The Importance of a Full Clinical Examination: Assessment of Index Lesions Referred to a Skin Cancer Clinic Without a Total Body Skin Examination Would Miss One in Three Melanomas

Abstract

Traditional clinical teaching emphasises the importance of a full clinical examination. In the clinical assessment of lesions that may be skin cancer, full examination allows detection of incidental lesions, as well as helping in the characterisation of the index lesion. Despite this, a total body skin examination is not always performed. Based on two prospective studies of over 1,800 sequential patients in two UK centres we show that over one third of melanomas detected in secondary care are found as incidental lesions, in patients referred for assessment of other potential skin cancers. The majority of these melanomas occurred in patients whose index lesion turned out to be benign. Alternative models of care--for instance some models of teledermatology in which a total body skin examination is not performed by a competent practitioner--cannot be considered equivalent to a traditional consultation and, if adopted uncritically, without system change, will likely lead to melanomas being missed.

Association of Skin Cancer and Indoor Tanning in Sexual Minority Men and Women

“…The US Preventive Services Task Force does not currently recommend routine skin cancer screening in the general population by primary care physicians because of insufficient evidence concerning its benefits and harms. 40 However, other studies [41][42][43] suggest skin cancer screening can significantly increase early detection of skin cancer and decrease disease-related mortality. Identifying sexual minority men as a high-risk population for skin cancer may help physicians risk stratify those patients in whom more diligent screening might be more beneficial.…”

Teledermatology: current perspectives

“…15 Additionally, it is not possible to perform full-body skin examinations, 56 and some authors have reported that relying on teledermatology to assess pigmented lesions may lead to under-detection of melanoma by general practitioners. 35,57 Therefore, teledermatology will not completely replace FTF consultations. Instead, it can be useful as a triage tool, to qualify which patients really need FTF specialized care and help to define the priority in which this care should be delivered.…”

Unimaged Melanomas in Store-and-Forward Teledermatology

“…12 Aldridge et al discovered 5 incidental melanomas among 336 patients referred from primary care for evaluation of lesions suspicious for skin cancer. 13 Kingsley-Loso et al discovered 87…”

“…[7][8][9][10][11] This concern is more related to the perceived inability of primary care providers (PCPs) to direct imaging of suspicious lesions than to the SFT dermatologist's ability to diagnose them. [12][13][14] At least three previous studies have ascertained the frequency of ''incidental'' melanomas in populations of patients referred for FTF dermatology care. An incidental melanoma is defined as a melanoma discovered by a dermatologist during full body skin examination (FBSE), but was not the subject of the referral.…”

“…14 Based on these studies, there is justifiable concern that unimaged melanomas may be present in patients being referred to SFT for other dermatologic concerns. 1,[12][13][14][15] We conducted this quality improvement study to ascertain the frequency at which unimaged melanomas occurred among patients enrolled in a VA SFT program and to determine what, if any, policy and procedural changes might be necessary to improve the program.…”