Melanoma screening increases detection with little impact on use of surgery, specialist referrals
Melanoma screening in the community medical setting increased melanoma diagnoses rates, but did not result in an upsurge of skin surgeries or dermatology office visits, according to study results published in Cancer.
“There has been some evidence supporting the potential efficacy of skin cancer screening in reducing mortality, but there has been a scarcity of evidence about the potential downstream harms of screening,” Martin A. Weinstock, MD, PhD, professor of dermatology and community health at Brown University, told HemOnc Today. “As a result of a grant, we produced an instructional program geared at primary care physicians, to educate them on melanoma screening. One feature of the program was to improve the ability to not just detect melanoma, but to confidently reassure patients about benign lesions that could be melanoma mimics.”
Martin A. Weinstock
Weinstock and colleagues offered the Internet Course for Melanoma Early Detection (INFORMED) to PCPs at University of Pittsburgh Medical Center (UPMC), which then initiated a melanoma screening program.
The researchers studied the impact of the screening program, as well as the instructional program, on patients aged 35 years or older who received an annual physical examination.
Patients were divided into three groups:
- Patients examined by the highest percentage of INFORMED–trained PCPs (group A1);
- patients examined by PCPs with a lower percentage of INFORMED training (group A2); and
- patients examined by PCPs with no INFORMED training (group B).
Groups A1 and A2 included 618 physicians, nurse practitioners and physician assistants. Approximately 26% of providers in these groups had INFORMED training (A1, n = 101; A2, n = 21).
A total of 16,472 patients were examined by PCPs in group A1 or A2, of whom 1,572 patients were screened by INFORMED–trained providers. Group B comprised 56,261 patients.
The researchers observed a 79% (95% CI, 15-138) increase in melanoma diagnoses among patients in group A1, whereas no statistically significant increase occurred in groups A2 and B.
The incidence of skin surgeries did not significantly increase in any group (A1, 2%; A2, 4%; B, 0%), despite the increased diagnosis in group A1. Similarly, all groups saw a modest but nonsignificant increase in dermatologist visits (A1, 2.5%; A2, 10.2%; B, 4.4%).
The researchers acknowledged study limitations, including the lack of randomization and the potential for coding errors. The researchers further reported that they did not have access to patient demographics.
“The training curriculum should focus not just on detecting malignancies, but on reassuring patients who are found to have noncancerous skin lesions,” Weinstock said. “As a result, those patients will not be referred for biopsy or excision, and the number of excess surgeries will be low.”
Effective strategies for early melanoma detection are needed, Clara Curiel-Lewandrowski, MD, associate professor of dermatology at The University of Arizona Cancer Center, and Susan M. Swetter, MD, professor of dermatology at Palo Alto Veterans Affairs Health Care System and director of the Pigmented Lesion and Melanoma Program at Stanford University Medical Center and Cancer Institute, wrote in an accompanying editorial.
“The need to improve the early detection of cutaneous malignancies is clearly highlighted by the increasing rate of melanoma mortality, with more than 10,000 melanoma deaths estimated in the United States in 2016,” Curiel-Lewandrowski and Swetter wrote. “Although unprecedented progress has been made in the field of therapy for metastatic melanoma, advances in early diagnosis have been hampered by inconclusive evidence regarding the value of skin cancer screening, particularly by PCPs.”
The research conducted by Weinstock and colleagues may change the overall perception of the risk-to-benefit ratio for skin cancer screenings.
“Both the lack of evidence demonstrating a screening-related mortality reduction and the assumption of potential harms represent the basis for the current U.S. Preventive Services Task Force draft recommendation grade of ‘insufficient’ for skin screening by PCPs,” Curiel-Lewandrowski and Swetter wrote. “The UPMC initiative is the first to our knowledge that specifically addresses the issue of potential harms of skin screening by PCPs in a large health care system, and it does not appear to demonstrate increased numbers of specialty referrals or undue patient harms. Further analyses from this ambitious UPMC effort may support that skin screening by trained PCPs can enhance the early detection of melanoma and other skin cancers, without increasing the burden on PCP and specialist time or causing overtreatment that contributes to physical and emotional harm for patients.” – by Cameron Kelsall
For more information:
Martin A. Weinstock, MD, PhD, can be reached at firstname.lastname@example.org.
Disclosure: Melanoma Research Alliance provided funding for this study. Weinstock reports personal fees from University Dermatology for research outside of the submitted work. Please see the full study for a list of all other researchers’ relevant financial disclosures. Curiel-Lewandrowski reports royalties from Clinical Care Options-Oncology and UpToDate, as well as patents, stock ownership and a consultant role with DermSpectra. Swetter reports no relevant financial disclosures.