Screening for melanoma should be a simple task, especially with the recent use of dermoscopy, but somehow it is not. The USPTF is one of the many bodies under the ACA which will create limitations on patient care, namely a means to reduce costs. Melanoma is an all too tragic disease, one which should and can be militated against. Unfortunately the death rate from melanoma has not decreased and with the current recommendations it may very well increase.
Let us begin by reviewing the current Government ruling on
skin examination. One should remember that this is the basis for Comparative
Clinical Effectiveness, CCE. We discussed this issue just a few postings back.
We have also been concerned since the beginning of the ACA debacle about its
negative impact on Health Care. The USPTF has presented a set of at best
non-recommendations[1].
The USPSTF concludes that the current evidence is
insufficient to assess the balance of benefits and harms of screening for skin
cancer by primary care clinicians or by patient skin self-examination. (I
statement)
Namely the recommendation is that primary care physicians
are not trained to make a correct diagnosis. However it does not admit that
Dermatologists do so as well. One may envision a great opportunity for
Teledermoscopy allowing the capture of in office dermoscope images and then
referral to a Dermatologist. Reading the dermoscopic images takes less than a
minute by a trained Dermatologist and the specificity of such a reading can be
quite high.
The USPTF Report continues:
Primary care physicians are moderately accurate in
diagnosing melanoma, with a sensitivity of 42% to 100% and a specificity of 70%
to 98%. A large systematic review analyzed the evidence on diagnostic accuracy
of primary care physicians and dermatologists; most of the studies used images
of lesions that had been histologically confirmed. The systematic review
included 11 studies with primary care physicians and found a sensitivity of 42%
to 100% and a specificity of 98% in the diagnosis of melanoma. The authors
concluded that the evidence was insufficient to determine whether
dermatologists and primary care physicians differed in accuracy . However,
most studies on the accuracy of diagnosis of melanoma by primary care
physicians evaluated the ability to identify melanoma from images of lesions of
a known diagnosis; the applicability of this evidence to a whole-body skin
examination in the setting of screening for skin cancer is not clear.
In a recent Editorial in Investigative Dermatology the
authors state regarding recent and currently standing USPTF recommendations the
following[2]:
….. incorporating new policy initiatives is paramount. The
USPSTF recently gave a B-level recommendation for behavioral counseling to
prevent skin cancer in patients 10 to 24 years old, an upgrade from the
previous I rating (insufficient evidence). Such ratings indicate at least fair
evidence that the service improves important health outcomes and concludes that
benefits outweigh harms. Results from the well-executed German screening and
educational program (albeit not a randomized study) should now be proactively
shared with the USPSTF, which has previously argued that there is insufficient evidence
to support the recommendation of population- based skin cancer screening. In
its most recent report on screening, the USPSTF noted that “no studies of the
benefits of screening have compared a screened population with an unscreened
population with respect to appropriate health outcomes”
This is recommendation is vague and to some degree flies in
the face of the obvious. Screening, especially with a dermoscope, works in most
cases. The specificity is high, and even if in doubt the removal of a
questionable lesion is hardly traumatic.
A study of potential harms of screening is key—although the
USPSTF has expressed concern that false-positive results may lead to biopsies
and unnecessary treatment, they have acknowledged that the evidence to back up
this theory is limited. Screening should be lodged within closed health-care
systems that have experience in large screening trials and the demonstrated
ability to follow up on all participants.
They would also need to be capable of capturing melanoma
thickness, mortality, and other relevant data. In addition, there may be the
potential to seek funding for a Medicare demonstration project, possibly in a
state with high melanoma mortality rates and physician networks lodged in
underserved areas. Lessons can be learned on obtaining cost estimates for
broad-scale public health efforts from the Assessing Cost-Effectiveness– Obesity
group and its important contribution to obesity prevention programs.
The authors of the Editorial conclude:
In summary, in the United States, melanoma remains the
only preventable cancer for which mortality rates are not dropping.
Nevertheless, population- wide screening rates remain low. As melanoma rates continue
to rise and patient demand for screening accelerates, the current deficit in
the dermatology workforce will become even more apparent. However, a confluence
of new developments holds much promise. Web-based technology affords the
potential to teach standardized skin cancer examinations to physicians,
physician extenders, and high risk patients in multiple settings. Digital
dermoscopy offers clinicians new options for distinguishing between benign, atypical,
and aggressive lesions.
The Affordable Care Act has the promise of providing
screenings to the majority of the US high-risk population that has yet to be
screened. Finally, the results of the German screening program provide new and
important evidence for the value and benefits of visual examination for
melanoma.
Thus we believe that although such screening is possible,
and highly productive in reducing morbidity and mortality, the way the USPTF
phrases its results will have a negative impact on patient survival.
References
USPTF, Screening for Skin Cancer: U.S. Preventive Services
Task Force Recommendation Statement, Ann Intern Med. 3
February 2009; 150(3):188-193
Geller, A., A. Halpern, The Ever-Evolving Landscape for
Detection of Early Melanoma: Challenges and Promises, Journal of Investigative
Dermatology (2013) 133, 583–585.
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