CHICAGO Dermatologists who conducted complete skin examinations of all their patients would detect more melanomas, and those cancers would be detected earlier, Dr. Jonathan Kantor said at the annual meeting of the American Society for Dermatologic Surgery.
"Full skin examination is a critical tool for detecting melanoma in patients visiting a dermatology or dermatologic surgery office," said Dr. Jonathan Kantor, who is in private practice in Jacksonville, Fla.
According to one published survey, only about 30% of dermatologists perform full skin examinations on all their patients, and half of respondents said that they screened only those patients deemed to be at increased risk (J. Am. Acad. Dermatol. 2002;46:710-4).
This survey "suggests that half of dermatologists are not screening patients at high risk of melanoma," said Dr. Kantor.
"Clearly, we cannot find all melanomas just by saying "hello," shaking the patient's hand, and talking to him about his acne. We know that when we screen patients actively, we're going to find melanomas at earlier stages," he said.
For this study, Dr. Kantor drew on 2 years of data on 76 consecutive patients who were diagnosed in an office setting, either with invasive melanoma (30) or melanoma in situ (46). Their average age was 60 years; 63% were men.
A total of 41 patients (54%) had made appointments because they saw something suspicious on their skin and thought it should be looked at. The remaining 35 (46%) came in for other reasons, such as acne, dry skin, warts, and other conditions, he explained.
Body locations for the melanomas were fairly evenly distributed among the head and neck, trunk, and extremities, with the lower extremities being slightly less represented. The trunk was the most common site of melanomas in men, but the legs were the most common site for women.
Dr. Kantor concluded that 46% of all the melanomas (43% of invasive melanomas and 48% of in situ lesions) may not have been found without the careful skin examination.
Physician-detected melanomas tended to be thinner, and at the in situ stage; although these trends were not statistically significant, they highlight the clinical validity of the study data. "It makes sense that screening finds melanoma earlier and at a stage where hopefully they're more likely to respond to treatment," Dr. Kantor said.
Although he believes that this study has implications for both clinical practice and health policyincluding screening recommendationshe conceded its important limitations. "Obviously, these data are not generalizable and this was a retrospective analytical case series, which limits further analysis. Also, there's the issue of screening versus examination. Those who are examined in a physician's office may be at higher risk than those who attend skin cancer screenings," he said.
Yet, he added, dermatologists should consider doing complete skin examinations on all patients and let future studies fill in the gaps left by this initial research.
The U.S. Preventive Services Task Force has concluded that there is insufficient evidence to recommend for or against routine screening for skin cancer using a total body examination.
"One of my main jobs as a dermatologist is to find melanoma and melanoma in situ, because early detection is an inconvenience while late detection becomes a tragedy," Dr. Kantor said, pointing out that the 10-year survival rate drops from 88% for a 1-mm melanoma to 32% for an ulcerated melanoma larger than 4 mm.
And melanoma in situ should never be underestimated, he added, explaining that in a study of 104 reassessed patients, almost a third of melanomas in situ were reclassified as invasive melanoma (Lancet 2002;359:1921-2).
This melanoma in situ was found on the foot of an 88-year-old who presented with a complaint of dry skin. Her toe was saved with geometric excision. Courtesy Dr. Jonathan Kantor