005 Na-
b Includes 2102 patients.
tional Prescription Audit; IMS Health, Norwalk, Con-
c Includes 2030 patients.
necticut; http://www.imshealth.com/media).
compared this prevalence with those from existing large- The mean (SD) number of melanoma risk factors per
scale surveys. patient was 3.0 (2.3). Most patients (85.0%) had at least
1 risk factor, and 69.2% had at least 2, most commonly
fair skin (56.9% of patients), blue eyes (42.0%), and se-
METHODS
vere or blistering sunburns in childhood (40.9%)
(Figure). A family history of melanoma was reported by
PATIENTS AND STUDY SITES
6.2% and prior melanoma by 3.4%. Written documen-
This 31-center, North American study enrolled adults with id- tation confirming the date and type of prior melanoma
iopathic PD from January 13 through September 7, 2003. At was obtained in 23 of 72 cases; others were classified on
visit 1, each movement disorder neurologist recruited PD pa- the basis of patients’ reports (Table 2).
tients, obtained informed consent, recorded demographic in-
formation, obtained a medical history, verified the PD diagno- DERMATOLOGIC EXAMINATION AND BIOPSY
sis, and recorded current medications. Study sites were guided
to offer participation to (1) all patients with early PD at the clin- From the dermatologic examinations, 519 patients were
ics who had not been treated with levodopa, (2) patients with reported with lesions; 346 of these were pigmented le-
non–motor-fluctuating PD who were receiving levodopa, and
(3) patients with advanced motor-fluctuating PD. Because this
sions, of which 294 were biopsied per the dermatologist’s
survey was part of a risk assessment program, patients could recommendation. An additional 98 patients with nonpig-
not have been previously exposed to rasagiline mesylate, an ex- mented lesions were also biopsied, for a biopsy rate of 18.6%
perimental drug at the time. At visit 2, a dermatologist later re- of total study patients. Of patients undergoing biopsy, 24
corded melanoma risk factors and reported previous skin dis- (1.1% of the original cohort) were newly diagnosed as hav-
orders, performed a whole-body dermatologic examination, and, ing invasive or in situ melanoma (Table 2).
at his or her discretion, performed a biopsy of skin lesions sug-
gestive of melanoma. If previous melanoma was noted, a con- FURTHER ANALYSIS OF MELANOMA CASES
certed effort was made to obtain documentation. A central der-
matopathology laboratory supervised by Clifton R. White Jr,
MD, Oregon Health Sciences University, Portland, evaluated
In this survey, 68 patients (3.2%) were diagnosed as hav-
the biopsy specimens for neoplasms. ing melanoma by history alone, 20 (0.9%) had newly di-
The following 2 analyses evaluated melanoma prevalence: (1) agnosed disease, and 4 (0.2%) had a history of mela-
histories and clinical screening data were compared with preva- noma and a newly diagnosed melanoma. The average age
lence expected on the basis of the 5-year limited-duration preva- of the patients with melanoma was significantly older than
lence reported in the Surveillance Epidemiology and End Results the average age of the melanoma-free patients (Table 3).

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 60

50

40
% of Patients

30

20

10

a∗
n

es

ho rn

ir

se er

sio r

ra r

no ory

M tly

n
Le la

he he
vit

kle

ol
io

Ta

sio
Ha

re nc
ild bu
Ey

ng en
d gu

m
lM
od

py

e
ex

ot Ot

ela st
iti

nt
ec

ol

es
r P Ca
Ch un

gi ist

no
te rre

M Hi
ue
pl

ns

yt
Re

ita

di or
Fr

pr
om

in S

an rs

ela
t o in
Bl

Se

ilit

of ily
en e/I

en

up
Ra A

Ch /Pe
g

or

as Sk

rM
V
ab
C

gm rg
rin

ng

os
PU
de

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ge
ir

(P er

Pi La
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te

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an
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≥1
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/B

Im
re
ve
Se

Figure. Proportions of patients with known melanoma risk factors (N = 2106). PUVA indicates psoralen–UV-A. *Includes 1 patient for whom the date of melanoma
diagnosis was missing.

Table 2. Prevalence of Melanoma and Other Skin Lesions Table 3. Demographic Correlates of Patients With Melanoma

Patients, Patients
No. of No. (%) Patients With Any
Dermatologic Finding Reports (N=2106) Without Melanoma
Melanoma at Any Time
Prior melanoma based on history 72 (3.4) a
Correlate (n=2014) (n=92) P Value
Malignant melanoma in situ 39 (1.9)
Invasive malignant melanoma 27 (1.3) Age, mean (SE), y 68.4 (0.2) 72.6 (0.9) ⬍.001 a
Unclassified melanoma 6 (0.3) Male, % 68.0 74.2 .15 b
Lesions suggestive of melanoma on examination 519 (24.6) PD duration, mean (SE), y 7.1 (0.1) 7.2 (0.5) .84 c
Patients with pigmented lesions suggestive of 346 (16.4) b Hoehn and Yahr score, mean (SE) 2.2 (0.02) 2.4 (0.1) .009 c
melanoma No. of melanoma risk factors, 2.9 (0.1) 5.3 (0.3) ⬍.001 c
Significant biopsy findings c 656 392 (18.6) mean (SE)
Malignant melanoma in situ 20 20 (0.9) Receiving levodopa therapy, % 84.9 82.8 .55 b
Invasive malignant melanoma 4 4 (0.2)
Basal cell carcinoma 117 86 (4.1) a Calculated using the 2-sample t test.
Actinic keratosis 31 29 (1.4) b Calculated using the ␹2 test.
Squamous cell carcinoma 28 22 (1.0) c Calculated using the Wilcoxon 2-sample test.
Melanocytic nevus (including simple lentigo) 289 179 (8.5)
Pigmented lesions (nonmelanocytic) 124 95 (4.5)
Other skin malignant neoplasms d 1 1 (0.05) ing the 5 years before study enrollment. Based on the SEER
Other skin lesions 42 41 (1.9) 5-year limited-duration prevalence,5 4.46 cases of invasive
a Date of the melanoma diagnosis was missing for 1 patient, who was not melanoma would be expected in a population of this size,
included in the Table. Four patients with a history of melanoma were also age, and sex. Thus, the RR for invasive malignant melanoma
diagnosed as having melanoma during the initial dermatologic evaluation. in our US study population compared with SEER data was
b Fifty-two of 346 patients with pigmented lesions suggestive of melanoma
2.24 (95% confidence interval [CI], 1.21-4.17). Regardless
did not undergo a biopsy, leaving 294 who did.
c The 392 patients who underwent biopsies consisted of the 294 patients with of whether the combined North American data or only the
pigmented lesions and 98 patients with nonpigmented lesions, all suggestive of US data were used for comparison, the RR for melanoma ap-
melanoma. Some patients underwent more than 1 biopsy and had more than 1 peared to be higher in PD patients than in surveys of the gen-
finding. eral population (Table 4). This difference was significant for
d Excludes malignant melanoma, basal cell carcinoma, and squamous cell
carcinoma. the US data.
Dermatologic screening identified 24 cases of mela-
For patients with melanoma, PD severity was signifi- noma of any stage. Compared with the expected num-
cantly worse by Hoehn and Yahr scores, and the average ber of cases in a population of this size based on sex- or
number of risk factors was significantly higher. Sex, PD age-adjusted results of the AAD skin cancer screening pro-
duration, and current levodopa use did not differ signifi- grams, the RRs for confirmed melanoma in our study
cantly for patients with or without melanoma (Table 3). population were 7.08 and 7.13 (sex and age adjusted, re-
spectively) in the United States and 6.21 and 6.28 (sex
HISTORICAL MELANOMA DATABASES and age adjusted, respectively) in North America
(Table 4), significantly higher than expected.
The frequency of melanoma was compared with prevalence
in 2 existing US databases using relative risk (RR; Poisson COMMENT
model) (Table 4). From the US centers, a total of 10 in-
vasive melanoma cases were detected during the dermato- Malignant melanoma, although potentially fatal, is a cur-
logic examination or were documented as diagnosed dur- able disease if treated early. Establishing that PD is a ma-

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 Table 4. Comparison of Melanoma Risk in Current Survey vs Expected a
Invasive Melanoma
Age-/Sex-Adjusted
SEER Data
No. of
Cases Expected No.
Observed of Cases RR (95% CI)
United States only (n=1692) 10 4.46 2.24 (1.21-4.17)
United States and Canada (N=2106) 10 5.47 1.83 (0.98-3.40)
Abbreviations: AAD, American Academy of Dermatology; CI, confidence interval; RR, relative risk; SEER, Surveillance Epidemiology and End Results database.
a Data are from the National Cancer Institute5 and Geller et al.10,11
jor risk factor for malignant melanoma therefore has the
potential for raising awareness and saving lives.
PREVALENCE OF MELANOMA IN PD PATIENTS
COMPARED WITH THE GENERAL POPULATION
Apparent associations between PD and melanoma must be
interpreted with caution. Our survey of PD patients offers
evidenceofaconsiderablyhighermelanomaprevalencethan
in the population at large. The results must be interpreted
carefully because of the differences in the way our data were
collected compared with the historical melanoma data re-
corded in the SEER database or from AAD screening. We
screened more aggressively and completely than was done
for the historical data. This careful screening might be ex-
pected to enhance diagnosis and better approximate the ac-
tual prevalence of melanoma in PD. The lack of a biopsy in
52 patients would be expected to cause an underestimation
of melanoma frequency, strengthening the observation of
an elevated melanoma frequency in the PD population. On
the other hand, for the SEER comparison, written documen-
tation substantiated the history of melanoma in 70% of cases,
so misclassification is possible but unlikely.
Finding an appropriate population for comparison is dif-
ficult. The SEER registry data are from hospital records. One
of their statistics is derived from a 5-year, limited-duration
prevalence counting method, which determines the propor-
tion of people alive on a certain day who had a diagnosis of
melanoma within the past 5 years. The National Cancer In-
stitutenormalizesthedatatothepopulationwithinthecatch-
ment areas of each participating hospital. The hospital-based
source minimizes early (in situ) melanoma, essentially re-
porting only invasive melanoma, which is much less preva-
lent than in situ melanoma. The risk-factor profiles of the
patients are not well specified, and the methods of detection
are not standardized. However, even if only invasive mela-
nomas in the present study are considered, the incidence of
malignant melanoma in our US patients is twice as high as
that expected from the SEER data.5
The question arises about whether the frequencies of
major risk factors in our population of PD patients might
differ in important ways from the frequencies in the refer-
ent populations. We adjusted for age and sex because older
age and male sex are known risk factors for melanoma.12
For example, it may be that men are at higher risk because
they tend to be employed in activities with more sun ex-
posure. The SEER and AAD databases do not report fre-
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Any Melanoma
Expected Confirmed
Melanoma, AAD Data RR (95% CI),
No. of AAD Data
Cases Age Sex
Observed Adjusted Adjusted Age Adjusted Sex Adjusted
22 3.08 3.11 7.13 (4.65-10.95) 7.08 (4.62-10.87)
24 3.82 3.86 6.28 (4.16-9.47) 6.21 (4.12-9.37)
quencies of melanoma risk factors in a manner that allows
for comparison, but a rough estimate of the frequency of
such risk factors in the United States can be obtained from
a combined database of 178 155 white North American
health care professionals described by Cho and col-
leagues.12 A history of severe sunburn in childhood was re-
ported by 40.9% of our patients compared with 77% in the
combined database. In the combined database, 18% of the
subjects had blond or red hair compared with 24.0% in ours;
4% had a family history of melanoma compared with 6.2%
in ours; and 44% had more than 1 large mole compared
with 19.6% with a pigmented lesion or congenital mole in
ours.12 If such differences exist between our population of
PD patients and the general North American population
from which they are drawn, the frequency of melanoma
may be skewed in complex ways.
AretrospectiveanalysisofPDpatientsfromtheDATATOP
trial likewise calculated that the incidence of melanoma in
PD patients was 3-fold higher than that expected on the ba-
sis of demographically matched patients from the SEER da-
tabase.8 As in our study, no relationship between levodopa
therapy and melanoma onset was discerned.
The AAD conducted screening at voluntary, free skin
examinations,10 resulting in subjects who were self-
selected and possibly motivated by concern about a skin
lesion. On the other hand, people with diagnosed mela-
noma may be under a physician’s care and unlikely to come
for community screenings. The AAD population was skewed
toward women (61%), higher educational levels (55% col-
lege or graduate school), and white race (94.9%) and tended
to be younger (41.6% who were younger than 51 years)
than PD patients.10 The net effect on melanoma preva-
lence is hard to predict given the much younger age, which
would reduce melanoma risk, and the self-selection, which
would increase melanoma risk. The rates at which history
of melanoma (known to be an important risk factor) were
reported were similar for the AAD population and the PD
patients in our sample.
RELATIONSHIP OF LEVODOPA USE
OR PD TO MELANOMA
Our finding of increased melanoma prevalence in PD pa-
tients might be confounded if levodopa increased the risk
of melanoma. However, a recent Danish case-control study
of patients with malignant melanoma revealed no evi-
dence that levodopa affected melanoma risk despite a 4-
WWW.ARCHNEUROL.COM
 to 5-fold increase in risk for malignant melanoma in PD
patients.13 Our study likewise provides no evidence that
levodopa use increases the incidence of melanoma.
Uncertainty about the role of medications as risk fac-
tors for melanoma in PD has led to changing guidelines.
Contraindications in the prescribing information of car-
bidopa/levodopa, ropinirole hydrochloride, rotigotine, and
pramipexole dihydrochloride note that epidemiologic stud-
ies have shown that PD patients have a higher risk (per-
haps 2- to 4-fold higher) of developing melanoma than does
the general population, but whether the risk can be attrib-
uted to PD or to drugs used to treat PD is unclear. They
therefore recommend periodic dermatologic screening by
a qualified dermatologist. Similar statements appear in sele-
giline hydrochloride and rasagiline prescribing informa-
tion. As suggested by the wording in the prescribing in-
formation, published evidence suggesting a link between
specific PD medications and melanoma is weak. During the
34 years since the association was first suggested, approxi-
mately 40 articles have described cases and editorialized
about the association.1-4,13-15 However, no controlled stud-
ies substantiate that the melanomas are drug related. Our
study does not support the idea that dopaminergic medi-
cations increase the risk of melanoma beyond that ex-
pected in PD patients.
STUDIES OF THE PREVALENCE
OF MELANOMA IN PD
Several systematic surveys suggest a relationship be-
tween PD and melanoma or skin cancer. A survey of 7046
PD patients in Denmark found a positive association of
PD with melanoma (RR, 1.96; 95% CI, 1.1-3.2) and other
skin cancers (1.24; 1.0-1.5),16 which was confirmed in a
survey of 14 088 patients.6 This group also found an el-
evated incidence of malignant melanoma and skin car-
cinoma in PD patients (odds ratios, 1.44 and 1.26,
respectively).17 A retrospective case-control study of 202
PD patients in Minnesota reported an RR of 1.76 (95%
CI, 1.07-2.89) for nonmelanoma skin cancer.18 These data
all suggest that the increased incidence of melanoma in
PD patients is related to the disease rather than to treat-
ments.17 Recently, a large-scale, controlled prospective
study in the United States demonstrated a 6-fold in-
creased risk of melanoma in PD patients.19
Looking at the relationship from the opposite per-
spective, a review of PD patients from the SEER data-
base noted that melanoma was the only cancer associ-
ated with significantly increased mortality risk.20
CONCLUSIONS
This is, to our knowledge, one of the few large studies of the
possible association of PD and melanoma and the only study
that includes prospective dermatologic examinations. The
data suggest that risk of melanoma may be higher in PD pa-
tients than in comparable populations. Our findings sup-
port earlier studies suggesting that melanoma prevalence is
higher in PD patients than in the general population.
This study provides the best estimate to date of the cur-
rentprevalenceofmelanomainPDpatientsinNorthAmerica
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(24 of 2106 [1.1%]). Comparisons with the population at
largearenotdefinitivebecausenosimilardermatologicscreen-
ingprogramhasbeenperformedonamatchedcohortwithout
PD. Existing epidemiologic data on melanoma prevalence
are not optimal for comparison because of likely biases.
Our study cannot provide an estimate of the incidence
of melanoma in PD patients because it is based on a single
dermatologic examination. Regardless of the exact preva-
lence of melanoma in the general population, a preva-
lence of greater than 1% warrants increased vigilance and
regular screening for melanoma in PD patients.
Accepted for Publication: September 1, 2009.
Author Affiliations: Department of Neurological Sci-
ences, University of Nebraska Medical Center and Vet-
erans Affairs Medical Center, Omaha (Dr Bertoni); Di-
vision of Surgical Oncology, University of Calgary,
Calgary, Alberta, Canada (Dr Arlette); Departments of
Neurology, University of Florida, Gainesville (Dr Fer-
nandez), Hartford Hospital, Hartford, Connecticut (Dr
Hassan), Keck School of Medicine of University of South-
ern California, Los Angeles (Dr Lew), Baylor College of
Medicine, Houston, Texas (Dr Ondo), and University of
Miami School of Medicine, Miami, Florida (Dr Singer);
Teva Pharmaceutical Industries Ltd, Netanya, Israel (Dr
Fitzer-Attas); The Parkinson’s & Movement Disorders
Institute, Fountain Valley, California (Dr Frei); Parkin-
son’s Disease and Movement Disorders Center, Boca Ra-
ton, Florida (Dr Isaacson); Movement Disorders Cen-
ter, Albany Medical Center, Albany, New York (Dr
Molho); Departments of Dermatology, Baylor College of
Medicine (Dr Wolf ), and Boston University School of
Medicine, Boston, Massachusetts (Dr Phillips); and Pa-
cific Neuroscience Medical Group, Oxnard, California (Dr
Sutton).
Correspondence: John M. Bertoni, MD, PhD, Depart-
ment of Neurological Sciences, University of Nebraska
Medical Center, 982045 Nebraska Medical Center,
Omaha, NE 68198-2045.
Author Contributions: Study concept and design: Ber-
toni. Acquisition of data: Bertoni, Arlette, Fernandez, Frei,
Hassan, Isaacson, Lew, Molho, Ondo, Phillips, Singer, Sut-
ton, and Wolf. Analysis and interpretation of data: Ber-
toni, Fernandez, Fitzer-Attas, Isaacson, Molho, Ondo, and
Wolf. Drafting of the manuscript: Bertoni, Hassan, Lew,
and Molho. Critical revision of the manuscript for impor-
tant intellectual content: Bertoni, Arlette, Fernandez, Fitzer-
Attas, Frei, Isaacson, Lew, Molho, Ondo, Phillips, Singer,
Sutton, and Wolf. Statistical analysis: Bertoni and Fitzer-
Attas. Obtained funding: Bertoni. Administrative, techni-
cal, and material support: Bertoni, Fitzer-Attas, and Hassan.
Study supervision: Bertoni, Frei, and Sutton.
Financial Disclosure: Dr Lew has served as a speaker for
Boehringer Ingelheim, GlaxoSmithKline, Allergan, Sol-
stice, and Teva Pharmaceutical Industries Ltd; as an ad-
visor/consultant for Teva Pharmaceutical Industries Ltd,
Boehringer Ingelheim, Solstice, Novartis, Valeant, Ipsen,
Schering-Plough, GlaxoSmithKline, Solvay, and Ova-
tion; and as a researcher for Teva Pharmaceutical Indus-
tries Ltd, Boehringer Ingelheim, GlaxoSmithKline, Kyowa,
Solstice, Novartis, Schwarz Pharma/UCB, Ipsen, NIH,
Eisai, Mentor, Solvay, and Schering-Plough.
WWW.ARCHNEUROL.COM
 North American Parkinson’s and Melanoma Survey Investigators

Movement Disorders Center, North Shore University Hospital, Chicago, Illinois: Kathleen M. Shannon, MD (principal investigator/
neurologist), and Arthur R. Rhodes, MD (principal dermatologist); Department of Neurology, University of Virginia Health System,
Charlottesville: Madaline B. Harrison, MD (principal investigator/neurologist), and Kenneth E. Greer, MD (principal dermatolo-
gist); The Parkinson’s Institute and Clinical Center, Sunnyvale, California: James W. Tetrud, MD (principal investigator/neurologist),
and Andrew B. Menkes, MD (principal dermatologist); Department of Neurology, University of Miami School of Medicine, Miami,
Florida: Francisco A. Kerdel, MD (principal dermatologist); Division of Neurology, Memorial Hospital of Rhode Island, Pawtucket:
Paul T. Zaydon, MD (principal dermatologist); Parkinson’s and Neurodegenerative Disorder Clinic, Ottawa, Ontario, Canada: Tilak
Mendis, MD (principal investigator/neurologist), and John E. Adam, MD (principal dermatologist); Penn Neurological Institute, Penn-
sylvania Hospital, Philadelphia: Amy Colcher, MD (principal investigator/neurologist), and Susan C. Taylor, MD (principal der-
matologist); Division of Neurology, Royal University Hospital, Saskatoon, Saskatchewan, Canada: Alexander Rajput, MD (principal
investigator/neurologist), and Peter Hull, MD (principal dermatologist); McGill Centre for Studies in Aging, Douglas Hospital, Mon-
treal, Quebec, Canada: Michel Panisset, MD (principal investigator/neurologist), and Marie St. Jacques, MD (principal dermatolo-
gist); Department of Neurology, University of Kansas Medical Center, Kansas City: Rajesh Pahwa, MD (principal investigator/neu-
rologist), and David L. Kaplan, MD (principal dermatologist); Department of Clinical Neurosciences, Medical Clinic at the Foothills
Medical Center, University of Calgary, Calgary, Alberta, Canada: Oksana Suchowersky, MD (principal investigator/neurologist); Emory
University, Atlanta, Georgia: Alan Freeman, MD (principal investigator/neurologist), and Carl V. Washington, MD (principal der-
matologist); Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles: Mark F. Lew, MD (prin-
cipal investigator/neurologist), and Bonnie Kerr, MD (principal dermatologist); Institute for Neurodegenerative Disorders, New Ha-
ven, Connecticut: Danna Jennings, MD (principal investigator/neurologist), and John W. Edelglass, MD (principal dermatologist);
Medical College of Georgia, Augusta: Kapil D. Sethi, MD (principal investigator/neurologist), and Jack L. Lesher Jr, MD (principal
dermatologist); Parkinson’s Disease and Movement Disorders Center, Albany Medical Center, Albany, New York; Jerome Hill, MD (prin-
cipal dermatologist); Boston University Medical Center, Boston, Massachusetts: Marie Helene Saint-Hilaire, MD (principal investigator/
neurologist); Colorado Neurology, PC, Englewood: Rajeev Kumar, MD (principal investigator/neurologist), and Richard G. Asarch,
MD (principal dermatologist); The Parkinson’s & Movement Disorder Institute, Fountain Valley, California: Tien Q. Nguyen, MD (prin-
cipal dermatologist); Veterans Affairs Medical Center, Minneapolis, Minnesota: D. A. Rottenberg, MD (principal investigator/neu-
rologist), and Karen Chen, MD (principal dermatologist); Creighton University, Omaha, Nebraska: Christopher Huerter, MD (prin-
cipal dermatologist); Department of Neurology, Long Island Jewish Medical Center, New Hyde Park, New York: David Cooper, MD
(principal dermatologist); Department of Neurology, University of Connecticut, Hartford: Caron M. Grin, MD (principal dermatolo-
gist);CentreHospitalierdeL’UniversitedeMontreal,Hôtel-Dieu,Montreal,Quebec,Canada:SylvainChouinard,MD(principalinvestigator/
neurologist), and Nathalie Provost, MD (principal dermatologist); University of California, Irvine: Neal Hermanowicz, MD (prin-
cipal investigator/neurologist), and Kenneth Linden, MD (principal dermatologist); Pacific Neuroscience Medical Group, Oxnard,
California: James P. Sutton, MD (principal investigator/neurologist), and Michael R. Bastien, MD (principal dermatologist); Sci-
entific Medical Research, LLC, Delray Beach, Florida: M. Farhan Siddiqui, MD, PhD (principal investigator/neurologist), and Eli Sa-
leebi, MD (principal dermatologist); and Parkinson’s Disease and Movement Disorders Center, Boca Raton, Florida: Stella D. Calo-
brisi, MD (principal dermatologist).

Additional Contributions: Stephanie G. Phillips, PhD, pro-
vided editorial and professional assistance. Shaul Kadosh,
MBA, and Svetlana Rubinchick, BA, of Teva Pharmaceu-
tical Industries Ltd, provided critical statistical analyses.
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