Screening for Skin Cancer by Dermatologists, Internists, and Family Practitioners

The most frequently diagnosed cancer in the United States is skin cancer. The most common forms of the disease are basal cell carcinoma and squamous cell carcinoma; together the 2 forms account for >1 million new cases each year. The most fatal form of skin cancer is malignant melanoma; there were an estimated 68,720 Americans diagnosed with malignant melanoma in 2009, with approximately 8650 associated deaths. Skin cancer is a significant public health problem in this country. Early detection of skin cancer has been shown to reduce morbidity and mortality. Individuals with established risk factors for melanoma would benefit significantly from active skin cancer screening and surveillance, and screening by dermatologists may also be cost-effective. However, according to researchers, there is a lack of randomized clinical trials that demonstrate the efficacy, feasibility, and cost benefits of skin cancer screening. In addition, there are inconsistencies in current guidelines on screening for skin cancer: guidelines range from no formal recommendations to annual screenings for all adults. Current screening rates in dermatology practices are high: in a recent survey, 79% of surveyed dermatologists said they perform full-body skin cancer screening on all of their adult patients or on those at high risk. Rates of screening for skin cancer are lower in primary care settings. The researchers recently conducted a study to identify the barriers and facilitating factors to skin cancer screening among physicians in the United States. The survey was conducted in the context of a larger randomized intervention study. Survey results were reported in Archives of Dermatology [2011;147(1):39-44]. Survey participants were randomly selected from the American Medical Association’s Medical Marketing Services database from April 1, 2005, through November 30, 2005. The survey was sent to 2999 dermatologists (n=1000), family practitioners (n=999), and internists (n=1000) in the United States. There were 1669 surveys returned for an overall response rate of 59.2%. The response rate by specialty was dermatologists, 70.8% (679/1000); family practitioners, 59.7% (559/999); and internists, 46.6% (431/1000). Full-body examinations were performed during complete physical examinations by 81.3% of dermatologists (n=552), 59.6% of family practitioners (n=333), and 56.4% of internists (n=243). Full-body examination rates were highest for patients with at least 1 additional risk factor for skin cancer; 72.8% of dermatologists said they screened for 76% to 100% of their patients at high risk for skin cancer, compared with 53.1% of family practitioners and 49.4% of internists (P<.05 for both comparisons) who reported similar screening rates for high-risk patients. Overall, the top 3 moderate or major barriers to performing full-body screenings for skin cancer were time constraints, competing comorbidities, and embarrassment or reluctance on the part of the patient. The barriers differed among the 3 specialties: compared with dermatologists (30.6%, n=208), more family practitioners (54.4%, n=304; P<.05) and internists (54.5%, n=235; P<.05) said time constraints were a moderate or major barrier. More family practitioners (50.4%, n=282) and internists (51.7%, n=223) also reported competing comorbidities as moderate or major barriers to full-body screening, compared with dermatologists (16.3%, n=111) (P<.05). More dermatologists (44.2%, n=300) reported patient embarrassment or reluctance as a major barrier, compared with family practitioners (31.3%, n=175) and internists (32.7%, n=141) (P<.05). Facilitating factors reported overall were having patients at high risk, patient demand for full-body examinations or mole checks, and the influence of medical training. By specialty, compared with internists and family practitioners, more dermatologists reported the following as moderate to major facilitating factors: (1) skill/expertise in performing full-body examinations and diagnosing skin cancer, (2) influence of medical training, and (3) having patients at high risk for skin cancer.