Full-Body Skin Examinations:  The Patient's Perspective FREE

Skin cancer is the most common malignancy in the United States, accounting for nearly half of all malignancies.¹ Malignant melanoma, the deadliest of the 3 major types of skin cancer, is increasing rapidly^2- 3 and is estimated to account for approximately 54 200 cases and 7600 deaths in 2003.¹ Nonmelanoma skin cancer, the most common malignancy, accounts for more than a million cases and 2200 deaths annually.¹

Skin cancer may be the ideal cancer for screening since many risk factors are well known and there are opportunities for early detection: approximately 85% of the population sees a physician every 2 years, and routine examinations are among the 10 most common reasons for patient visits.⁴ Although the US Preventive Services Task Force⁵ concludes that there is insufficient evidence to recommend for or against routine skin cancer screening, the American Cancer Society⁶ recommends skin cancer screening as part of a cancer-related checkup every 3 years for people aged 20 to 40 years and annually for those older than 40 years.

Many inherent features of skin cancer render it suitable for screening, including (1) its high prevalence, (2) its considerable costs (such as morbidity, mortality, and economic cost), (3) a natural history that is well known, and (4) the possibility that early treatment may reduce these associated costs. Furthermore, screening examinations are easily performed, inexpensive, noninvasive, well tolerated, and safe.⁷ A recent study⁸ conducted in a population of predominantly elderly white male veterans demonstrated that 54% of patients first seen for skin cancer screening were found to have findings suggestive of skin cancer; this finding suggests that skin cancer screening in a population of veterans might be beneficial.

For a variety of reasons, however, the full effect of screening for melanoma and nonmelanoma skin cancers in the general population has not been achieved. Previous studies^9- 11 using medical chart reviews and surveys have demonstrated a low incidence of skin cancer screening among primary care practitioners (PCPs) and dermatologists. Estimating the true incidence of skin cancer screening is difficult, since practitioner self-reported frequency may overestimate screening rates and medical chart review may underestimate rates. Practitioners may also selectively screen only patients perceived to be at increased risk for skin cancer relative to the general population.^10- 11

In addition, it is important to assess patients' perceptions and satisfaction with respect to skin cancer screening, since in today's era of increased managed care, patients are thought of as health care consumers and ultimately the purchasers of health care resources. To assess the rate of skin cancer screening by PCPs, whether patient risk factors for cutaneous malignancy alter this rate, and patient preferences regarding screening, we surveyed patients in the primary care and dermatology clinics at the West Haven Veterans Affairs Medical Center.

The West Haven Veterans Affairs Medical Center provides care for more than 29 000 veterans who are older (average age, 61 years) and predominantly male (91%). Patients are enrolled in primary care, and referral to subspecialty clinics must be made by patients' PCPs. Primary care clinics are staffed by internal medicine attending physicians, nurse practitioners, physician assistants, and internal medicine residents (who work under the supervision of attending physicians). Dermatology clinics are staffed by dermatology attending physicians, and dermatology residents work under their supervision. The attending physicians and residents in the dermatology and primary care clinics are affiliated with Yale University School of Medicine.

Eligible patients were veterans older than 40 years awaiting scheduled appointments in the waiting rooms of the primary care and dermatology clinics. Participants were recruited on 21 clinic days between January 3, 2002, and March 29, 2002. A trained research assistant administered the study questionnaires to a convenience sample of patients before their primary care or dermatology clinic appointment.

All participants were asked whether their PCP regularly performed a full-body skin examination (FBSE); regular FBSE was defined for each participant as examination of a patient's entire skin after the patient is completely unclothed, either yearly or every other year. Participants were also asked whether they would feel embarrassed by an FBSE, whether it would be appropriate for a PCP to perform regular FBSEs, and whether they thought the PCP was being thorough if he or she performed the examination.

Participants were asked if they had risk factors for cutaneous malignancy, such as childhood blistering sunburns, employment that required work outdoors, leisure activities that included outdoor exposure, moles on their skin, and a family or personal history of skin cancer. Those who admitted to having a history of skin cancer were asked what type of skin cancer they had. All participants were also asked their eye color, whether they examine themselves for skin cancer, and whether when exposed to sunlight they always burn, sometimes burn and sometimes tan, or always tan.

Study participants were also asked questions regarding their desire to undergo an FBSE by their PCP vs a dermatologist and which they would prefer if given a choice. They were also asked how they would feel about undergoing an FBSE if the examiner were of the opposite sex.

Possible responses to questions regarding their desire to undergo FBSE by their PCP and a dermatologist were "strongly agree," "agree," "neither agree nor disagree," "disagree," and "strongly disagree." For analysis, "strongly agree" and "agree" were combined, and the 3 remaining responses were also combined into an "all others" category.

Demographic information, including participants' age, sex, level of education, and self-reported health status, was obtained at the interview.

To assess for potential differences between the groups, we used the t test for continuous variables such as age and education and the χ² test for categorical variables such as self-reported skin cancer history and outdoor sun exposure. When the expected number in a contingency table was less than 5, the Fisher exact test (likelihood ratio χ² test) was used. The significance level was set at P <.05 for all tests. Simple and multivariate regression was performed to determine factors predictive of a patient having skin cancer and undergoing FBSE. The analyses were performed using statistical software (SAS version 8.0; SAS Institute Inc, Cary, NC). The study protocol was approved by the local investigational review board at the West Haven Veterans Affairs Hospital.

A total of 356 patients were asked to participate: 210 in the primary care clinic and 146 in the dermatology clinic. Of these, 251 patients completed the questionnaire, for an overall participation rate of 71%. Rates of participation did not vary by clinic site: 149 (71%) of the 210 general medicine clinic patients agreed to participate compared with 102 (70%) of the 146 dermatology clinic patients. Participant average age was 66 years for general medicine clinic patients vs 67 years for dermatology clinic patients; 97% of all participants were men, and 86% described themselves as white, 3% as Hispanic, 1% as Asian, 7% as African American, and 3% as "other." Forty-five percent of participants reported having more than 12 years of education. There was no difference between the groups in educational level or perception of self-rated health status (data not shown). Individuals in the dermatology clinic were more likely to report a history of skin cancer. Of the 149 participants in the primary care clinic, 18% reported a history of skin cancer, whereas 35% of the 102 participants in the dermatology clinic reported a history of skin cancer (P = .004).

Thirty-two percent of all respondents reported undergoing regular FBSEs by their PCP, whereas 55% stated that they did not and 13% were unsure. There was no difference in respondent report of FBSE between individuals in the dermatology clinic vs the primary care clinic (P = .43). Patients with a personal history of skin cancer were more likely to report undergoing regular FBSEs than were those without. Of 62 participants with a history of personal skin cancer, 34 (55%) reported undergoing regular FBSEs by their PCP, whereas only 35 (23%) of the 154 patients who denied a history of skin cancer reported undergoing regular FBSEs (P <.001). No other risk factors were independently associated with an increased report of skin cancer screening, although there was a tendency for patients who practice self-examination and those with a family history of skin cancer, childhood blistering sunburns, the tendency to always burn when exposed to sunlight, and hazel or blue eyes to report skin cancer screening more often (Table 1). Most individuals with a personal history of skin cancer could not recall what type of malignancy they were previously treated for. Of the 62 participants with a history of skin cancer, 44 (71%) could not identify whether they had a history of basal cell carcinoma, squamous cell carcinoma, melanoma, or other skin cancer. Multivariate analysis revealed that individuals with a history of skin cancer were almost 4 times more likely to report undergoing FBSE relative to those without such a history (odds ratio, 3.92; 95% confidence interval, 1.77-8.70). We did not find any other significant predictors of FBSE (Table 2).

Only 8% of participants reported that they would be embarrassed by undergoing an FBSE, whereas 83% and 82% reported that their PCP would be considered thorough and appropriate, respectively, by performing regular FBSEs.

Participants were asked whether a sex difference between the examiner and the patient would affect their decision to undergo an FBSE. Of the 246 participants who responded to this question, 6 (2%) stated that they would refuse the examination, 39 (16%) stated that they would be less willing to be examined but would not refuse the examination, 182 (74%) stated that it would not affect their decision, and 19 (8%) stated that they would be more willing to be examined.

Participants expressed a desire to be screened for skin cancer by their PCP or a dermatologist. Of 247 respondents, 216 (87%) agreed with the statement, "I would like my primary care practitioner to perform a full-body skin examination regularly to detect skin cancer," whereas only 12 (5%) disagreed. Similarly, of 247 respondents, 204 (83%) agreed with the statement, "I would like to have a dermatologist (specialist in skin diseases) perform a full-body skin examination on me regularly to detect skin cancer," whereas 10 (4%) disagreed.

Participants were also asked whether they would prefer undergoing skin cancer screening as part of routine physical examinations done by their PCP or having an examination done at a different time by a dermatologist. Overall, 59 (24%) preferred having a screening examination for skin cancer done by their PCP, 118 (49%) preferred a separate appointment with a dermatologist, and 66 (27%) reported no preference (P <.001). No difference was observed for these responses between clinic sites.

A minority of patients reported performing self-examinations for skin cancer. Of 241 respondents, 101 (42%) reported that they examine themselves for skin cancer, whereas 140 (58%) do not. Patients with a self-reported personal history of skin cancer were more likely to perform skin self-examination than were those who denied such a history (P <.01) (Table 3). Patients with a childhood blistering sunburn (P = .02) and those with a job that required outdoor sun exposure (P = .03) were also more likely to perform skin self-examination than were those without these risk factors, although when the analysis was adjusted for age, sex, and clinic site, these factors were no longer statistically significant (Table 2).

We found that patients do not report a high rate of undergoing FBSE by PCPs to screen for skin cancer. Our rate of 32% is similar to skin cancer screening rates obtained using different methods: 28% with medical chart review of patients seen in primary care⁹ and 31% by questionnaires administered to PCPs.¹⁰ Those with a personal history of skin cancer were more likely to recall undergoing an FBSE than were those without such a history. We could not determine whether this was attributable to actual practice, since patients with a history of previous skin cancer are more likely to develop skin cancer than those without such a history, or to recall bias by patients who might be more attuned to skin cancer screening. However, it is intriguing that almost three fourths of patients with a self-reported history of skin cancer could not recall the type of cutaneous malignancy that they were diagnosed as having. Additional educational efforts targeted at these patients seems warranted.

Although our study is underpowered to detect differences in the frequency of FBSE for those with and without selected risk factors for skin cancer, the low overall rate of skin cancer screening suggests that educational efforts should be undertaken to increase the rate of skin cancer screening, especially in those with risk factors for cutaneous malignancy.

Previously, the authors¹⁰ identified barriers to skin cancer screening perceived by physicians. In the present study, we found that from the patient perspective, FBSE is well accepted, and only a few patients reported embarrassment with the examination, whereas more than 80% of participants reported that their PCP would be thorough and appropriate by performing an FBSE. We also found that the desire to undergo FBSE was not tremendously altered if the examiner was of a different sex. In fact, more patients stated that they would be more willing to undergo FBSE than those that would refuse the examination. A physician-patient sex difference does not seem to be a major barrier to skin cancer screening from the patient perspective.

There are several limitations to this study. We could not confirm participants' self-report of skin cancer, since veteran participants have the option of receiving care outside the Veterans Affairs system. Participants who reported a history of skin cancer might have confused actinic keratoses, dysplastic nevi, or other nonmalignant lesions with skin cancer. In addition, we relied on patient self-report to determine the rate of FBSE, although patients may not know they are being examined for skin cancer even when unclothed, or, alternatively, they might state that their provider performed skin cancer screening when he or she had not. We cannot determine whether patient self-report was equivalent to actual practice, although our rates of FBSE are similar to those of other studies using different methods.^9- 10

Although most patients do not undergo regular skin cancer screening, we found that patients have a considerable desire to undergo screening, either by their PCP or by a dermatologist. It is interesting that when given the choice of undergoing FBSE within the context of their regular primary care visits or making an additional visit to a dermatologist, patient convenience was not a major influential factor as more patients preferred the dermatologist, and almost a quarter had no preference. Furthermore, although participants expressed a desire to undergo FBSE, only a few performed self-examination. Patients with a personal history of skin cancer were more likely than those without these risks to report performing skin self-examination.

Our study confirms low rates of skin cancer screening in the context of primary care. The authors¹⁰ previously found that PCPs reported lack of training and lack of confidence in diagnosing skin cancer as significant impediments to widespread implementation of FBSE. The present study demonstrates a high level of patient acceptance of and desire to undergo the examination. Educational efforts to increase the low rate of skin cancer screening should be aimed at PCPs and patients.

Corresponding author: Daniel G. Federman, MD, Veterans Affairs Connecticut Health Care System (11ACSL), 950 Campbell Ave, West Haven, CT 06516 (e-mail: daniel.federman@med.va.gov).

Accepted for publication July 8, 2003.