Health
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
- WITH THIS STORY:
- » What we know about checking
- » External links
- » Related content
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.