We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Total-Body Examination vs Lesion-Directed Skin Cancer Screening

Isabelle Hoorens, MD1; Katrien Vossaert, MD2; Lore Pil3; Barbara Boone, MD, PhD1; Sofie De Schepper, MD, PhD1; Katia Ongenae, MD, PhD1; Lieven Annemans, MD, PhD3; Ines Chevolet, MD1; Lieve Brochez, MD, PhD1
[+] Author Affiliations
1Department of Dermatology, University Hospital Ghent, Ghent, Belgium
2private practice, Maldegem, Belgium
3Department of Public Health, University Ghent, Ghent, Belgium
JAMA Dermatol. 2016;152(1):27-34. doi:10.1001/jamadermatol.2015.2680.
Text Size: A A A
Published online

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.

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?






You need to register in order to view this quiz.
Submit a Comment
Posted on November 14, 2015
Eoin R Storan, Susan M O'Gorman
University College Hospital, Galway, Ireland
Conflict of Interest: None Declared
I read with great interest the article by Hoorens et al(1) printed in the October edition of JAMA Dermatology. The subject of performing total body examinations (TBE) in patients is contentious. Total body examinations can uncover hidden skin malignancies such as melanoma that can be fatal if not detected early. They do however greatly increase the length of time per patient visit. The paper by Hoorens et al(1) reports an examination time of 232 seconds which does not include the time taken for counseling and discussion of treatment options. In health services with long waiting lists and limited budgets this can have repercussions such as limiting the number of patients that can be seen in a session and further lengthening patient waiting lists.
Traditional teaching has been to perform TBE. A previous paper by Kirby et al highlighted the importance of performing TBE in all patients referred to a dermatology clinic(2). They found two invasive melanomas and a melanoma in-situ in 483 patients screened separate to the index lesion, with one patient having a past history of melanoma. No squamous cell carcinoma was identified and the mean patient age was 68 years.
The dilemma lies between providing an expeditious service without compromising patient care. The paper by Hoorens et al reported no cases of malignancy in patients under 35 years(1). Lesion-directed skin examinations (LDS) have the advantage of saving time and there was no significant difference in skin cancer detection rate reported in this paper at 2.3% (39 of 1668) for TBE versus 3.2% (8 of 2480) for LDS. We propose that patients under the age of 35 do not warrant TBE as their risk of skin malignancy does not justify the resources required. In patients above the age of 35, a LDE approach could be adopted and TBE considered if risk factors are present and the presence of suspicious lesions should be enquired about.
Yours sincerely,
Dr. Eoin Storan
Department of Dermatology,
UCH, Galway,


1. Hoorens I, Vossaert K, Pil L, Boone B, De Schepper S, Ongenae K, et al. Total-Body Examination vs Lesion-Directed Skin Cancer Screening. JAMA Dermatol. 2015 Oct 14.
2. Moran B, McDonald I, Wall D, O'Shea SJ, Ryan C, Ryan AJ, et al. Complete skin examination is essential in the assessment of dermatology patients: findings from 483 patients. Br J Dermatol. 2011 Nov;165(5):1124-6.

Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Skin cancer by the numbers. Health After 50 Sci Am Consum Health 2016;27(15):8.
Dermoscopy of Skin Adnexal Neoplasms:A Continuous Challenge. Acta Dermatovenerol Croat 2016;24(2):158-60.

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Make the Diagnosis: Melanoma