Melanoma screening is worth the money, study shows
■ But opinions are not unanimous. Experts are calling for controlled randomized trials to answer the question definitively.
By Victoria Stagg Elliott — Posted Feb. 5, 2007
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A one-time total-body skin exam to hunt for melanoma in patients who are older than 50 is as cost effective as other widely accepted cancer screenings such as mammograms and Pap smears. For those with a family history that includes skin cancer, getting checked every two years is also cost effective, according to a paper in last month's Archives of Dermatology.
"We suggest everybody 50 and older be screened once. Those in higher-risk categories should be screened more often. This would be a huge benefit to a lot of people," said Elena Losina, PhD, lead author of the study and associate professor of biostatistics at the Boston University School of Public Health and Massachusetts General Hospital.
The response from organizations and physicians that support more frequent melanoma screening -- the least used of all the cancer screening modalities -- was positive.
"It's a commonsense kind of thing that the cost of screening would be worth preventing somebody from dying from melanoma," said Brett Coldiron, MD, chair of the American Academy of Dermatology's health care finance committee and clinical assistant professor of dermatology at the University of Cincinnati College of Medicine.
Support for this perspective, however, is far from universal. The AAD and the American Cancer Society recommend regular skin exams, but the U.S. Preventive Services Task Force finds insufficient evidence to recommend either for or against this practice. The USPSTF does advocate that physicians be alert to possible lesions while conducting physical exams for other purposes.
"We didn't say that you should not do it, but we don't have the evidence to make a recommendation one way or another," said Task Force Chair Ned Calonge, MD, MPH.
This policy, which was issued in 2001, is due for review, although few signs indicate that it will change dramatically, because the problem of a lack of evidence persists. Cost effectiveness, such as found in this recent analysis, is not taken into account during the task force evidence review process. The type of prospective randomized controlled trial that provides the highest level of evidence and brought many other screening methods into widespread use also has not been completed for skin cancer.
Nor is one expected. A trial of this nature was attempted in Australia in the late 1990s but was discontinued after the pilot phase because of a lack of funding. Since then, data from the project have trickled out, and final results involving the pilot's small cohort are eagerly anticipated, particularly since many believe that a large-scale trial might never be completed because of the associated cost and effort.
"The major problem in this area is that we don't have the rigorous trial to document that such screening can have a significant effect on mortality," said Martin Weinstock, MD, PhD, chair of the American Cancer Society's skin cancer advisory board and professor of dermatology and community health at Brown University in Providence, R.I. "When the Australian data are reported, they will probably be the best data we will ever get, and I'm anxiously awaiting the results."
More motivation for study
Work such as Dr. Losina's, along with other emerging data from AAD screening programs and various case-control studies, is leading some observers to sense an increase in motivation to do the large-scale research.
"This paper gives us a new layer of sophistication that's very valuable," said Howard Koh, MD, MPH, associate dean for public health practice at the Harvard School of Public Health, who wrote an accompanying editorial. "But this issue has not been resolved yet to anybody's satisfaction."
And although many experts are considering the feasibility of such a study, others are debating the practicality of more widespread skin screening, particularly if it depends on dermatologists as with this analysis. Many wondered if there were enough physicians in this specialty to carry out these screenings and what the role of primary care physicians would be.
"Skin screenings are a good idea," said Barbara Reed, MD, clinical professor of dermatology at the University of Colorado Health Sciences Center in Denver and a former AAD president, although she was speaking personally. "But I wouldn't want to spend all my time screening. It would get a little boring."
Several projects, including one run by Dr. Weinstock, are focused on improving skin cancer detection in the primary care setting, and Dr. Losina's group intends to turn its attention to the cost effectiveness of interventions in this type of practice.
A physician exam also might not be the only way to achieve early melanoma detection. Research is being done to investigate the effectiveness of teaching patients to examine themselves.
According to another study by researchers from Northwestern University's Feinberg School of Medicine in Chicago in the same issue of the Archives of Dermatology, those who receive education about this type of screening with their partners are far more likely to carry it out than those who are instructed by themselves.