Total-Body Examination vs Lesion-Directed Skin Cancer Screening

Abstract

IMPORTANCE Skin cancer is the most frequent cancer type. It remains unknown if and how screening programs can be organized in a cost-effective manner. OBJECTIVE To compare the 2 screening strategies of systematic total-body examination (TBE) and lesion-directed screening (LDS), with a focus on the participation rate, detection rate, anxiety, and cost. DESIGN, SETTING, AND PARTICIPANTS Population-based cross-sectional screenings by a team of 6 dermatologists were organized in 2 sociodemographically similar regions. The TBE was organized in a community of 9325 inhabitants 18 years and older (Wichelen, East Flanders, Belgium) during a 5-day screening (March 14-18, 2014). The LDS was organized in a sociodemographically comparable community (Nevele, East Flanders, Belgium) of 9484 adult inhabitants during a 4-day screening (April 22 and 25-27, 2014). The first population received a personal invitation for a standard TBE. In the second population, individuals were invited for an LDS if they had a lesion meeting 1 or more of the following criteria: ABCD rule (A, asymmetry; B, borders; C, colors; and D, differential structures), ugly duckling sign, new lesion lasting longer than 4 weeks, or red nonhealing lesions. MAIN OUTCOMES AND MEASURES In total, 1982 individuals were screened, and 47 skin cancers (2.4%) were histologically confirmed, including 9 melanomas (0.5%), 37 basal cell carcinomas (1.9%), and 1 squamous cell carcinoma or Bowen disease (0.1%). RESULTS The positive predictive value for all suspicious lesions was 56.6% (47 of 83). The participation rate was 17.9% (1668 of 9325) in the TBE group vs 3.3% (314 of 9484) in the LDS group (P < .01). The skin cancer detection rate per 100 participants did not differ significantly between the 2 groups, with rates of 2.3% (39 of 1668) in the TBE group vs 3.2% (8 of 248) in the LDS group (P = .40). The operational effectiveness per 100 invitees was 0.4% (39 of 9325) in the TBE group vs 0.1% (8 of 9484) in the LDS group (P < .01). In addition, LDS was 5.6 times less time consuming than TBE. Participants in the LDS group had significantly higher baseline anxiety levels compared with participants in the TBE group (3.7 vs 3.3 points on a visual analog scale, P < .01). In screenees without a suspicious lesion, anxiety levels significantly dropped after screening. CONCLUSIONS AND RELEVANCE Total-body examination yielded a higher absolute number of skin cancers. Lesion-directed screening had a similar detection rate of 3.2% (8 of 248) but was 5.6 times less time consuming. When performed by dermatologists, LDS is an acceptable alternative screening method in health care systems with limited budgets or long waiting lists.

Mobile teledermatology for skin cancer screening

“…In contrast, lesion directed examinations are more time-efficient and have similar detection rates, but still require time-expensive face-to-face consultations and similar constraints as to total-body examinations apply. [9] Teledermatological assessments on the other hand, especially lesion directed store and forward procedures can be performed in a most speedy manner. In several former studies, the reliability of teledermatology based management recommendations was shown to be comparable to face-to-face consultations.…”

Detection of dermatological abnormalities in the rheumatology clinic using a standardized screening exam

“…The development of a standardized dermatologic exam has been particularly important in screening for skin cancer. Skin surveillance for skin cancer has been assessed in several studies . This type of screening is usually done by physicians, but patients are also instructed to examine their skin on a regular basis, looking for abnormalities.…”

Cost-effective Melanoma Screening

“…In 2011, the annual cost of treating newly diagnosed melanoma in the United States was $457 million, and by 2030 it is expected to increase 252.4% to $1.6 billion. 9 In the study by Hoorens et al, 4 the screening cost per melanoma detected varied from €4631 to €7449. The cost of detecting a melanoma by self-detection of concerning lesions was, not surprisingly, less than by population-based screening.…”

“…The Belgian study by Hoorens et al 4 tests 2 potential innovations for population-based organized screening for skin cancer. First, they compared a general population–based invitation for screening with a more selective approach based on concerning lesions in 2 communities with equivalent populations.…”

“…Of note, among participants presenting with a concerning lesion, total-body skin examination had a significant yield for additional skin cancers. 4 …”