We Can Do Better

The US Preventive Services Task Force (USPTF) has spoken, and its message on population-based screening for skin cancer remains the same.¹

There are not enough data to determine whether a visual skin examination by a primary care provider in low-risk, asymptomatic individuals reduces complications or deaths from skin cancer.¹

The USPTF is calling for more research to determine whether to recommend screening adolescents and adults without symptoms of skin cancer in the primary care environment.

It is the same conclusion the USPTF reached in 2016. This recommendation specifically applies to people who do not have any signs or symptoms of skin cancer, risk factors for skin cancer, a family history of skin cancer, or any suspicious moles or other spots on their bodies.

The American Academy of Dermatology (AAD) does not recommend such regular screenings, but the group does recommend that patients perform skin self-checks. The AAD also operates a program to help organize free skin cancer screenings, which have been shown to locate skin cancers earlier in the general population, particularly in areas of lower socioeconomic income.²

We can do better.

If primary care doctors are to serve as gatekeepers to health care in the US, the onus remains on dermatologists to educate our primary care, family practice, and internal medicine colleagues about who is considered at elevated risk for skin cancer so they can better differentiate between high- and low-risk patients. Many primary care doctors do not receive comprehensive training in skin disorders.

In a National Cancer Institute-supported study, 600,000 people went to see their primary care physician for a routine visit. Of these, those who were screened for skin cancer during the 5-year study period were more likely to be diagnosed with very early-stage melanoma than those who were not screened.³ More early-stage melanomas were diagnosed in both groups. People in the screening group were 160% more likely to be diagnosed with an in-situ melanoma, and 80% more likely to be diagnosed with a stage 1 melanoma, the study found.

Educating primary care physicians in skin cancer risks

The question is: how can we best educate our colleagues so that they know when to refer patients at elevated risk for skin cancer or those with suspicious lesions to dermatologists for further evaluation?

There are many skin cancer education interventions aimed at primary care providers available including literature-based interventions, live teaching sessions, and online courses.

When researchers reviewed studies of educational interventions, they found that while several interventions did improve skin cancer knowledge and competency on written exams, only a few changed clinical practices such as biopsy review or referral analysis.⁴

PRIMARY PREVENTION

Primary prevention consists of limiting exposure to sunlight, judicious use of broad-spectrum sunscreen, and being aware of any changes in the skin. Although the data are not uniformly supportive, another important educational message is that patients should promptly seek medical attention when they notice a changing nevus. Several studies have documented average patient delays of 8 to 12 months after first noticing a changing nevus. In one, 46% of patients with melanoma did not seek medical attention until they found ulceration, bleeding, or a lump in the pigmented lesion, all signs of late melanoma.⁵

A campaign in Scotland to educate the public about the significance of suspicious and changing nevi resulted in an overall reduction in melanoma thickness as well as a trend toward decreased mortality in women.⁶

Of course, the overall prognosis of a patient with melanoma depends on the tumor’s inherent biologic aggressiveness and the time to diagnosis so these primary preventative measures may not always lead to a change in morbidity and mortality.

SECONDARY PREVENTION

Secondary prevention consists of routinely performing a total skin examination. In theory, routine screening for melanoma could save lives because earlier detection of thinner tumors is associated with better survival rates. Screening can be performed on whole populations (population-based screening) or on subgroups of the population deemed to be at higher risk for melanoma.

A study from 2006 suggested that five factors, remembered with the acronym HARMM (history of previous melanoma; age over 50; regular dermatologist absent; mole changing; and male gender) independently increased the likelihood of suspected melanoma being found in 362,804 patients screened.⁷

Individuals at the highest risk represented only 6% of the general population yet accounted for 14% of melanoma findings. Skin screening independently increased the likelihood of identifying suspected melanoma. In a study from the University of Virginia, 2,305 patients were evaluated for skin cancer via free screenings, with 9% diagnosed with skin cancer, including 29% referred for biopsy and follow-up care.⁸

The screening of high-risk patients by dermatologists has yielded positive results. In one surveillance program, the mean thickness of initially detected index lesions was 1.44mm, versus 0.52mm for surveillance melanomas.⁹ Other studies show primary melanomas were more likely to be smaller and thinner when diagnosed during routine surveillance of high-risk patients.¹⁰

No studies of the identification or surveillance of high-risk groups for skin cancer have been performed in primary care populations. It is not known what percentage of any given primary care practice would be at elevated risk. In addition, a study found that although dermatologists may fail to make the clinical diagnosis of melanoma in 25% of cases, primary care physicians may fail to do so 40% of the time.¹¹

Therefore, the educational needs of primary care physicians must also be addressed to ensure accurate skin examination and identification of high-risk patients.

In addressing malignant melanoma, primary care physicians should emphasize primary prevention. This includes educating patients about the importance of avoiding excessive sun exposure, preventing sunburns, and advising them about the importance of prompt self-referral for changing nevi. Primary care education regarding risks for skin cancer is a vital component of skin cancer surveillance allowing for risk stratification and referral of high-risk patients for dermatologic surveillance.¹¹ Secondary prevention or screening of all patients coming in for routine primary care needs to occur at the same time. Education of primary care physicians on routine identification of appropriate elevated risk patient populations is part of our duty to make sure we are providing the highest level of care to all patients.

1. U.S. Preventive Services Task Force. Final recommendation statement skin cancer: screening. Published April 18, 2023. Accessed April 18, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/skin-cancer-screening

2. Beaulieu D, Gao DX, Swetter SM, Hawryluk EB, Geller AC. Association between income and suspected nonmelanoma and melanoma skin cancers among participants of the American Academy of Dermatology’s SPOT Skin Cancer screening program: A cross-sectional analysis. Epub 2021 Jun 2. J Am Acad Dermatol. 2022 Jun;86(6):1401-1403. doi: 10.1016/j.jaad.2021.05.048. PMID: 34089798.

3. Matsumoto M, Wack S, Weinstock MA, et al. Five-year outcomes of a melanoma screening initiative in a large health care system. JAMA Dermatol. 2022 May 1;158(5):504-512. doi: 10.1001/jamadermatol.2022.0253. PMID: 35385051; PMCID: PMC8988026.

4. Brown AE, Najmi M, Duke T. et al. Skin cancer education interventions for primary care providers: A scoping review. J Gen Intern Med. 37, 2267–2279 (2022). https://doi.org/10.1007/s11606-022-07501-9

5. Krige JE, Isaacs S, Hudson DA, King HS, Strover RM, Johnson CA. Delay in the diagnosis of cutaneous malignant melanoma. A prospective study in 250 patients. Cancer. 1991 Nov 1;68(9):2064-8. doi: 10.1002/1097-0142(19911101)68:9<2064::aid-cncr2820680937>3.0.co;2-3. PMID: 1913555.

6. MacKie RM, Hole D. Audit of public education campaign to encourage earlier detection of malignant melanoma. BMJ. 1992 Apr 18;304(6833):1012-5. doi: 10.1136/bmj.304.6833.1012. PMID: 1586781; PMCID: PMC1881745.

7. Goldberg MS, Doucette JT, Lim HW, et al. Risk factors for presumptive melanoma in skin cancer screening: American Academy of Dermatology National Melanoma/Skin Cancer Screening Program experience 2001-2005. J Am Acad Dermatol. 2007. 57: 60-66. https://doi.org/10.1016/j.jaad.2007.02.010.

8. Van Dyke SD, Russell MA. Examination of the benefits of free annual skin cancer screenings. J Am Acad Dermatol. 2019. 81(4). doi: https://doi.org/10.1016/j.jaad.2019.06.767

9. Masri GD, Clark WH, Guerry D, Halpern A, Thompson CJ, Elder DE. Screening and surveillance of patients at high risk for malignant melanoma result in detection of earlier disease. J Am Acad Dermatol. 1990; 22:1042-8.

10. Richert SM, D’Amico F, Rhodes AR. Cutaneous melanoma: patient surveillance and tumor progression. J Am AcadDermatol. 1998 Oct;39(4 Pt 1):571-7. doi: 10.1016/s0190-9622(98)70006-4.

11. Edelman RL, Wolfe JT. Prevention and early detection of malignant melanoma. Am Fam Physician. 2000 Nov 15;62(10):2277-85.