 |
|
A Survey of Skin Cancer Screening in the Primary Care Setting
A Comparison With Other Cancer Screenings
Jamie F. Altman, MD;
Susan A. Oliveria, ScD;
Paul J. Christos, MPH;
Allan C. Halpern, MD
Arch Fam Med. 2000;9:1022-1027.
ABSTRACT
| |
Objective To determine primary care physicians' perceived importance and frequency of performance of skin cancer screening in comparison with other cancer screening examinations.
Design Descriptive survey study.
Participants Five thousand US family physicians and internal medicine specialists randomly selected from the Official American Board of Medical Specialists Directory of Board-Certified Medical Specialists.
Main Outcome Measures Self-reported importance and performance of cancer screening examinations.
Results Eligible physicians (1363 total: 814 family physicians and 549 internists) completed the survey with a response rate of 30%. Overall, 52% of respondents rated skin cancer screening as "extremely" important, compared with 79% for digital rectal examination, 88% for clinical breast examination, and 87% for Papanicolaou testing. Thirty-seven percent of physicians reported performing complete body skin examinations on 81% to 100% of patients, compared with digital rectal examination, for which 78% of physicians reported performing the examination on 81% to 100% of patients, or the clinical breast examination, for which 82% of physicians reported performing the examination on 81% to 100% of patients. A higher percentage of physicians in practice for more than 30 years ranked skin cancer screening as extremely important and reported a higher frequency of screening examinations. Physicians in a suburban practice setting reported performing skin examinations more often than those in urban or rural settings. Overall, the self-reported frequency of skin examination was strongly correlated with the physician's importance rating of skin cancer screening.
Conclusions A majority of primary care physicians rate skin cancer screening as extremely important. The reported importance of skin cancer screening and frequency of skin cancer examination among primary care physicians is significantly less than for other cancer examinations. This likely represents a multitude of factors, including logistic constraints and lack of consensus on the efficacy of skin cancer screening.
INTRODUCTION
SKIN CANCER is the most common cancer.1 It is estimated that there will be 47 700 new cases of malignant melanoma and 7700 melanoma deaths in the United States during 2000.1 While incidence data on nonmelanoma skin cancers are not monitored, it is estimated that there are more than 1 million newly diagnosed basal cell and squamous cell carcinomas in the United States each year. Nonmelanoma skin cancer accounts for approximately 1900 deaths each year.1 Nonmelanoma skin cancer has limited metastatic potential but is associated with significant morbidity from the potentially disfiguring effects of the tumors and the scarring associated with therapy.
Recognition of the disease burden associated with skin cancer and concerns regarding the dramatic and persistent rise in skin cancer incidence during the past decades has led to efforts in the primary and secondary prevention of skin cancer. Primary prevention of skin cancer has focused on minimizing exposure to the sun and sun protection.2-3 Secondary prevention of skin cancer entails the detection of skin cancer in its earliest stages when it can readily be cured by simple outpatient excision.4-9 Given its location on the surface of the skin, skin cancer is amenable to early detection by visual whole body skin examination.
Primary care physicians play a central role in the prevention and detection of cancer. The majority of Americans see their primary care physicians regularly.10 Nonetheless, studies have demonstrated that complete body skin examinations are infrequently performed by primary care physicians.11-18 Few studies have looked at skin cancer screening in comparison with other cancer screening examinations.13, 17-18 Specific barriers to skin cancer screening in the primary care setting include low lethality of skin cancer, inconsistent public health recommendations on skin cancer screening, inadequate physician training in skin cancer recognition, competing health promotional activities, lack of time, and inadequate reimbursement for preventive care.19-20
Recommendations on skin cancer screening vary from no formal recommendation, to encouraging skin cancer examinations in routine care without specific screening examinations, to screening every 3 years in patients between the ages of 20 and 39 years and annually thereafter, to annual screening for all adults. These inconsistent recommendations reflect both optimism and uncertainty about the public health utility of skin cancer screening. Skin cancer screening is intuitively attractive, but there is a lack of randomized trials assessing the effect of skin cancer screening on mortality. As no such studies are ongoing, efforts in prevention of skin cancer mortality will remain anchored in the implicit potential of screening and early detection.
We conducted a descriptive survey of primary care physicians to determine the perceived importance and self-rated frequency of performance of skin cancer screening in comparison with other cancer screening examinations.
PARTICIPANTS AND METHODS
STUDY POPULATION
The Official American Board of Medical Specialists Directory of Board Certified Medical Specialists,21 which contains professional and biographical information on board-certified physicians in the United States, was used to identify physicians specialized in family practice (n = 51 718 ) and internal medicine (n = 149 053). Physicians with multiple board certifications or any subcertifications were excluded to enrich the sample with physicians who spend a majority of their time practicing primary care (family practice, n = 4657; internal medicine, n = 85 479). We further excluded physicians with incomplete mailing addresses (family practice, n = 7137; internal medicine, n = 5744) and those identified as deceased (family practice, n = 657; internal medicine, n = 3432). A random sample (n = 5000: 2500 family physicians and 2500 internists) was selected from the remaining list of 39 267 family physicians and 54 398 internists.
SURVEY METHODS AND QUESTIONNAIRE CONTENT
In April 1999 a 1-page 6-question survey (Figure 1) was mailed to each of the 5000 primary care physicians selected for the study. Two weeks after the initial mailing, a second mailing was sent to all nonresponders. Two questions also included, but not shown in Figure 1, related to the use of nonphysician health care providers for cancer screening. These results will be reported in a separate article.
|
|
|
|
The primary care survey. Respondents were asked to circle the appropriate response.
|
|
|
DATA ANALYSIS
Descriptive frequencies and percentages were calculated to characterize physician demographics and survey responses. Odds ratios,  2 tests, and P values (2-tailed) are presented. The 2 tests for trend were performed to assess the correlation between frequency and importance of cancer screening. The Statistical Analysis System22 was used for all analyses.
RESULTS
Four hundred seventy-five surveys were returned as undeliverable owing to an incorrect address. Of the returned surveys, 385 were considered ineligible because (1) physician was deceased (n = 3), (2) physician indicated that he or she was retired or no longer practicing medicine in his or her specialty (n = 70), or (3) physician indicated that 50% or less of their practice was devoted to primary care or physician failed to answer this question (n = 145 and n = 167, respectively). The final study population was composed of 1363 completed surveys from eligible practicing primary care physicians (1021 surveys were returned after the first mailing, and 342 surveys were returned after the second mailing). The overall response rate was 30% (1363/5000; 385 ineligibles); the response rate by specialty was 35% of family physicians and 24% of internists.
Characteristics of the respondents are presented in Table 1. We explored differences between responders and nonresponders by geographic region and years since graduation. The distributions for geographic region and years since graduation were similar between the responders and nonresponders.
|
|
|
|
Table 1. Characteristics of Survey Respondents*
|
|
|
IMPORTANCE OF SKIN CANCER SCREENING EXAMINATIONS
The reported relative importance of the various cancer screening examinations is presented in Table 2. Complete body skin examination was rated significantly lower in "extreme importance" than the other screening examinations (52% of physicians rated skin examination as "extremely" important [a rating of 3] compared with 79% to 88% for other cancer screenings; P<.001). There were no important differences by specialty, geographic region, or practice setting for ratings of importance of skin examination. Importance ratings for skin examination and digital rectal examination were significantly higher for physicians who graduated more than 30 years ago (percentage who reported "3" [highest rating]: skin examination, 66%; digital rectal examination, 89%) than those who graduated less than 10 years, 11 to 20 years, or 21 to 30 years ago (percentage who reported "3": skin examination, 48%-52%; digital rectal examination, 71%-82%; P = .001). Furthermore, importance rating by graduation year did not significantly vary by specialty.
|
|
|
|
Table 2. Importance of Skin Cancer Screening Compared With Other Cancer Screening Examinations*
|
|
|
FREQUENCY OF SKIN CANCER SCREENING
The frequency of cancer screening examination performance is presented in Table 3. Thirty-seven percent of physicians reported performing complete body skin examinations on 81% to 100% of patients. This was significantly lower than the percentage of physicians performing this level of digital rectal examinations or clinical breast examinations (78% and 82%, respectively) (P<.001 for skin examination vs either examination). No significant differences were seen for skin examination performance by physician specialty or region. Physicians who reported a suburban practice setting were more likely to perform skin examinations on 81% to 100% of patients (42.0%) than urban (36%) or rural (31%) physicians (P = .005). Significant differences were also observed for years since graduation, with physicians who graduated more than 30 years ago performing skin examination more frequently than those who graduated within the past 10 years (46% vs 36% for performing skin examination on 81%-100% of patients; P = .01). Furthermore, frequency of skin cancer screening by graduation year did not significantly vary by specialty.
|
|
|
|
Table 3. Performance of Screening Examinations by Primary Care Physicians (N = 1363)*
|
|
|
Frequency of skin examination was strongly correlated with the physician's importance rating of skin examination (2 test for test, P = .001). The percentage of physicians rating skin examination "extremely important" was 23% for physicians performing skin examinations on 0% to 20% of patients, 17% for physicians performing skin examinations on 21% to 40% of patients, 31% for physicians performing skin examinations on 41% to 60% of patients, 50% for physicians performing skin examinations on 61% to 80% of patients, and 83% for physicians performing skin examinations on 81% to 100% of patients.
COMMENT
The dramatic rise in skin cancer incidence coupled with the central role of primary care physicians in cancer prevention and detection has led many to emphasize the importance of skin cancer screening in routine primary care.23-29 Data suggest that melanomas detected by physicians are thinner than those detected by patients themselves, and that they therefore may be associated with improved survival.30-31 There are, however, multiple barriers to skin cancer screening in the primary care setting. These include inadequate physician training in skin cancer recognition, competing health promotional activities, lack of time, and inadequate reimbursement for preventive care.19-20,32 Our survey sought to elucidate the relative importance placed on skin cancer screening by primary care physicians. In our study, we found that primary care physicians considered skin examination less important than digital rectal examination, clinical breast examination, and Papanicolaou testing. Several factors may contribute to the lower ranking of importance of skin cancer screening beyond the logistic barriers. These include the lower lethality of skin cancer, including the fact that skin cancer is not one of the leading causes of cancer death, the relative lack of knowledge and training about skin cancer diagnosis among primary care providers, lack of patient desire or expectation for a total body skin examination, and inconsistent recommendations regarding skin cancer screening among various health care organizations.32-37 These inconsistent recommendations reflect both optimism and uncertainty about the public health utility of skin cancer screening. Skin cancer screening is intuitively attractive, but formal studies of its clinical efficacy are lacking. Recommendations on skin cancer screening vary from no formal recommendation (US Preventive Services Task Force), to encouraging skin cancer examinations in routine care without specific screening examinations (National Cancer Institute), to screening every 3 years between the ages of 20 and 39 years and annually thereafter (American Cancer Society), to annual screening for all adults (American Academy of Dermatology).33-37 It is interesting to note that digital rectal examination was reported as being important and performed by physicians; however, this type of screening has also been subject to conflicting recommendations.
The lower importance placed on skin cancer screening by our survey respondents was strongly correlated with lower self-reported skin cancer screening frequencies. This latter finding is consistent with past observations. A 1989 survey of primary care physicians found that only 30% of respondents even broached the subject of skin cancer with most of their patients, while more than 90% of physicians stated that they perform digital rectal examination, clinical breast examination, and Papanicolaou tests on asymptomatic patients without a personal history of cancer.17 Other studies11-16,18 have demonstrated similar low frequencies of skin examination performance by primary care physicians ranging from approximately 25% to 50%. A recent descriptive analysis using data from the National Ambulatory Medical Care Survey on office-based physician visits during 1997 revealed that the frequency of skin cancer prevention and screening activities in the primary care setting was much lower than other cancer screening and prevention activities.18 In another study,13 the frequency of documented examinations and procedures was obtained by medical record review. Skin examination was documented less often as compared with other cancer screening examinations and procedures.
The specific frequencies of screening reported in our study are highly susceptible to recall bias, as physician self-reporting may not accurately reflect their true practices. Indeed, a previous study has demonstrated low correlation between physician reporting and patient reporting or medical record review.38 Nonetheless, the frequencies recorded in our survey are similar to previously published self-reported rates, and they confirm the continued performance of skin cancer screening at rates significantly below that of other cancer screening examinations. A strength of our study is the size of the surveyed population with responses from more than 1300 primary care physicians from across the entire United States. A significant potential weakness of the study is the final response rate of 30%, which raises the possibility of significant sampling bias if responders and nonresponders are different on factors likely to affect the study results. Furthermore, we excluded physicians with incomplete mailing addresses in the database from the sampling frame, which has the potential to bias the study results. However, several factors support the representativeness of our sample. Demographic data with regard to geographic location and years since medical school graduation were very similar among responders and nonresponders, although responders consisted of more family practice physicians than nonresponders (60% responders vs 47% nonresponders). In addition, results from our first mailing were very similar to results from the second mailing with respect to specialty, years since medical school graduation, and geographic region. This is consistent with a 1989 survey of physicians' attitudes and practices in early cancer detection, which formally addressed the issue of "error from nonresponse" between hard-to-reach and easy-to-reach physicians, and found no evidence of sampling bias.17 Most importantly, there are no apparent systematic biases that are likely to contribute to significant differences among responders and nonresponders for the questions under study, and our data are consistent with previous reports.
Reporting bias may have affected the findings on the relative importance of skin examination if physicians prioritized the importance based on frequency of skin cancer relative to breast, cervical, and prostate cancer, which are more common than melanoma, the most lethal skin cancer. The physicians' patient population may affect both the importance and frequency of cancer screening. For instance, if the majority of the patient population is African American, then patients may be screened for skin cancer less often, because they are not considered at high risk. We focused physicians' responses to the patient subgroups of interest, asking about certain groups such as older men, women, and whites (Figure 1). Finally, this study did not have the ability to show how physicians might use risk assessment to identify high-risk patients and provide tailored screening in the form of skin examination and prevention counseling.
In conclusion, 52% of primary care physicians regard skin cancer screening to be extremely important. This likely represents an appreciation by primary care physicians of the disease burden associated with skin cancer. Primary care physicians place less emphasis on the importance and performance of skin cancer screening than on other cancer screening examinations. This likely represents a multitude of factors, including logistic constraints and lack of consensus on the efficacy of skin cancer screening.
AUTHOR INFORMATION
Accepted for publication September 14, 2000.
We would like to express our thanks and gratitude to the physicians who completed the survey and participated in our study.
Corresponding author and reprints: Allan C. Halpern, MD, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021 (e-mail: halperna{at}mskcc.org).
From the Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY.
REFERENCES
| |
1. American Cancer Society. Cancer Facts and Figures-1999. Atlanta, Ga: American Cancer Society; 1999.
2. Ferrini RL, Perlman M, Hill L. American College of Preventive Medicine practice policy statement: skin protection from ultraviolet light exposure. Am J Prev Med. 1998;14:83-86.
FULL TEXT
|
ISI
| PUBMED
3. Hill L, Ferrini RL. Skin cancer prevention and screening: summary of the American College of Preventive Medicine's practice policy statements. CA Cancer J Clin. 1998;48:232-235.
ISI
| PUBMED
4. Schuchter L, Schultz DJ, Synnestvedt M, et al. A prognostic model for predicting 10-year survival in patients with primary melanoma: the Pigmented Lesion Group. Ann Intern Med. 1996;125:369-375.
FREE FULL TEXT
5. Soong SJ, Shaw HM, Balch CM, McCarthy WH, Urist MM, Lee JY. Predicting survival and recurrence in localized melanoma: a multivariate approach. World J Surg. 1992;16:191-195.
FULL TEXT
|
ISI
| PUBMED
6. Aitchison TC, Sirel JM, Watt DC, MacKie RM. Prognostic trees to aid prognosis in patients with cutaneous malignant melanoma: Scottish Melanoma Group. BMJ. 1995;311:1536-1541.
FREE FULL TEXT
7. Huang X, Soong S, McCarthy WH, Urist MM, Balch CM. Classification of localized melanoma by the exponential survival trees method. Cancer. 1997;79:1122-1128.
FULL TEXT
|
ISI
| PUBMED
8. Koh HK. Cutaneous melanoma. N Engl J Med. 1991;325:171-182.
ISI
| PUBMED
9. Lang PG Jr. Malignant melanoma. Med Clin North Am. 1998;82:1325-1358.
FULL TEXT
|
ISI
| PUBMED
10. Benson V, Marano MA. Current estimates from the National Health Interview Survey, 1995. Vital Health Stat 10. 1998;199:1-428.
11. Geller AC, Koh HK, Miller DR, Clapp RW, Mercer MB, Lew RA. Use of health services before the diagnosis of melanoma: implications for early detection and screening. J Gen Intern Med. 1992;7:154-157.
ISI
| PUBMED
12. Dolan NC, Martin GJ, Robinson JK, Rademaker AW. Skin cancer control practices among physicians in a university general medicine practice. J Gen Intern Med. 1995;10:515-519.
ISI
| PUBMED
13. Federman DG, Concato J, Caralis PV, Hunkele GE, Kirsner RS. Screening for skin cancer in primary care settings. Arch Dermatol. 1997;133:1423-1425.
FREE FULL TEXT
14. Kirsner RS, Muhkerjee S, Federman DG. Skin cancer screening in primary care: prevalence and barriers. J Am Acad Dermatol. 1999;41:564-566.
ISI
| PUBMED
15. Girgis A, Campbell EM, Redman S, Sanson-Fisher RW. Screening for melanoma: a community survey of prevalence and predictors. Med J Aust. 1991;154:338-343.
ISI
| PUBMED
16. Heywood A, Sanson-Fisher R, Ring I, Mudge P. Risk prevalence and screening for cancer by general practitioners. Prev Med. 1994;23:152-159.
FULL TEXT
|
ISI
| PUBMED
17. 1989 survey of physicians' attitudes and practices in early cancer detection. CA Cancer J Clin. 1990;40:77-101.
ISI
| PUBMED
18. Oliveria SA, Christos PJ, Halpern AC. Skin cancer screening and prevention in the primary care setting: analysis of the National Ambulatory Medical Care Survey, 1997. J Gen Intern Med. In press.
19. Wender RC. Barriers to effective skin cancer detection. Cancer. 1995;75:691-698.
FULL TEXT
|
ISI
| PUBMED
20. Williams PA, Williams M. Barriers and incentives for primary-care physicians in cancer prevention and detection. Cancer. 1987;60:1970-1978.
FULL TEXT
|
ISI
| PUBMED
21. The American Board of Medical Specialties. The Official ABMS Directory of Board-Certified Medical Specialists. London, England: Reed Elsevier Inc with the American Board of Medical Specialties; Winter 1998-1999.
22. SAS Institute Inc. Statistical Ananlysis Software Version 6.12. Cary, NC: SAS Institute Inc; 1996.
23. McDonald CJ. American Cancer Society perspective on the American College of Preventive Medicine's policy statement on skin cancer prevention and screening. CA Cancer J Clin. 1998;48:229-231.
ISI
| PUBMED
24. National Institutes of Health Consensus Development Conference. Diagnosis and treatment of early melanoma. JAMA. 1992;268:1314-1319.
FREE FULL TEXT
25. Shenefelt PD. Skin cancer prevention and screening. Prim Care. 1992;19:557-571.
ISI
| PUBMED
26. Ward J, Macfarlane S. Needs assessment in continuing medical education: its feasibility and value in a seminar about skin cancer for general practitioners. Med J Aust. 1993;159:20-23.
ISI
| PUBMED
27. Boyce JA, Bernhard JD. Routine total skin examination to detect malignant melanoma. J Gen Intern Med. 1987;2:59-61.
ISI
| PUBMED
28. Boyce JA, Bernhard JD. Total skin examination: patient reactions [letter]. J Am Acad Dermatol. 1986;14:280.
29. Koh HK, Geller AC, Miller DR, et al. Melanoma screening and education. In: Balch CM, Houghton AN, Sober AJ, et al, eds. Cutaneous Melanoma. St Louis, Mo: Quality Medical Publishing; 1998:573-586.
30. Epstein DS, Lange JR, Gruber SB, Mofid M, Koch SE. Is physician detection associated with thinner melanomas? JAMA. 1999;281:640-643.
FREE FULL TEXT
31. Brady MS, Oliveria SA, Christos PJ, et al. Patterns of detection in patients with cutaneous melanoma. Cancer. 2000;89:342-347.
FULL TEXT
|
ISI
| PUBMED
32. Weinstock MA, Goldstein MG, Dube CE, Rhodes AR, Sober AJ. Basic skin cancer triage for teaching melanoma detection. J Am Acad Dermatol. 1996;34:1063-1066.
FULL TEXT
|
ISI
| PUBMED
33. Goldsmith LA, Koh HK, Bewerse BA, et al. Full proceedings from the National Conference to Develop a National Skin Cancer Agenda. American Academy of Dermatology and Centers for Disease Control and Prevention, Washington, DC, April 8-10, 1995. J Am Acad Dermatol. 1996;35:748-756.
FULL TEXT
|
ISI
| PUBMED
34. Ferrini RL, Perlman M, Hill L. American College of Preventive Medicine policy statement: screening for skin cancer. Am J Prev Med. 1998;14:80-82.
FULL TEXT
|
ISI
| PUBMED
35. Houston TP, Elster AB, Davis RM, Deitchman SD. The U.S. Preventive Services Task Force Guide to Clinical Preventive Services, Second edition. AMA Council on Scientific Affairs. Am J Prev Med. 1998;14:374-376.
FULL TEXT
| PUBMED
36. McDonald CJ. American Cancer Society perspective on the American College of Preventive Medicine's policy statements on skin cancer prevention and screening. CA Cancer J Clin. 1998;48:229-231.
37. Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa, Ontario: Canada Communication Group; 1994:850-861.
38. Montano DE, Phillips WR. Cancer screening by primary care physicians: a comparison of rates obtained from physician self-report, patient survey, and chart audit. Am J Public Health. 1995;85:795-800.
FREE FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Time Required for a Complete Skin Examination With and Without Dermoscopy: A Prospective, Randomized Multicenter Study
Zalaudek et al.
Arch Dermatol 2008;144:509-513.
ABSTRACT
| FULL TEXT
|
