Skin cancer screening and prevention in the primary care setting: national ambulatory medical care survey 1997

Outcomes and Follow-Up Data From Two Skin Cancer Screening Events

This study investigated the outcomes and follow-up behaviors of participants from two free skin cancer screening events in the United States. This survey, with 296 participants and a 31% response rate, gathered information on participant demographics, personal history of skin cancer, knowledge of skin screening practices, and follow-up behaviors. There was a high follow-up rate of 92.3% among individuals recommended for further dermatological consultation, but a low (22%) concordance rate between the preliminary diagnoses from the screening and patient-recalled diagnoses. Additionally, about one-sixth of participants identified limited access to care as a motivation for participating in the screening. The study emphasizes the need to improve awareness about the limitations of free screenings, enhance participant education, and ensure equitable access to skin cancer screening. Future research should focus on factors influencing follow-up behaviors and the development of targeted interventions to increase awareness and access to skin cancer screening.

Dermoscopy Training Effect on Diagnostic Accuracy of Skin Lesions in Canadian Family Medicine Physicians Using the Triage Amalgamated Dermoscopic Algorithm

Background

Accurate identification of cutaneous lesions is an essential skill for family medicine physicians (FMPs). Studies show significant improvement in skin cancer detection with dermoscopy use. Frontline FMPs are an ideal target group for dermoscopy training. The 3-step Triage Amalgamated Dermoscopic Algorithm (TADA) facilitates high sensitivity and specificity for pigmented and nonpigmented skin lesions. Step I requires unequivocal identification of dermoscopic features for 1 of 3 benign skin lesions: angioma, dermatofibroma, or seborrheic keratosis. If absent, steps II and III are applied assessing for features of architectural disorder and malignancies with organized, symmetric patterns, respectively.

Objective

To assess FMPs' diagnostic accuracy of benign and malignant skin lesions before and after training in TADA step I.

Methods

In this repeated-measures observational study, 33 dermoscopy-naive FMPs attending an introductory dermoscopy workshop each assessed gross and corresponding dermoscopic photographic images of 50 pigmented and nonpigmented skin lesions (23 benign, 27 malignant) for features of TADA step I lesions before and after training. Analyses compared diagnostic accuracy in relation to training and baseline physician characteristics.

Results

Diagnostic accuracy improved from 76.4% to 90.8% (P < 0.001) and from 85.0% to 90.0% (P = 0.01), respectively, for all lesions and for all TADA I lesions. Female sex was significant as a predictor of individual posttraining performance (all lesions combined, P = 0.02).

Conclusions

Results show significant improvement in diagnostic accuracies for benign and malignant skin lesions with introductory dermoscopy training using TADA step I. This will reduce unnecessary benign lesion excision and enhance referral sensitivity, conserving specialist resources.

Low Rates of Dermatologic Care and Skin Cancer Screening Among Inflammatory Bowel Disease Patients

BACKGROUND

Dermatologic manifestations of inflammatory bowel disease (IBD) are common, and certain IBD medications increase the risk of skin cancer.

AIMS

To define the rates of care and factors associated with dermatologic utilization with a focus on skin cancer screening.

METHODS

We utilized a prospective, natural history IBD research registry to evaluate all outpatient healthcare encounters from 2010 to 2016. Gastrointestinal, dermatologic and primary care visits per individual were identified. We calculated the proportion of patients obtaining care, categorized primary indications for dermatologic visits, determined the incidence of melanoma and non-melanoma skin cancers, and used logistic regression to determine factors associated with dermatology utilization.

RESULTS

Of the 2127 IBD patients included, 452 (21.3%) utilized dermatology over the study period, and 55 (2.6%) had a total body skin examination at least once. The 452 patients incurred 1633 dermatology clinic visits, 278 dermatologic procedures, and 1108 dermatology telephone encounters. The most frequent indication was contact dermatitis or dermatitis. Factors associated with dermatology use were family history of skin cancer, employment, systemic steroids, longer disease duration, emergency room use, and the number of IBD-related clinic visits. Between 8.3 and 11% of IBD patients recommended for skin cancer screening visited dermatology each year, and the resulting incidence of non-melanoma skin cancer was 35.4/10,000 [95% CI 23.3-51.5] and melanoma was 6.56/10,000 [95% CI 2.1-15.3].

CONCLUSIONS

Less than one in ten IBD patients obtain dermatologic care. Given the increased risk of skin cancers among IBD patients, an emphasis on education, prevention, and screening merits attention.

Assessment of postgraduate skin lesion education among Iowa family physicians

Background:

Family medicine physicians play a pivotal role in the prevention and early detection of skin cancer. Our objective was to evaluate how family physicians believe their postgraduate training in skin cancer screening and prevention has prepared them for independent practice and to assess the need for enhanced skin lesion teaching in a family medicine residency setting.

Methods:

A descriptive, cross-sectional survey investigating provider demographics, confidence in providing dermatological care, residency training, current medical practice, and skin cancer prevention beliefs was mailed to all family medicine physicians in the state of Iowa as listed in the Iowa Academy of Family Physicians annual directory in 2006 (N = 1069).

Results:

A total of 575 family medicine physicians completed the survey for an overall response rate of 53.8%. Overall, family medicine physicians reported feeling confident in their ability to diagnose skin lesions (83.2%), differentiate between benign and malignant lesions (85.3%), and perform a biopsy of a lesion (94.3%). Only 65% of surveyed physicians felt that their residency program adequately trained them in diagnosing skin lesions and 65.7% of physicians agree that they could have benefited from additional training on skin lesions during residency training. Nearly 90% of clinicians surveyed believe that skin cancer screenings are the standard of care; however, only 51.8% perform skin cancer screening examinations during adult health maintenance visits more than 75% of the time. The primary reason listed by respondents who said they do not routinely perform skin cancer screenings was inadequate time (68.2%).

Conclusion:

Family medicine physicians in the state of Iowa are confident in evaluating skin lesions. However, they reported a need for additional enhanced, targeted skin lesion education in family medicine residency training programs. Physicians believe that skin cancer screening examination is the standard of care, but find that inadequate time increasingly hinders skin cancer screening during routine health maintenance examinations.

Five-point checklist for skin cancer detection in primary care

BACKGROUND

Skin cancer screening interventions often relay on the involvement of general practitioners (GPs). Many interventions up to now have been directed to training approaches focusing on the clinical features of skin malignancies to increase GPs skill in skin cancer recognition.

METHODS

Based on the available current knowledge about skin cancer epidemiology and risk factors, we built up a 5-point checklist to help GPs in triaging patients to be referred to a dermatologist.

RESULTS

Five-point check-list: 1) visible sun damaged skin on exposed areas (red and brown to black macules and crusts on visible skin); 2) more than 20 nevi on the arms; 3) one or more ABCD positive lesions (flat, large and asymmetric macules); 4) one or more EFG positive lesions (elevated, firm and growing skin lesions); 5) a pigmented lesion larger than 1.5 cm in diameter.

CONCLUSIONS

Our aim was to provide a short list of practical rules, easy to adopt into a routine practice, in order to achieve a more effective triage of patients requiring a dermatology consultation for skin cancer examination. The novelty of the proposed method relies on the approach. The proposed method does not require the GP to diagnose skin cancer. The aim is to involve GPs in the selection of patients to be referred to the specialist, in order to reduce the waiting time while avoiding the risk to leave cancers untreated.

Skin cancer screening in the medically underserved population: A unique opportunity for APNs to make a difference

PURPOSE

To implement and evaluate the feasibility of an annual skin cancer screening program for the medically underserved at a free clinic in Marion, Indiana.

DATA SOURCES

Clinical initiative with descriptive analysis of results. IRB approval was obtained and the project was found to be exempted.

CONCLUSIONS

The participation rate of 65% supported the feasibility of the skin screening program in a free clinic. The skin screening program allowed for detection of 17 worrisome lesions and all of these patients were referred to either the small procedure clinic, general surgeon, or dermatologist for definitive treatment.

IMPLICATIONS FOR PRACTICE

The project affirmed that clients in this setting are interested in total body skin exams and will participate in the screening program. Furthermore, there were a significant number of worrisome lesions discovered, which underscores the importance of this screening exam and the need for healthcare providers to either perform or refer patients for skin cancer screening on a regular basis. This area of screening is a unique opportunity for advanced practice nurses to make a difference in the medically underserved population who often lack skin cancer screening.

Skin cancer screening and primary prevention: facts and controversies

Skin cancer is both common and responsible for significant morbidity and mortality. Opportunities for both primary and secondary prevention are available to both dermatologists and non-dermatologists. Counseling selected patients about ultraviolet avoidance and proper use of sunscreens is recommended. Due to technical and financial barriers, no study has conclusively confirmed the benefits of skin cancer screening. Both dermatologists and non-dermatologists often do not perform total body skin examinations during clinical encounters, despite high acceptance rates by patients. Many non-dermatologists would benefit from additional education pertaining to the diagnosis of cutaneous malignancy. Teledermatology may have a role in areas with poor access to dermatologists. There are ample opportunities for more to be learned in the future.

Problematic lesions in the elderly

As the population continues to age, clinicians and dermatologists are increasingly faced with geriatric patients presenting with a range of dermatologic manifestations, including benign and malignant skin tumors. Knowledge of epidemiologic and morphologic features, including dermoscopy of common and benign melanocytic and nonmelanocytic skin tumors, provides the basis for a better understanding and management of problematic skin tumors in this age group. This article provides an overview of common and problematic skin lesions in elderly patients and addresses epidemiologic, clinical, and dermoscopic clues that aid the differential diagnosis and management of challenging skin lesions.

The impact of subspecialization and dermatoscopy use on accuracy of melanoma diagnosis among primary care doctors in Australia

BACKGROUND

Dermatoscopy improves accuracy of melanoma diagnosis, but the impact of subspecialization in skin cancer practice among general practitioners on melanoma diagnostic accuracy is not known.

OBJECTIVE

To assess the impact of dermatoscopy use and subspecialization on the accuracy of melanoma diagnosis by general practitioners.

METHODS

We did a prospective study on the Skin Cancer Audit Research Database and measured melanoma 'number needed to treat' (NNT), with 21,900 lesions excised to diagnose 2367 melanomas.

RESULTS

Melanoma NNT fell from a high of 17.0 (95% confidence interval [CI] 14.5-20.7) among general practitioners with a generalist practice to 9.4 (CI 8.9-10.1) among those with a specific interest in skin cancer, and 8.5 (CI 8.1-9.0) among those practicing only skin cancer medicine (P < .0001). Melanoma NNT fell from a high of 14.6 (CI 12.0-18.6) among dermatoscopy low/non-users to 10.9 (CI 9.8-12.4) among medium users, and 8.9 (CI 8.6-9.3) among high users (P < .0001). The association between NNT and practice type remained (P < .0001) when adjusted for dermatoscopy use and other variables. The association between NNT and dermatoscopy use disappeared (P = .41) when adjusted for practice type and other variables.

LIMITATIONS

There is selection bias with respect to participating doctors and completeness and accuracy of data are not independently verified in the Skin Cancer Audit Research Database (SCARD).

CONCLUSIONS

General practitioners who subspecialize in skin cancer have a higher use of dermatoscopy and diagnose melanoma with greater accuracy than their generalist counterparts.

Assessing students' ability to detect melanomas using standardized patients and moulage

BACKGROUND

Detection of melanoma by physicians via opportunistic surveillance during focused physical examinations may reduce mortality. Medical students may not encounter a clinical case of melanoma during a dermatology clerkship.

OBJECTIVE

This study examined the proficiency of fourth-year University of Illinois at Chicago medical students at detecting melanomas.

METHODS

Melanoma moulages were applied to the second digit of the left hand of standardized patients (SPs) participating in a wrist pain scenario during a required clinical skills examination. An observer reviewed videotapes of the examination, written SP checklists, and student notes for evidence that the student noticed the moulage, obtained a history, or provided counseling.

RESULTS

Among the 190 fourth-year medical students, 56 students were observed noticing the lesion; however, 13 failed to write it in their notes or advise the patient. The detection rate was 22.6% (43 of 190 students). Students who detected the probable melanoma consistently inquired about changes in the lesion and symptoms, but did not examine the rest of the skin or regularly palpate for adenopathy.

LIMITATIONS

Testing one class of students from a single medical school with a time-restricted SP encounter while focusing the students' attention toward a different presenting symptom may hinder exploration of medical issues.

CONCLUSION

The low detection rate and failure of students who noticed the moulage to identify the lesion as atypical represents a lost opportunity to provide a patient intervention. Use of SP examinations may help physicians in training build confidence and competence in cutaneous malignancy screening.

Advances and short comings in the early diagnosis of melanoma

Malignant melanoma kills more people each year than any other skin cancer, with approximately 8000 lives lost and a cost of over 3 billion dollars annually in the US alone. Tumor depth is the most important prognostic factor in melanoma. Thus, early detection has the potential to diagnose melanoma when lesions are thinner, and to improve survival in primary melanomas. In this review, we discuss the implications, barriers, and advantages of melanoma screening, and describe the currently employed methods of detection, newly available modalities, and current areas of research. We also discuss the efficacy, advantages and disadvantages, and clinical practicality of each, and suggest various means of combining different methodologies as well as tailoring various strategies to individual patient needs.

Inoculation theory: a framework for the reduction of skin cancer

This paper analyzes skin cancer in detail and explains how inoculation theory, which demonstrates how attitudes can be strengthened and made resistant to counter-attitudinal persuasive messages, is a unique method for specifically targeting and conferring resistance to unprotected and excessive ultraviolet exposure to people of all ages. As many previous efforts to reduce exposure to ultraviolet rays have had minimal impact, inoculation theory is appropriate in this context because the theory has been successful in other health campaigns and may increase the efficacy of skin cancer interventions. In justifying the need for this analysis, we illustrate the prevalence and detrimental impact of skin cancer to clarify the seriousness of the disease and how people oftentimes fail to adequately shield themselves. This conceptual analysis not only has the potential to be applied in rendering subjects resistant to engaging in unprotected (and/or excessive) sunbathing and artificial tanning, but it also represents an addition to the disciplinary domains of health communication and social policy and offers clues for further exploration in this area.

Melanoma early detection

Recognizing early forms of melanoma may have significant impact on decreasing mortality from this malignancy. As a result, multiple efforts have focused on developing new and improving current early detection strategies. These include educating patients about the importance of performing skin self-examination, increasing rates of complete skin examinations by physicians in the context of routine care, initiating mass screening campaigns, creating specialized skin cancer clinics, and developing better diagnostic tools through advances in technology. In this article, the current state of these efforts is reviewed.

Preventing skin cancer among a farming population: implementing evidence-based interventions

Agricultural workers are at risk for developing skin cancer due to exposures to ultraviolet radiation. Occupational health nurses implemented a skin cancer screening during an agricultural trade show to facilitate primary and secondary prevention of skin cancer through risk assessment, visual skin examination, counseling, and education. The purpose of this article is to present an evidence-based practice model that describes the demographics of a skin cancer screening population, self-reported risk factors, the occurrence of presumptive diagnoses, and compliance with health-related recommendations. Eighty-eight individuals were screened. Thirty-nine (44%) of all screened participants were referred for further evaluation. Of the 39 referrals, 16 (41%) were recommended for biopsy. One month after the screening, 21 (54%) of the participants had completed or arranged follow-up. Status of the identified lesion was also explored. General comments yielded statements that demonstrated appreciation for the screening, teaching, reminders, and encouragement.

The value of screening in melanoma

The incidence of cutaneous melanoma has increased substantially in most white populations during the past several decades. Despite improvements in the early recognition of melanoma and the use of novel diagnostic techniques that enhance our diagnostic capabilities, disease-related mortality remains a significant public health issue. In the absence of effective treatment approaches for advanced disease, the best means for reducing deaths by melanoma are screening as well as professional and public education. The role of population-or community-based screening remains controversial, but evidence from self-selected screening campaigns, health care professional surveillance, and specialized pigmented lesions clinics underscores the value of screening and early detection programs, particularly in high-risk groups. Annual screening campaigns coupled with intense media promotion have become commonplace in many countries, and despite their low yield of melanoma detection, the dissemination of educational material and information to the public during these events is important in increasing public awareness. Future directions should include using screening campaigns to target middle-aged and older men and persons of lower socioeconomic status, who suffer most from the burden of the disease and its associated mortality. On a worldwide scale, comprehensive educational and screening campaigns should be implemented or intensified in underserved areas and geographic regions with lower survival rates, such as Eastern European countries. A better understanding of the biology of the disease, already occurring with notable strides, will help us to define better those individuals who will benefit most from screening and early detection efforts. Technologic advances and new diagnostic modalities will afford a more reliable and vigilant surveillance of high-risk individuals, whereas the wide use of the Internet will enhance the distribution of relevant information to the public with the ultimate goal of achieving a better control of melanoma.

Time-trend of melanoma screening practice by primary care physicians: a meta-regression analysis

OBJECTIVE

To assess whether the proportion of primary care physicians implementing full body skin examination (FBSE) to screen for melanoma changed over time.

METHODS

Meta-regression analyses of available data.

DATA SOURCES

MEDLINE, ISI, Cochrane Central Register of Controlled Trials.

RESULTS

Fifteen studies surveying 10,336 physicians were included in the analyses. Overall, 15%-82% of them reported to perform FBSE to screen for melanoma. The proportion of physicians using FBSE screening tended to decrease by 1.72% per year (P =0.086). Corresponding annual changes in European, North American, and Australian settings were -0.68% (P =0.494), -2.02% (P =0.044), and +2.59% (P =0.010), respectively. Changes were not influenced by national guide-lines.

CONCLUSIONS

Considering the increasing incidence of melanoma and other skin malignancies, as well as their relative potential consequences, the FBSE implementation time-trend we retrieved should be considered a worrisome phenomenon.

Prevalence and correlates of indoor tanning among US adults

BACKGROUND

Little is known about the prevalence of indoor tanning among the US general adult population.

OBJECTIVES

This study sought to: (1) describe the prevalence of indoor tanning throughout adulthood; (2) identify demographic and psychosocial correlates of indoor tanning; and (3) determine whether these correlates vary by age group.

METHODS

This study used data from the 2005 National Health Interview Survey, an annual health survey of the US adult population.

RESULTS

Indoor tanning rates were higher among individuals who were young, white, and female. Rates of indoor tanning in the last year varied from 20.4% for those aged 18 to 29 years to 7.8% for those aged 65 years and older. A variety of demographic, health, and behavioral health risk factors correlated with indoor tanning.

LIMITATIONS

The study design was cross-sectional and all data were self-reported.

CONCLUSIONS

Health care providers should address indoor tanning as a health risk factor across the lifespan.

Screening and early detection of skin cancer

Skin cancer is the most common type of cancer in the United States. US incidence of malignant melanoma is increasing faster than any other type of cancer. To minimize increasing morbidity and mortality rates, it is imperative that appropriate screening and early detection of skin cancer become more widespread. All physicians who see patients clinically have the potential for detecting skin cancers. The scope of skin cancer as a health-care problem is discussed. Evidence for the effectiveness and necessity of skin cancer screening and early detection is presented. Costs of screening and detection are discussed in relation to impact on treatment costs and overall costs of skin cancer burden. Current methods and recommendations for skin cancer screening and detection are reviewed, especially with regard to individuals and populations that may require more specialized or intensive screening and follow-up. Newer approaches involving instrument-assisted screening and detection of skin cancer are under intense development, and these exciting emerging technologies are reviewed.

Screening, early detection, and trends for melanoma: Current status (2000-2006) and future directions

In the past 5 years, there have been notable strides toward the earlier recognition and discovery of melanoma, including new technologies to complement and augment the clinical examination and new insights to help clinicians recognize early melanoma. However, incidence and mortality rates throughout most of the developed world have risen over the past 25 years, while education and screening, potentially the best means for reducing the disease, continue to be severely underutilized. Much progress needs to be made to reach middle-aged and older men and persons of lower socioeconomic status who suffer a disproportionate burden of death from melanoma. Worldwide melanoma control must also be a priority, and comprehensive educational and screening programs should be directed to Northern Ireland and a number of Eastern European nations, whose 5-year survival rates range between 53% and 60%, mirroring those of the United States and Australia more than 40 years ago.

LEARNING OBJECTIVE

After completing this learning activity, participants should be aware of the most recent melanoma epidemiologic data, both in the United States and internationally; worldwide early detection and screening programs; clinical strategies to recognize and improve the detection of early melanoma; the latest technologies for early detection of melanoma; and public and professional education programs designed to enhance early detection.

Epidemiology of nonmelanoma skin cancer (NMSC) in Europe: accurate and comparable data are needed for effective public health monitoring and interventions

Nonmelanoma skin cancer (NMSC) is the most common malignancy occurring in white populations. It is currently becoming an important challenge in terms of public health management as the increasing incidence rates will probably have a tremendous impact on healthcare costs. Possible factors driving this rise in NMSC numbers are increases in both acute and prolonged UV exposure together with increasing numbers of older people in the population. A better understanding of NMSC epidemiology in Europe is essential if an evidence-based European-wide public health policy is to be developed. It is obvious this can only be achieved by recording and analysing comparative epidemiological data. Finally, by improving the skin examination training for physicians, developing guidelines and exchanging best practices, a high level of healthcare could be provided for NMSC.

Crafting a melanoma educational campaign to reach middle-aged and older men

BACKGROUND

From 1973 through 2002, melanoma mortality rates have risen steeply in middle-aged and older men. Men's higher mortality rate from melanoma is hardly an isolated example of the ways in which men's health lags behind women's health. Given the significantly higher melanoma mortality rates of men compared with women, there is now a need for a melanoma education program targeted to middle-aged and older men and their closest contacts, including spouses, significant others, and health care professionals.

OBJECTIVES

In this article, we discuss the theoretical and practical foundations for such a program. Then, taking into account factors such as socioeconomic status, health literacy, and residence, we present suggestions for creating such a campaign.

CONCLUSIONS

Planners for a new educational campaign must understand the target audience's motivations for and perceived barriers to behavioral change. Future studies should examine what motivates certain men to conduct skin self-examinations, ask their physicians about melanoma, and attend melanoma screenings, whereas other men with similar risk factors are less prevention conscious. Issues of health literacy and understandability of our messages must be further explored.

Diagnosing and managing cutaneous pigmented lesions: primary care physicians versus dermatologists

BACKGROUND

Primary care physicians (PCPs) are often expected to screen for melanomas and refer patients with suspicious pigmented lesions to dermatologists.

OBJECTIVE

To assess whether there is a difference between dermatologists and PCPs in accurately diagnosing melanoma and appropriately managing (based on decisions to refer/biopsy) suspicious pigmented lesions.

DESIGN, PARTICIPANTS

A survey based on a random sample of 30 photographs of pigmented lesions with known pathology was administered to 101 dermatologists and 115 PCPs from October 2001 to January 2003.

MEASUREMENTS

Likelihoods that a photographed lesion was melanoma and that the lesion should be biopsied/referred were scored on a 1 to 10 scale. Accuracy of melanoma diagnosis and appropriateness of pigmented lesion management were compared between dermatologists and PCPs by using the areas under (AUC) the receiver operating characteristic (ROC) curves.

RESULTS

Dermatologists were superior to PCPs in diagnosing melanomas (AUC 0.89 vs 0.80, P<.001) and appropriately managing pigmented lesions (AUC .84 vs 0.76, P<.001). PCPs who tended to biopsy lesions themselves did better at managing pigmented lesions than PCPs who did not perform biopsies. Dermatology training during residency did not significantly improve the diagnostic accuracy of PCPs nor their management of pigmented lesions.

CONCLUSIONS

Dermatologists have both better diagnostic accuracy and ability to manage pigmented lesions than PCPs. Yet, there is a shortage of dermatologists to meet the demand of accurate melanoma screening. More innovative strategies are needed to better train PCPs and enhance skin cancer screening.

Breslow depth of cutaneous melanoma: impact of factors related to surveillance of the skin, including prior skin biopsies and family history of melanoma

BACKGROUND

Because the early detection of cutaneous melanoma can dramatically improve survival, identification and surveillance of persons at risk have received much attention.

OBJECTIVE

Our purpose was to examine the influences of personal or family history, patterns of detection, and prior skin biopsies (considered to be a measurement of surveillance by medical personnel) on the Breslow depth of cutaneous melanomas.

METHODS

A retrospective cohort analysis of 218 patients with a history of at least one invasive cutaneous melanoma who visited the Yale Pigmented Lesion Clinic between January 1995 and January 1996 was performed. Data on patterns of detection, melanocytic nevi, and skin biopsies before and after the initial diagnosis of melanoma were collected, and patients with a family history of melanoma were compared with sporadic patients.

RESULTS

Initial melanomas discovered by dermatologists were more likely to be 0.75 mm or less in depth than those found by other physicians (P = .03). Although patients detected 45% of the initial primary melanomas (98/218), dermatologists discovered 80% of the second primary tumors (33/41; P = .001). A personal history of melanoma was predictive of a thinner Breslow depth (P = .01), but a family history of melanoma was not. Having a biopsy of any type or combination of types of skin lesion(s) performed in the 5 years, 2 years, or 1 year before the first diagnosis of melanoma did not predict a melanoma of thinner Breslow depth among either familial or sporadic patients. The mean number of skin biopsies performed per patient was 8 times higher in the 5-year period after (5.6) versus the 5-year period before (0.7) the initial diagnosis of melanoma, with a peak in the first year after the diagnosis (2.3 vs 0.25 in the prior year). In 27 patients, one or more skin biopsies were performed in the year before the initial diagnosis of melanoma; 41% of these biopsies (23/56) were of lesions in normally exposed sites (eg, the face, neck, and forearms) compared with 22% of the melanomas (6/27).

LIMITATIONS

Since an invasive melanoma (with the possible exception of a nodular melanoma) would likely have been present for at least a year, plausible explanations for why evidence of previous dermatologic care did not appear to result in earlier detection include performance of a limited rather than a total body skin examination as well as subtle clinical features of early melanomas. However, this study cannot give weight to these explanations because at the time new Pigmented Lesion Clinic patients were not routinely asked about previous total body skin examinations.

CONCLUSIONS

The disappointing trends seen in this study, with neither the well-established risk factor of a family history of melanoma nor previously having a skin biopsy predicting thinner melanomas, highlight the need to establish criteria defining the subset of patients for whom appropriate management requires periodic total body skin examination.

Dermoscopy Improves Accuracy of Primary Care Physicians to Triage Lesions Suggestive of Skin Cancer

Purpose

Primary care physicians (PCPs) constitute an appropriate target for new interventions and educational campaigns designed to increase skin cancer screening and prevention. The aim of this randomized study was to determine whether the adjunct of dermoscopy to the standard clinical examination improves the accuracy of PCPs to triage lesions suggestive of skin cancer.

Patients and Methods

PCPs in Barcelona, Spain, and Naples, Italy, were given a 1-day training course in skin cancer detection and dermoscopic evaluation, and were randomly assigned to the dermoscopy evaluation arm or naked-eye evaluation arm. During a 16-month period, 73 physicians evaluated 2,522 patients with skin lesions who attended their clinics and scored individual lesions as benign or suggestive of skin cancer. All patients were re-evaluated by expert dermatologists at clinics for pigmented lesions. Referral accuracy of both PCP groups was calculated by their scores, which were compared to those tabulated for dermatologists.

Results

Referral sensitivity, specificity, and positive and negative predictive values were 54.1%, 71.3%, 11.3%, and 95.8%, respectively, in the naked-eye arm, and 79.2%, 71.8%, 16.1%, and 98.1%, respectively, in the dermoscopy arm. Significant differences were found in terms of sensitivity and negative predictive value (P = .002 and P = .004, respectively). Histopathologic examination of equivocal lesions revealed 23 malignant skin tumors missed by PCPs performing naked-eye observation and only six by PCPs using dermoscopy (P = .002).

Conclusion

The use of dermoscopy improves the ability of PCPs to triage lesions suggestive of skin cancer without increasing the number of unnecessary expert consultations.

Clinical outcomes from skin screening clinics within a community-based melanoma screening program

BACKGROUND

Within a randomized trial of population screening for melanoma, primary care physicians conducted whole-body skin examinations and referred all patients with suspect lesions to their own doctor for further treatment.

OBJECTIVE

Our aim was to describe characteristics of skin screening participants, clinical screening diagnoses, management following referral, and specificity and yield of screening examinations.

METHODS

Information collected from consent forms, referral forms, and histopathological reports of lesions that had been excised or undergone biopsy was analyzed by means of descriptive statistics.

RESULTS

A total of 16,383 whole-body skin examinations resulted in 2302 referrals (14.1% overall; 15.5% men, 18.2% > or = 50 years of age) for 4129 suspect lesions (including 222 suspected melanoma, 1101 suspected basal cell carcinomas [BCCs], 265 suspected squamous cell carcinomas [SCCs]). Histopathologic results were available for 94.8% of 1417 lesions excised and confirmed 33 melanomas (23 in men; 24 in participants > or = 50 years of age), 259 BCCs, and 97 SCCs. The probability of detecting skin cancer of any type within the program was 2.4%. The estimated specificity of whole-body skin examinations for melanoma was 86.1% (95% confidence interval = 85.6-86.6). The positive predictive value (number of confirmed/number of lesions excised or biopsied x 100) for melanoma was 2.5%, 19.3% for BCC, and 7.2% for SCC (overall positive predictive value for skin cancer, 28.9%).

LIMITATIONS

Follow-up of participants with a negative screening examination has not been conducted for the present investigation.

CONCLUSIONS

The rate of skin cancer detected per 100 patients screened was higher than previously reported and men and attendees older than 50 years more frequently received a referral and diagnosis of melanoma. The specificity for detection of melanoma through whole-body skin examination by a primary care physician was comparable to that of other screening tests, including mammography.

Increase in skin cancer screening during a community-based randomized intervention trial

Survival from cutaneous melanoma is mainly dependent on the thickness of the lesion at diagnosis. Skin screening may increase detection of thin lesions and hence improve survival. Within a community-based randomized controlled trial of a population screening program for melanoma in Queensland, Australia, 9 communities were randomly assigned to the 3-year intervention and 9 communities to the control group. Skin screening prevalence was monitored by cross-sectional surveys at baseline, 1, 2 and 3 years into the intervention and 2 years later. At baseline, prevalence of whole-body clinical skin examination was similar in intervention and control communities. In intervention communities, the prevalence of whole-body skin examinations increased to 29.2%, an absolute difference of 18% from baseline, with a peak of 34.8% 2 years after baseline, and began to decline again at the end of the intervention period. The largest increases were seen in men and women > or =50 years. Uptake of screening did not differ according to melanoma risk factors; however, the decline in screening was less in participants who reported a number of melanoma risk factors. The prevalence of skin self-examination remained stable during the intervention program. No changes were observed in the control communities. These results indicate that the intervention program significantly increased the prevalence of whole-body clinical skin examinations in intervention communities. Once the intervention program ceased, and particularly after skin clinics ceased, levels of skin screening began to decline. The provision of specialized skin screening clinics may be needed to achieve sufficient screening rates should population based screening for skin cancer be considered.

Prevention practices and cancer screening among general practitioners in Picardy, France

BACKGROUND

Due to their frequent contact with a large proportion of the population, general practitioners (GPs) appear to play a particularly important role in primary and secondary (screening) cancer prevention. The objective of this survey was to describe the attitudes of GPs in relation to the major risk factors of cancer, and the most frequent forms of cancer screening.

METHODS

A questionnaire concerning primary prevention and cancer screening by GPs was sent to all doctors in the Picardy region. In total, 480 GPs agreed to participate in this survey (31%). The questions concerned primary prevention (alcohol, smoking, diet, sun exposure, etc.) and cancer screening (breast, cervix, colorectal, prostate and other cancers). GPs were also questioned about their perception of these preventive actions and the difficulties that they encounter in application of these measures.

RESULTS

The most structured preventive action appears to concern smoking in terms of primary prevention. GPs report greater difficulties in the prevention of alcoholism or dietary advice. A marked diversity of clinical practice was also observed in terms of cancer screening, even for cancers for which clear guidelines have been defined, such as breast, cervical and colorectal cancer.

CONCLUSION

GPs appear to be receptive to cancer prevention, but encounter many difficulties in daily application due to lack of time or poor patient compliance.

Diagnostic and referral accuracy of family doctors in melanoma screening: effect of a short formal training

Little is known about ability of family doctors in the diagnosis and management (decision as to dermatologic referral) of pigmented skin lesions. We sought to evaluate the impact of a short formal training on diagnostic and referral accuracy of family doctors in melanoma screening. A formal 4-h training session was given to a sample of 41 practising family doctors working in the Florence health district, Tuscany, Italy. Before and after the course, a diagnostic test with a series of clinical images of pigmented skin lesions including four invasive melanomas (mean thickness, 1.5 mm; range, 0.8-2.2) was performed (open intervention study). Although only 46.8% of observations yielded a correct melanoma diagnosis at baseline, 96.1% of melanoma observations were correctly associated with intention to refer the lesion to dermatologist. After training, the percentage of correct melanoma diagnosis significantly increased (76.2%, P=0.01) while no further improvement was found as to sensitivity of referral (94.8%, P=0.58). Compared to baseline, post-training evaluation showed a significant reduction of benign lesions sent to dermatologist: the percentage lowered from 52.1 to 35.8% (P=0.0014) for melanocytic nevi and from 38.6 to 17.5% (P<0.001) for benign non-melanocytic lesions (pigmented seborrheic keratoses, dermatofibromas, and vascular lesions). Grouping these two diagnostic categories, the overall specificity in dermatology referral increased from 55.0% at baseline to 73.1% after training (P<0.001). In conclusion, attendance at a 4-h formal training session was able to increase the specificity of family doctors as to dermatologist referral of suspicious lesions (less false-positive referral of benign lesions) without significant loss in sensitivity concerning melanoma.

Freqüência de aconselhamento para prevenção de câncer da pele entre as diversas especialidades médicas em Caxias do Sul

FUNDAMENTOS: O câncer da pele é a forma mais comum de câncer atualmente, apesar de ser um dos mais preveníveis. Não foram encontrados dados na literatura nacional quanto à freqüência de orientação para prevenção desse tipo de câncer de acordo com as diversas especialidades médicas. OBJETIVOS: O objetivo do trabalho foi verificar a freqüência de aconselhamento para prevenção de câncer da pele entre as diversas especialidades médicas em uma amostra da população de Caxias do Sul. MÉTODOS: Trata-se de um estudo transversal. Foram entrevistadas e examinadas 499 pessoas que procuraram atendimento na área de dermatologia em ações comunitárias realizadas em Caxias do Sul de janeiro a julho de 2002. RESULTADOS: Apenas 31,9% (n=159; IC 27,8 - 36,2) das pessoas entrevistadas já haviam recebido aconselhamento pela classe médica para prevenção de câncer da pele. Os pacientes de alto risco com o maior potencial para intervenção, ou seja, pacientes com idade inferior a 20 anos, receberam orientação em freqüência menor do que os pacientes com 20 anos ou mais (26,5% versus 42,5%, respectivamente; p = 0,03). A especialidade de dermatologia foi responsável por mais da metade dos aconselhamentos para prevenção de câncer da pele na população estudada. CONCLUSÃO: A freqüência de aconselhamento para prevenção de câncer da pele pelos profissionais da saúde é baixa, mesmo para os pacientes de alto risco. A orientação também varia de acordo com a especialidade consultada, tendo apenas a especialidade de dermatologia apresentado alta freqüência de aconselhamento.

Skin cancer prevention and detection by nurses: attitudes, perceptions, and barriers

BACKGROUND

To examine attitudes and perceptions of nurses with respect to skin cancer prevention and detection; to identify barriers to skin cancer prevention and detection by nurses.

METHODS

Descriptive survey of 457 nurses from the Texas State Board of Nurse Examiners in 1997.

RESULTS

Eighty-nine percent of the nurses reported that skin cancer was a serious problem, and 97% believed that many people were at risk. More than 89% stated that skin cancer prevention/detection would benefit patients, and 94% believed that such skills would benefit nurses. Eighty-four percent reported that it was in their scope of practice to teach skin cancer prevention to patients, and 61% stated that it was in their scope of practice to detect skin cancer in patients. Barriers to skin cancer prevention and detection included lack of national guidelines (69%), low priority among doctors (63%), and the belief that patients should take full responsibility for prevention (50%). Barriers to continuing education for skin cancer screening included lack of money (43%), not knowing how to obtain education (41%), time away from work (36%), and time away from home (26%).

CONCLUSIONS

These findings may suggest that nurses can play a role in skin cancer prevention and detection.

Skin cancer prevention: education and public health issues

OBJECTIVES

To examine current public health initiatives related to skin cancer prevention and early detection, and public education issues.

DATA SOURCES

Review articles, research reports, web sites, and government reports.

CONCLUSIONS

Skin cancer remains a major public health problem. Efforts to decrease the morbidity and mortality associated with skin cancer are gradually shifting toward primary prevention. Primary prevention efforts should not only be limited to using sunscreen, but should also focus on reductions in ultraviolet light exposure. Secondary prevention efforts include professional skin examinations and skin self-examination. Tertiary efforts focus on the prevention and detection of additional primary skin cancers.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can influence the public to practice primary, secondary, and tertiary prevention strategies for skin cancer.

Screening for melanoma

This article describes major screening studies of the past two decades, discusses the evidence-based screening recommendations, highlights the need to screen high-risk and previously unscreened populations, and concludes with suggestions for risk assessment and physician-nurse training in the skin cancer examination.

Using nurse practitioners for skin cancer screening: a pilot study

BACKGROUND

Skin cancer screening has the potential to detect early precancerous lesions and may ultimately be important in reducing melanoma mortality. The purpose of this study was to evaluate the ability of trained nurse practitioners to accurately identify suspicious lesions in a clinical setting.

METHODS

We identified five nurse practitioners who had no previous experience in evaluating skin lesions. Each nurse practitioner participated in a training program for skin cancer detection consisting of a workshop, clinical apprenticeship, and didactic lectures.

RESULTS

Evaluation of nurse practitioner competency involved three assessments. First, the nurse practitioner's ability to distinguish benign and malignant lesions was assessed using clinical color slides. The sensitivity of all five nurse practitioners to refer benign and malignant lesions for dermatologic follow-up based on the slides was 100%, whereas the specificity ranged from 53% to 100%. Second, each nurse practitioner evaluated approximately 25 different patients along with a single dermatologist. The nurse practitioner's ability to correctly refer patients with suspicious lesions for dermatologic follow-up was determined based on the dermatologist's assessment of need for referral. Results suggested a referral sensitivity and specificity ranging from 67% to 100% and 62% to 100%, respectively. In the final clinical assessment, 30 patients were independently examined by two dermatologists and four nurse practitioners. Using the consensus clinical diagnosis of the dermatologists as the gold standard, the nurse practitioner's sensitivity for detecting significant skin cancer lesions ranged from 50% to 100% and the detection specificity was 99% to 100%.

CONCLUSIONS

These preliminary results have important implications for skin cancer screening efforts and suggest that nurse practitioners can be trained to accurately identify and triage suspicious lesions.