MADRID – A novel program of recalls for twice-yearly full skin examinations in patients at increased risk for melanoma has uniformly resulted in very early detection and cure of melanomas over a 17-year period in a private-practice dermatologist’s office.
This extensive experience refutes the recent controversial U.S. Preventive Health Services Task Force statement that screening for melanoma hasn’t been shown to be of value.
“It is my belief that it is now possible to protect patients at increased risk or at high risk of melanoma with extraordinary efficacy. What is needed is to identify such individuals and to offer them the opportunity to participate in a serial screening program,” explained Dr. Shore, a Rockville, Md., dermatologist who is also on the clinical faculty at Johns Hopkins University, Baltimore.
“When patients present with recognized risk factors for melanoma, dermatologists should seriously consider recommending and performing such serial screening procedures,” he added. “The skill that is required when examining patients is not to know what lesions are melanomas, but what lesions could be melanomas, so that such lesions are biopsied or at least monitored. Dermatologists, who are familiar with the numerous benign entities that occur in human skin, are almost uniquely prepared to perform this function so that large numbers of biopsies are not necessary.”
The genesis for Dr. Shore’s screening program lay in the teachings of the well-known dermatopathologist Dr. Wallace Clark, who asserted that melanomas in their early developmental radial growth phase almost never metastasize, and that this phase lasts for at least 6 months.
Building upon this principle, Dr. Shore fashioned a screening program founded on what he considered to be five key elements: performing thorough skin exams, biopsying all suspicious lesions, recalling patients every 6 months, carefully educating patients regarding the importance of returning when called, and encouraging self-screening through teaching the classical features of melanoma.
In retrospect, however, he has concluded that the self-examination component wasn’t particularly useful. For example, during a recent 5-year period in which 10 new cases of melanoma were detected through the screening program, all were in the radial growth phase, the greatest Breslow depth was only 0.15 mm, and seven melanomas were in men over age 50—but only one cancer was detected by a patient.
“This was particularly surprising to us, as all patients had been familiarized with the features of melanoma. It appears that in very early cases of melanoma, where lesions are asymptomatic and flat, most patients are not particularly adept at recognizing them,” the dermatologist continued. “Based on our extensive experience, particularly with older patients, we do not believe self-examination by patients compares at all well to what can be achieved by trained professionals. If our experience is at all reflective of the larger community, we believe there should be a much greater emphasis on dermatologists’ examinations and less on self-screening by patients themselves.”
Median time between skin examinations in the series was 9 months rather than the sought-after 6 months. Despite this indication of slight foot-dragging, patients have enthusiastically embraced the serial screening program, according to Dr. Shore.
“Most patients feel wonderful coming in for exams because they know what our experience has been and they feel reassured that they will not die of melanoma,” he observed in response to an audience question.
In an interview, the dermatologist explained that he didn’t incorporate routine total body photography in his repetitive follow-up program because the technology wasn’t available when he started out. It’s still not part of his screening system because he wants the program to be readily generalizable for other dermatologists, relatively few of whom use whole body photographs.
Dr. Shore noted that two prior studies have also reported 100% survival of screened patients at increased risk for melanoma: one led by Dr. Darrell S. Rigel (Cancer 1989; 63:386-9), and another more recent study led by investigators at the University of Minnesota (J. Am. Acad. Dermatol. Jan. 2004; 50:15-20).