Affirming the Benefits of Full Body Skin Exams… And Overcoming Obstacles

As addressed in this department in May (available online at PracticalDermatology.com), the US Preventive Services Task Force (USPSTF) recently recommended against Full Body Skin Exams (FBSE) by general practitioners.¹ That recommendation was viewed as affirming the role of dermatologists in early detection of both melanoma and nonmelanoma skin cancers. A recent study² supports the benefits of routine FBSE by dermatologists and suggests that more melanomas may be detected by physician-initiated exams than as a result of patients presenting with complaints about new or changing moles.

SUPPORT FOR DERMATOLOGIST-INITIATED FBSE
The USPSTF, based on a review of evidence published since 2001, recently stated that there is "fair evidence that screening by clinicians is moderately accurate in detecting melanoma" but that the "evidence is insufficient to determine the extent to which screening by patient self-examination accurately detects skin cancer." Given that the report states that current evidence regarding the benefits of exams by GPs "is insufficient to assess the balance of benefits and harms" and "lacking, of poor quality, or conflicting," the Task Force recommended against exams by general practitioners but encouraged GPs to be vigilant for suspicious lesions when the evaluation of other patient complaints requires examination of the skin.¹ A recently-published analysis³ suggests that rates of FBSE performed by primary care physicians have decreased in North America, Europe, and Australia over the past 15 years. The proportion of PCPs reporting that they perform FBSE decreased by about 1.72 percent annually, according to the report.

The Task Force's analysis and subsequent recommendation were aimed only at GPs, not dermatologists. Multiple studies support the benefits of skin exams by dermatologists. A recent publication adds to that body of data.² A retrospective analytical case series from a private dermatology practice in Florida identified 126 melanomas diagnosed between July 2005 and October 2008. Fifty-one of these were invasive melanomas, and 75 were melanoma in situ. More than half (56.3 percent) of melanomas overall were initially identified by the dermatologist and were not part of the presenting complaint. Sixty percent of melanomas in situ were detected by the dermatologist. Dermatologist detection was significantly associated with thinner melanomas (less than 1mm).

HINDRANCES TO FBSE
Clinicians Don't Offer Exams. Despite the documented benefits of FBSE, there is still reluctance among some dermatologists to provide exams to all patients. Just a few years ago, a survey of a convenience sample of primary care and dermatology patients from a VA Medical Center found that only a third of respondents in either group reported undergoing FBSE.⁴ Yet 84 percent of all respondents suggested that they would like to receive regular FBSE from a dermatologist.

Patient Embarrassment. Eight percent of all respondents (the majority were male) in the above survey⁴ said they would be embarrassed to undergo FBSE, and two percent of subjects stated that they would refuse the examination if provided by a physician of the opposite sex. An additional 16 percent of respondents stated that they would be less willing to be examined (but would not refuse) by a physician of the opposite sex, while 74 percent stated that the examiner's sex would not affect their decision. Eight percent of respondents stated that they would be more willing to be examined by a member of the opposite sex.

Lack of Education. A much earlier study⁵ suggests that patient education about the aims and benefits of FBSE increases patient acceptance. Patients presenting to a public skin cancer screening were randomized to receive written educational materials prior to evaluation or no specific instruction. Among those who received education, there was less concern about genital examination. Compared to people with no concerns, individuals concerned about genital exams tended to be younger, worried about privacy, and had a preference for same-sex physicians.

Gender Disparity. An analysis of data, including some from the veteran survey described above, further investigated patient comfort with FBSE.⁶ Findings suggest that women are more likely than men to conduct skin self-exams but were less likely to report undergoing FBSE. Women were more likely to report embarrassment with FBSE and were more likely to refuse exams from physicians of the opposite sex.

PROMOTING FBSE
Dermatologists know and an increasing number of patients now recognize that FBSE are an important tool for the detection of both melanoma and NMSC. Importantly, exams are associated with early diagnosis of malignant lesions and identification of thin melanomas more amenable to treatment. Physician-initiated FBSEs are shown to identify suspicious lesions with greater frequency than patient self-surveillance. Useful data regarding patient acceptance and perceptions of FBSE reveal certain trends. To enhance the acceptance of FBSEs, dermatologists might consider these steps in their practices:

Educate. Dermatologists must continue to educate patients about the role and potential benefits of FBSE. Given the positive influence of education on patient acceptance of exams, written educational materials in the waiting areas and exam rooms may be particularly useful. Consider adding information about FBSE to your practice website. Staff should be prepared to answer questions about the exam process and the need for it.

Be Sensitive. Dermatologists must be sensitive to patient concerns about FBSE, particularly as they relate to modesty. Patients may be more willing to undergo a FBSE from a clinician of the opposite sex when a nurse or medical technician is in the room, especially when the non-physician is the same sex as the patient. If the patient desires a full body exam but is uncomfortable receiving one from a provider of the opposite sex, another provider in the practice may be recruited for the exam.

Finally, if the patient identifies a particular lesion in the genital region that they wish for the physician to examine, allow the patient to position exam robes or drapes in a way to preserve their modesty as much as possible while allowing for an examination of the lesion in question.

Encourage Self-Exams. All patients should be instructed in the proper conduct of skin self-exams and encouraged to perform these at regular intervals. Patients should be familiar with the ABCDE criteria. Most importantly, they should be urged to present to the dermatologist for evaluation of any new or changing mole or lesion. It may be particularly important to encourage men to conduct self-exams, as data indicate they are less likely than women to conduct them.

Dr. Wolfe has no relevant disclosures.

1. US Preventive Services Task Force. Screening for Skin Cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009 Feb 3;150(3):188-93.
2. Kantor J, Kantor DE. Routine Dermatologist-Performed Full-Body Skin Examination and Early Melanoma Detection. Arch Dermatol. 2009;145(8):873-876.
3. Valachis A, Mauri D, et al. Time-trend of melanoma screening practice by primary care physicians: a meta-regression analysis. Ups J Med Sci. 2009;114(1):32-40.
4. Federman DG, Kravetz JD, et al. Full-body skin examinations and the female veteran: prevalence and perspective. Arch Dermatol. 2006 Mar;142(3):312-6.
5. Leffell DJ, Berwick M, Bolognia J. The effect of pre-education on patient compliance with full-body examination in a public skin cancer screening. J Dermatol Surg Oncol. 1993 Jul;19(7):660-3.
6. Federman DG, Kravetz JD, Ma F, Kirsner RS. Patient gender affects skin cancer screening practices and attitudes among veterans. South Med J. 2008 May;101(5):513-8.