Skin cancer screening: Quick, effective -- and neglected

Conflicting guidelines on screening for skin cancer as well as primary care physicians' lack of confidence in detecting suspicious lesions could hinder broader use.

By Susan J. Landers — Posted June 14, 2004

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Washington -- Patients understand the importance of a top-to-toe and back-to-front skin exam for early detection of cancer, and they even believe a physician who performs full-body skin screens is admirably thorough.

But not very many primary care physicians are doing them, according to several studies.

"In primary care, visits are so compact with issues from disease management to immunizations to other prevention that physicians will often neglect simple skin cancer screening," said Daniel G. Federman, MD, a primary care physician at the Veterans Administration Hospital in West Haven, Conn. He would like to see that situation change.

Preventive care that includes other cancer screenings is finding a proper niche in the offices of primary care physicians, and many ask, why not skin cancer screening, too?

Skin cancer is the most common malignancy in the United States, and it could be the ideal cancer for screening, since many risk factors are well known and there are opportunities for early detection, note Dr. Federman and colleagues in a May article in the Archives of Dermatology. Approximately 85% of the population sees a physician every two years, and routine examinations are among the 10 most common reasons for patient visits, they write.

For his most recent study, Dr. Federman and colleagues asked 251 patients whether their physicians had checked their skins and also asked the patients how they felt about it. "Some people might think it's a little weird if they have a wart and someone asks them to get naked," he said. But the researchers found that patients were accepting.

The researchers also asked whether it made a difference if a physician of the opposite sex examined them. This variable, too, didn't seem to matter.

Despite patient willingness, only 32% of patients reported undergoing regular full-body skin screenings by their primary care physicians, 55% said they had no screenings, and 13% were unsure. Patients with a history of skin cancer, however, were more likely to undergo screening than those without such a history, Dr. Federman said.

The findings don't surprise Martin A. Weinstock, MD, PhD, professor of dermatology and community health at Brown University, who has done research on skin screenings for several years.

For one study, he and his colleagues asked Rhode Islanders how often their physicians examined the skin on their backs. The most common response was "never," he said. Very few had the skin on the backs of their legs checked, either. Both are common sites for possible malignancies, Dr. Weinstock said.

Obstacles to screening

Studies have shown that primary care physicians are not always confident of their ability to detect a suspicious skin lesion. It's not always included in medical school curricula, and very few primary care physicians will ever see a malignant lesion.

But since there aren't enough dermatologists to meet the demand, there is support for extra training for primary care physicians.

Dr. Weinstock, who also chairs the American Cancer Society's skin cancer advisory group, has done research involving the training of physicians and patients to conduct skin exams. Not surprisingly, he has found that along with training comes an improvement in skills, performance and attitudes.

Conflicting guidelines about the effectiveness of the procedure present another obstacle to broad screening that might be more difficult to overcome. The U.S. Preventive Services Task Force found insufficient evidence to recommend for or against routine screening for early detection. The American Cancer Society recommends a cancer-related checkup by a physician, including skin examination, every three years between ages 20 and 40 and annually for those older than 40.

There also are practical office-based obstacles to be overcome. Time must be allowed for patients to undress, and elderly patients might take considerable time. But the exam itself likely would take only a minute or two, said James Spencer, MD, vice chair of the Dept. of Dermatology at Mount Sinai School of Medicine.

"I would encourage all internists and family physicians to do annual skin screens on their patients," Dr. Spencer said. And if the physician sees something that looks suspicious, they can always send the patient to a dermatologist.

A primary care physician might see one patient out of 100 with a suspicious lesion, but finding and referring that patient to a dermatologist would be a great public health service, he said.

Back to top


What we know about checking

The U.S. Preventive Services Task Force arrived at the following clinical considerations for screening for skin cancer after surveying available data:

  • Benefits from screening are unproven, even in high-risk patients. Clinicians should be aware that fair-skinned men and women older than 65, patients with atypical moles and those with more than 50 moles make up known groups at substantially increased risk for melanoma.
  • Clinicians should remain alert for skin lesions with malignant features noted in the context of physical examinations performed for other purposes. Asymmetry, border irregularity, color variability, diameter greater than 6 mm, or rapidly changing lesions are features associated with an increased risk of malignancy. Suspicious lesions should be biopsied.
  • The USPSTF did not examine the outcomes related to surveillance of patients with familial syndromes, such as familial atypical mole and melanoma syndrome.

Back to top

External links

U.S. Preventive Services Task Force recommendations for screening for skin cancer (link)

American Cancer Society on skin cancer, in pdf (link)

Food and Drug Administration's "Primer on Summer Safety" (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn