Physician Skin Examinations for Melanoma Screening

Another prospective cohort study in Queensland was designed to detect a 20% reduction in mortality from melanoma during a 15-year intervention period in communities that received a screening program.¹¹ A total of 44 communities (aggregate population, 560,000 adults aged ≥30 years) were randomized into intervention or control groups to receive a community-based melanoma screening program for 3 years versus usual medical care.Overall, thinner melanomas were identified in communities with the screening program versus neighboring communities without it.¹¹ Of the 33 melanomas found through the screening program, 39% (13/33) were in situ lesions, 55% (18/33) were thin (<1 mm) invasive lesions, and 6% (2/33) were 1-mm thick or greater.¹⁶ Within the population of Queensland during the period from 1999 through 2002, 36% were in situ lesions, 48% were invasive thin melanomas, and 16% were invasive melanomas 1-mm thick or more, indicating that melanomas found through screening were thinner or less advanced.¹⁷

Comment

Our review identified 5 studies describing the impact of PSEs for melanoma screening on tumor thickness at diagnosis and melanoma mortality. Key findings are highlighted in Figure 2. Our findings suggest that PSEs are associated with a decline in melanoma tumor thickness and melanoma-specific mortality. Our findings are qualitatively similar to prior reviews that supported the use of PSEs to detect thinner melanomas and improve mortality outcomes.^18-20

^{Figure 2. Key findings from included studies.}

The greatest evidence for population-based screening programs was provided by the SCREEN study. This landmark study documented that screening programs utilizing primary care physicians (PCPs) and dermatologists can lead to a reduction in melanoma mortality.¹⁵ Findings from the study led to the countrywide expansion of the screening program in 2008, leading to 45 million Germans eligible for skin cancer screenings every 2 years.²¹ Nearly 
two-thirds of dermatologists (N=1348) were satisfied with routine PSE and 83% perceived a 
better quality of health care for skin with the 
2008 expansion.²²

Data suggest that physician-detected melanomas through PSEs or routine physical examinations are thinner at the time of diagnosis than those found by patients or their partners.^14,23-26 Terushkin and Halpern²⁰ analyzed 9 worldwide studies encompassing more than 7500 patients and found that 
physician-detected melanomas were 0.55 mm thinner than those detected by patients or their significant others. The workplace screening and education program reviewed herein also reported a reduction in thicker melanomas and melanoma mortality during the study period.¹²

Not all Americans have a regular dermatologist. As such, educating PCPs in skin cancer detection has been a recent area of study. The premise is that the skin examination can be integrated into routine physical examinations conducted by PCPs. The previously discussed studies, particularly Aitken et al,¹⁴ Schneider et al,¹² and Katalinic et al,¹⁵ as well as the SCREEN program studies,¹⁵ suggest that integration of the skin examination into the routine physical examination may be a feasible method to reduce melanoma thickness and mortality. Furthermore, the SCREEN study¹⁵ identified participants with risk factors for melanoma, finding that approximately half of men and women (N=360,288) had at least one melanoma risk factor, which suggests that it may be more practical to design screening practices around high-risk participants.

Several studies were excluded from our analysis on the basis of study design, including cross-sectional observational studies; however, it is worth briefly commenting on the findings of the excluded studies here, as they add to the body of literature. 
A community-based, multi-institutional study of 
566 adults with invasive melanoma assessed the role of PSEs in the year prior to diagnosis by interviewing participants in clinic within 3 months of melanoma diagnosis.²⁴ Patients who underwent full-body PSE in the year prior to diagnosis were more than 2 times more likely to have thinner (≤1 mm) melanomas (OR, 2.51; 95% CI, 1.62-3.87]). Notably, men older than 60 years appeared to benefit the most from this practice; men in this age group contributed greatly to the observed effect, likely because they had 4 times the odds of a thinner melanoma (OR, 4.09; 95% CI, 1.88-8.89]). Thinner melanomas also were associated with an age of 60 years or younger, female sex, and higher education level.²⁴

Pollitt et al²⁷ analyzed the association between prediagnosis Medicaid enrollment status and melanoma tumor thickness. The study found that men and women who intermittently enrolled in Medicaid or were not enrolled until the month of diagnosis had an increased chance of late-stage melanoma when compared to other patients. Patients who continuously enrolled during the year prior to diagnosis had lower odds for thicker melanomas, suggesting that these patients had greater access to screening examinations.²⁷