Are Skin Self-Exams Worthwhile?

Should you be encouraging patients to check for moles and other signs of skin cancer at home?

Since the 1980s, the incidence of melanoma has continued to rise, making it one of the most common preventable cancers. During this time, the trend has been for more and more thin melanomas to be detected, suggesting that the disease is being detected earlier, possibly because of the encouragement of more vigilant self-screening practices and greater public awareness of the disease. Because the best treatment for early stage melanoma is surgery, earlier discovery of melanoma may seem to be a positive trend; but there is currently no satisfactory treatment for metastatic melanoma, and two recent presentations suggest that clinical physician melanoma examinations are even more important than currently recognized, while one called into question the utility of many patient self-examinations. Physician Examinations identify Thinner Lesions “In our study, physician examinations are associated with thinner melanomas to a greater degree than are patient self skin examinations,” says Susan M. Swetter, MD, Director of the Pigmented Lesion and Cutaneous Melanoma Clinic and Associate Professor of Dermatology at Stanford University School of Medicine. “But we are trying to promote both practices, to try to get patients in to see their physicians earlier,” says Dr. Swetter, who presented a poster, “Efficacy of Physician- and Skin Self-Examination Practices for Early Melanoma Detection,” at the 2008 annual meeting of the American Society of Clinical Oncology (ASCO) in Chicago. Dr. Swetter and her colleagues recommend that patients perform self-examinations once a month, and that patients enlist the assistance of a spouse to look on the back. “Almost one-third of melanomas occur on the back in men,” explains Dr. Swetter. Various guidelines also recommend a routine physician examination once or twice a year. “There are really two issues here,” says Allan C. Halpern, MD, Chief of Dermatology at Memorial Sloan Kettering Cancer Center, who also gave a presentation on melanoma detection at the ASCO conference. “First, we need to have the funding for the science to determine what a difference screening would make. Right now there are none immediately planned, despite a recognized need,” says Dr. Halpern, noting that a study on the subject had been planned in Australia before the funding was cancelled. Only the pilot was completed. “Secondly, in the absence of the science that proves that screening is effective, there is no funding for the act of screening. Screening is not a reimbursable exercise by Medicare, for example. There’s a difference between finding somewhat thinner lesions and proving that it actually affects mortality,” he says. Dr. Halpern points out that all Caucasians over 50 years old should get at least one lifetime screening. Siblings and first-degree relatives of melanoma patients should be tested at least every other year, while melanoma patients should be examined annually, he says.

Study Details Out of 223 melanoma patients studied in the Dr. Swetter poster, those who identified themselves as having had a physician skin exam in the last year had a mean tumor depth of 1.58 millimeters at diagnosis, as opposed to 2.51 millimeters in those who did not. Because self-examination practices were more modest predictors of tumor depth, “more precise definitions of vigilant SSE (skin self-examination) are required,” according to the abstract, number 9037. “When melanomas are picked up incidentally by a doctor, they tend to be thinner, not when a patient comes in because the melanoma is symptomatic, such as if it is bleeding or itching,” says Dr. Swetter. The study, which began about a year and a half ago, looked at 223 patients, 57% of whom were male. The mean age was 56.4 years, and included patients diagnosed with primary invasive melanoma. Patients with in situ, mucosal, genital, perianal, ocular and unknown primary melanoma were excluded, according to the poster. In contrast to the evidence showing thinner tumors in patients who had a physician examination, evidence of the benefit of self-examination was less conclusive. Those patients who examined their moles every 1 or 2 months had a mean tumor depth of 2.05 millimeters at diagnosis, compared 2.11 millimeters in those who never examined their moles, according to the poster. On the other hand, among patients who conducted self skin examinations, those who used a picture to identify melanoma had a mean tumor depth of 1.5 millimeters at diagnosis, compared to 2.3 millimeters in those who engaged in self skin examination without a picture guide, the study found. The study looked at how many possible locations patients examined for melanoma. The locations were the face, neck, chest, abdomen, groin, anterior arm, front thigh, front lower leg, foot, posterior neck, shoulder, lower back, buttocks, posterior arm, posterior thigh, posterior calve and lower leg. Though those patients who examined themselves more regularly or examined more body spots, had slightly thinner tumors, the difference was less conclusive, according to the poster. The study, which is being conducted at the Palo Alto Health Care System, the Stanford Comprehensive Cancer Center, Boston University, the University of Michigan, and Harvard Medical School, is ongoing and will accrue a total of 500 patients, according to Dr. Swetter. Plusses of Self-Exams “On average, physician-detected melanomas are indeed thinner than patient-detected melanomas,” says Dr. Halpern. “But that’s not to say that self-detection is not important; in fact, it’s very important,” he says, noting that the majority of melanomas are self-detected. “In men, close to 80% of melanomas are detected either by the patient or someone in the patient’s life, as opposed to a physician, whereas in women, that number is close to 90%,” he explains. “As to why the number is higher in women, one possibility is that women are generally more health conscious than men, and tend to play the health gatekeeper role more than men.” Notwithstanding the accumulating evidence that physician screening is more effective, there has to date been no randomized controlled trial to make a definitive determination of any survival advantage. “The indirect evidence for an advantage to physician screening in the case of superficial spreading melanomas, the most common form of melanoma, is exceedingly strong. Even in the case of nodular melanomas, which make up 15% of the cases, it may be less obvious that physician detection will be more successful, but it is not clear that would be the case, because even for nodular melanomas, the thinner they are when detected, the better prognosis, although nodular melanomas have some potential from their inception to spread and kill people,” says Dr. Halpren. Funding for the research has simply been lacking, Dr. Halpern notes. Even the U.S. Preventive Screening Task Force has not recommended formal melanoma screening, he explains. Screening Techniques Despite these circumstances, better methods are evolving in order to try to pick up melanoma occurrence at an earlier stage. “The visual cues used to identify melanoma have changed since we were in medical school,” said Dr. Halpern during his address at ASCO, entitled “Dermatologic Screening in Persons at High Risk for Melanoma.”’ Dr. Halpern identified high-risk factors for melanoma as white skin color, those with more moles or with a personal or family history of melanoma, those who burn easily or who are past four decades in age, and those with funkier, or dysplastic, nevi. One long-established technique for teaching patients to identify melanoma is referred to as the ‘ABCD’ method, according to Dr. Halpern. ABCD stands for asymmetry, border irregularity, color variation and diameter greater than a pencil eraser. However, the ABCD criteria are in the process of being updated now, according to Dr. Swetter, with the possible addition of “evolving.” “But I think we can do better than the ABCDs,” says Dr. Halpern, noting that another method, called the ‘Ugly Duckling’ method, has evolved since the turn of the century. The term was coined by Jean-Jacques Grob about 10 years ago. “All of us have seen age spots that look for all the world like melanoma,” he says. “Nonetheless, we should ask patients whether they have any new or changing lesions,” he explains, noting that patients may not disclose the symptoms otherwise. “And we should look for outliers,” he adds, noting that by definition, any isolated lesion is an outlier. A third manner of identifying melanoma is what Dr. Halpern calls the “overall gestalt-heuristic approach.” “We can teach the public with lots of pictures of melanoma, and we can use differential recognition: W hich of these don’t belong with the others?” he says, noting that at least four different subsets of melanoma have been identified, and they tend to have different distinguishing characteristics. In reality, the gestalt-heuristic approach is the way physicians have always tried to educate patients about melanoma. “That’s why we have used brochures that rely heavily on illustrations,” he explains. Other visual cues patients and medical professionals should know about include the presence of multiple characteristics in one lesion: white scar-like areas or milky red areas, red globules and atypical networks. Patients with funkier, or dysplastic nevi, also need closer observation.