Physician Skin Examinations for Melanoma Screening
A variety of estimates of the value and impact of physician skin examinations (PSEs) in screening for melanoma have been published. Although current melanoma screening guidelines vary, new evidence supports improved melanoma outcomes associated with PSEs. In this systematic review, we evaluated 5 observational studies of the impact of PSEs on melanoma thickness at diagnosis and melanoma mortality rates. Although definitive evidence from randomized controlled trials supporting improved health outcomes associated with PSEs is lacking, these well-designed observational studies have found PSEs to be correlated with thinner melanomas at diagnosis and reduced melanoma mortality rates.
Practice Points
- Current guidelines regarding melanoma screening are inconsistent.
- There is a growing pool of evidence supporting screening to improve melanoma outcomes.
Roetzheim et al28 analyzed data from the SEER-Medicare linked dataset to investigate patterns of dermatologist and PCP visits in the 2 years before melanoma diagnosis. Medicare beneficiaries seeing both a dermatologist and a PCP prior to melanoma diagnosis had greater odds of a thinner melanoma and lower melanoma mortality compared to patients without such visits.28
Durbec et al29 conducted a retrospective, population-based study of 650 patients in France who were seen by a dermatologist for melanoma. The thinnest melanomas were reported in patients seeing a dermatologist for prospective follow-up of nevi or consulting a dermatologist for other diseases. Patients referred to a dermatologist by PCPs tended to be older and had the highest frequency of thick (>3 mm), nodular, and/or ulcerated melanomas,29 which could be interpreted as a need for greater PCP education in melanoma screening.
Rates of skin examinations have been increasing since the year 2000, both overall and among high-risk groups as reported by a recent study on skin cancer screening trends. Prevalence of having at least one total-body skin examination increased from 14.5% in 2000 to 16.5% in 2005 to 19.8% in 2010 (P<.0001).30 One study revealed a practice gap in which more than 3 in 10 PCPs and 1 in 10 dermatologists reported not screening more than half their high-risk patients for skin cancer.31 The major obstacle to narrowing the identified practice gap involves establishing a national strategy to screen high-risk individuals for skin cancer and requires partnerships among patients, PCPs, specialists, policy makers, and government sponsors.
Lack of evidence that screening for skin cancer with PSEs reduces overall mortality does not mean there is a lack of lifesaving potential of screenings. The resources required to execute a randomized controlled trial with adequate power are vast, as the USPSTF estimated 800,000 participants would be needed.4 Barriers to conducting a randomized clinical trial for skin cancer screening include the large sample size required, prolonged follow-up, and various ethical issues such as withholding screening for a cancer that is potentially curable in early stages. Lessons from screenings for breast and prostate cancers have taught us that such randomized controlled trials assessing cancer screening are costly and do not always produce definitive answers.32
Conclusion
Although proof of improved health outcomes from randomized controlled trials is still required, there is evidence to support targeted screening programs for the detection of thinner melanomas and, by proxy, reduced melanoma mortality. Amidst the health care climate change and payment reform, recommendations from national organizations on melanoma screenings are paramount. Clinicians should continue to offer regular skin examinations as the body of evidence continues to grow in support of PSEs for melanoma screening.
Acknowledgments—We are grateful to Mary Butler, PhD, and Robert Kane, MD, both from Minneapolis, Minnesota, for their guidance and consultation.
