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PCP training improves skin cancer screening rates, diagnostic outcomes
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CHICAGO — Skin cancer screening of patients performed in the primary care setting during routine examinations resulted in detection of thinner melanomas, according to the results of a study presented at the ASCO Annual Meeting.
“Due to a lack of randomized studies, the United States Preventive Services Task Force has insufficient evidence to support screening programs,” Laura Ferris, MD, PhD, associate professor in the department of dermatology at the University of Pittsburgh Medical Center (UPMC), said during a presentation. “The goal of screening is to detect early-stage disease when it is still surgically curable.”
Laura Ferris
In 2003, as part of a German trial, PCPs and dermatologists partook in an 8-hour training session, and then screened 19% of the eligible population of the state of Schleswig-Holstein for melanoma. Melanoma-related mortality declined in the area of the study following the screening.
These results, as well as subsequent data from new German screening protocols, prompted Ferris and colleagues to evaluate the effectiveness of an organized PCP–based screening program at UPMC.
Researchers evaluated demographics of patients eligible for screening, characteristics of newly diagnosed melanoma (depth, invasive disease, etc.) and procedures performed by PCPs.
Every PCP in the UPMC system was offered online education in skin cancer screening using the INFORMED module and was then asked to provide an annual skin examination during routine care for patients aged 35 years or older.
Sixteen percent (n = 142) of the participating PCPs who performed at least one screen completed online training. Those who completed the training performed approximately 39% of all screenings and had higher rates of screening of eligible patients they examined.
Diagnosed melanoma was considered screen detected if it was diagnosed in a patient who had been screened in 2014 and if the skin biopsy was performed on or after the date of screening.
The analysis included 333,788 individuals eligible for screening who were seen at UPMC in 2014, 15.4% of whom underwent screening, 84.6% of whom were not screened and 0.9% of whom declined screening.
Median age of screening patients was 60 years (range, 35-91) and 43.28% were male.
Researchers examined records and cancer registry data for screen-eligible patients and identified 40 incident melanomas among individuals who had been screened and 137 among individuals who had not been screened.
These data equated to a melanoma diagnosis in one per 1,1318 individuals in the screening group compared with one per 2,333 in the unscreened group (P = .002).
Melanomas detected in the screening group had a smaller median Breslow depth than those in the unscreened group (0.35 mm vs. 0.61 mm; P = .003). In addition, whereas 20% of the melanomas detected outside of screening were thicker than 1 mm, only 5% of screen-detected melanomas were thicker than 1 mm.
The ratio of in situ to invasive disease was 1:1.5 for patients with screen-detected melanoma and 1:2.3 for non–screen-detected melanoma, which did not represent a significant difference.
PCPs performed one or more biopsies to rule out malignancy on 433 patients. Of these, 316 were benign, 101 indicated nonmelanoma skin cancer and 15 indicated melanoma.
“The price of treating melanoma is currently increasing — it is predicted to triple by 2030 ... but evidence does not suggest a significant increase in health care costs measured by benign biopsies, dermatologist visits and skin surgeries,” Ferris said. – by Nick Andrews
References:
Ferris L, et al. Abstract 1508. Presented at: ASCO Annual Meeting; June 3-7, 2016; Chicago.
Disclos ure: Ferris reports consultant/advisory roles with and research funding from Abbvie, Amgen, Castle Biosciences, Celgene, DermTech, GlaxoSmithKline, Janssen, LEO Pharma, Lilly, MedImmune, Novartis, Pfizer, and Regeneron. Please see the abstract for a list of all other researchers’ relevant financial disclosures.
Perspective
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Frank L. Meyskens, Jr., MD
Finding that simple physician training can improve the screenings rate is a good outcome.
However, I was unclear about the pathology that may have been done by dermatologists. In some open systems, dermatologists have been known to do their own pathology without reporting results through the tumor registry. Research on this phenomenon has shown that as many as one-third more melanomas approximately 30,000 melanomas last year alone may not have been recorded in registries.
Further, by initiating screening for those aged 35 years or older, an important at-risk population may have been missed. Some of the most devastating cases of melanoma are seen in women who are diagnosed right before or during pregnancy. Most would agree that the majority of nonmelanoma skin cancers are a result of ultraviolet light. Melanoma however, is more complicated. This study could have expanded on the potential risk for women who are aged 23 to 27 years and provided important screening data for that population.
There is a need to develop accurate risk profiles that use all of the parameters at our disposal to identify and screen those patients who are at the greatest risk.
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