Underdiagnosis of Skin Cancer in Veterans Identified in Quality Improvement Study

A quality improvement study at the Madison Veterans Affairs Primary Care Clinic, presented at the 2025 AAD Annual Conference, has confirmed a significant underdiagnosis of skin cancer among veterans aged 70 years and older. Despite an intervention aimed at increasing detection rates, the study found that skin cancer diagnoses remained well below the expected prevalence. 

The retrospective review of 421 patient charts revealed that only 9.03% of veterans had a documented skin cancer diagnosis, significantly lower than the estimated 20% prevalence in the general population (P<0.0001). This discrepancy prompted the implementation of an intervention—a 34”x22” skin cancer infographic placed in resident physicians’ examination rooms—to encourage patient inquiries and improve diagnostic rates. 

However, 4 months post-intervention, only 5 additional skin cancer diagnoses were made, and the follow-up analysis showed that the diagnostic rate remained significantly below the expected prevalence (P<0.0001). 

"The persistent diagnostic deficiency likely stems from the previously noted system-level issue of time constraints," the study reported. Internal medicine residents cited limited time per patient visit and competing priorities related to comorbidities as the primary barriers to increased skin cancer detection. 

The study highlights the need for validated risk assessment tools to stratify high-risk patients and improve targeted screening. The United States Preventive Services Task Force currently acknowledges the need for improved risk assessment in its “Skin Cancer: Screening” recommendation. 

"Without further stratification of high-risk patients, this diagnostic gap may persist for veterans aged 70 and older," the study concluded. 

These findings suggest that while visual prompts can increase patient engagement, systemic barriers in primary care settings continue to limit effective skin cancer screening and diagnosis. Dermatologists may need to collaborate with primary care providers to develop more efficient, targeted screening strategies for high-risk populations.

Reference
A quality improvement project to identify and improve the skin cancer diagnostic gap in veterans aged 70 and older. News Release. presented at: AAD Annual Meeting; March 7–11, 2025; Orlando, FL.