Physician Skin Examinations for Melanoma Screening

In the United States an estimated 73,870 new cases of melanoma will be diagnosed in 2015.¹ Although melanoma accounts for less than 2% of all US skin cancer cases, it is responsible for the vast majority of skin cancer deaths. From 2007 to 2011, melanoma mortality rates decreased by 
2.6% per year in individuals younger than 50 years but increased by 0.6% per year among those 50 years and older.¹ Reports of the direct annual treatment costs for melanoma in the United States have ranged from 
$44.9 million for Medicare recipients with existing cases of melanoma to $932.5 million for newly diagnosed melanomas across all age groups.²

Melanoma survival rates are inversely related to tumor thickness at the time of diagnosis.³ Melanoma can be cured if caught early and properly treated. Secondary preventative measures include physician skin examinations (PSEs), which may increase the likelihood of detecting melanomas in earlier stages, thereby potentially increasing survival rates and quality of life as well as decreasing treatment costs. Physician skin examinations are performed in the physician’s office and are safe, noninvasive, and painless. Patients with suspicious lesions should subsequently undergo a skin biopsy, which is a low-risk procedure. False-positives from biopsies do not lead to extreme patient morbidity, and false-negatives will hopefully be detected at a subsequent visit.

There is a lack of consensus regarding recommendations for PSEs for skin cancer screening. Due to a lack of randomized controlled trials on the effects of skin cancer screening on patient morbidity and mortality, the US Preventive Services Task Force (USPSTF) has concluded that there is insufficient evidence to recommend for or against such screening⁴; however, other organizations including the American Cancer Society and the American Academy of Dermatology recommend periodic skin cancer screening examinations.^1,5 In a rapidly changing health care climate and with the rollout of the Patient Protection and Affordable Care Act, a USPSTF recommendation for skin screening with PSEs for skin cancer would have a large impact on clinical practice in the United States.

This article provides a systematic review of 
the current domestic and international data regarding the impact of PSEs on melanoma tumor thickness at the time of diagnosis as well as mortality 
from melanoma.

Methods

Search Strategy

A systematic search of PubMed 
articles indexed for MEDLINE and Embase for studies related to melanoma and PSEs was performed for the period from each database’s inception to November 8, 2014. One of the authors (S.L.M.) designed a broad search strategy with assistance from a medical librarian who had expertise in searching research bibliographies. Articles were excluded if they had a cross-sectional study design or were editorials or review articles. Search terms included skin neoplasm, skin cancer, or melanoma in combination with any of the following: skin examination, mass screening, screening, and secondary prevention.

Study Selection

All published studies reporting outcomes and correlations with PSEs and cutaneous melanoma in adult patients were screened. If multiple studies were published describing the same study, follow-up studies were included for data extraction, but the original study was the primary resource. Observational studies were a focus in this review, as these types of studies are much more common in this subject area.

One of the authors (S.L.M.) screened the titles and abstracts of identified studies for eligibility. If the reviewer considered a study potentially eligible based on the abstract review, a full-text review was carried out. The reference lists of eligible studies were manually searched to identify additional studies.

Data Extraction, Quality Assessment, and Data Synthesis

Data items to be extracted were agreed on before search implementation and were extracted by one investigator (S.L.M.) following criteria developed by review of the Cochrane Handbook for Systematic Reviews of Interventions.⁶ Study population, design, sample size, and outcomes were extracted. Risk of bias of individual articles was evaluated using a tool developed from the RTI item bank (RTI International) for determining the risk of bias and precision of eligible observational studies.⁷ Studies ultimately were classified into 3 categories based on the risk of bias: (1) low risk of bias, 
(2) medium risk of bias, and (3) high risk of bias. The strength of evidence of included studies was evaluated by the following items: risk of bias, consistency, directness, precision, and overall conclusion. Data from the included studies was synthesized qualitatively in a narrative format. This review adhered to guidelines in the Cochrane Handbook for Systematic Reviews of Interventions⁶ and the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines.⁸

^{Figure 1. Flow diagram for identification of eligible studies.}