Background
Cutaneous melanoma (CM) is the leading cause of skin cancer mortality with associated high healthcare costs. Up-to-date reporting of epidemiological trends for CM is required to project future trends, assess the burden of disease, and aid evaluation of new diagnostic, therapeutic and preventative strategies.

Objectives
To describe the trends in CM mortality, incidence, mortality-to-incidence indices (MIIs) and disability-adjusted life-years (DALYs) over the last 3 decades.

Methods
A population-based cross-sectional study of the Global Burden of Disease (GBD) database between 1990 and 2019 was performed. Nineteen high income countries with similar health expenditure and classified as having high-quality mortality data including the UK, USA, Australia and selected European Union countries were included. Annual age-standardised incidence rates (ASIRs), age-standardised death rates (ASDRs) and DALYs for each country were extracted. Mortality-to-incidence indexes were calculated by dividing the ASDR by the ASIR. Trends were described using Joinpoint regression analysis.

Results
Almost all countries demonstrated increasing ASDR in males over the observation period with greatest percentage increase in Greece (+87%), and there was greater heterogeneity between countries in females. CM mortality was greater for males than females in all countries. The most recent Joinpoint analysis shows significantly decreasing mortality in all countries except the UK (+0.5% males between 2007-2019, +0.1% females between 2002-2019). Incidence rates increased in all countries, with evidence of plateau from 2015 onwards. While MIIs cannot be used as a proxy for survival, statistically significant decreases in MII were observed in all countries. Overall, DALYs remained static.

Conclusions
Over the past 30 years, CM mortality and incidence has increased in most EU15+ countries. There is evidence that in recent years, CM mortality is decreasing. The burden of disease as assessed using DALYs has remained mostly unchanged. Future work should not solely focus on expensive innovative therapies, but also on optimising primary prevention.

Key learning points:
• Why was the study undertaken? Cutaneous melanoma is one of the most aggressive skin cancers and accounts for the majority of skin cancer deaths. Understanding previous epidemiological trends aids future trend predictions and may also guide disease management and prevention strategies. We firstly aim to present an up-to-date analysis of CM trends across high-income countries and relatively high-quality data. Secondly, we aim to compare these mortality trends with trends in melanoma incidence across the same time period.
• What does this study add? Almost all countries demonstrated increasing age-standardised death rates in males over the observation period, with greater heterogeneity between countries in females. The most recent trend analysis between 2016 and 2019, shows significantly decreasing mortality in all countries except the UK. Despite significant innovation in management strategies including high-cost systemic therapies, overall, disability-adjusted life years remained static.
• What are the implications of this study for disease understanding and/or clinical care? Further research into the disparities between the countries studied and trends in cutaneous melanoma mortality rate should be taken. Given the generally unchanged disability-adjusted life years over the observation period and the financial strain associated with innovative therapies, research and public health initiatives may wish to prioritise more cost-effective strategies including primary prevention.