In 2001, the U.S. Preventive Services Task Force (USPSTF) initially issued a recommendation statement on screening for skin cancer based on a statistical review and updated it in 2009 (Wolff, Tai, & Miller, 2009). One of the key questions was, "Did the research support, with evidence, that whole body skin exam by a health care provider benefited the patient." This task force concluded that there is insufficient evidence that the benefit (reduction in morbidity and mortality) outweighs the potential harm when skin cancer screening is done by a clinician. In June 2016, the USPSTF again looked at the evidence in the literature and updated its recommendation after a review of public comments (Wernli et al., 2016). The conclusion was the same-that there is insufficient evidence to recommend skin screening by health professionals.
The initial reaction by much of the dermatology community has been to disagree and dispute this finding, and for a good reason; whole-body skin screening can identify skin cancer, and early detection saves lives. An Italian study concluded that melanomas detected by a physician during whole-body skin screening were thinner than those discovered by patients who had not had a whole-body skin screening (Carli et al., 2003). A German study showed reduced mortality when whole-body skin screenings were conducted by trained physicians on a specific geographic population (Boniol, Autier, & Gandini, 2015). However, the USPSTF determined that there were too many limitations in that study to consider its findings completely valid (USPSTF et al., 2016). The USPSTF based their findings on data alone. No weight was placed on "expert opinion" or "biological plausibility." The current literature fails to show conclusively that recommending routine skin screening is a factor in decreasing morbidity and mortality from skin cancer (USPSTF et al., 2016). Dr. Freeman, an oncologist who also disagrees with the findings noted that, "After identifying nearly 13,000 articles spanning two decades of work worldwide, the authors selected only 13 studies to answer the specified 'key questions'" (Freeman, 2016). In addition, the President of the American Society for Dermatologic Surgery Association (ASDSA) is advocating for reform of the USPSTF and has written to Congress supporting H.R. 1151, the USPSTF Transparency and Accountability Act of 2015, because the ASDSA disagrees with the composition of the task force and its review methods (Lawrence & ASDSA, 2016).
Because it is, for the most part, standard practice for dermatologists and dermatology nurse practitioners to do whole-body skin screening, a recommendation by the USPSTF may primarily impact nondermatology clinicians. A study designed "to determine barriers and facilitating factors to skin cancer screening practices among US primary care physicians and dermatologists" surveyed "physicians randomly selected from the American Medical Association's Medical Marketing Services database from April 1 through November 30, 2005. The survey found that 81.3% of dermatologists reported performing full-body skin examinations on patients compared to 59.6% of family practitioners and 56.4% of internists" (Oliveria, Heneghan, Cushman, Ughetta, & Halpern, 2011).
It is indisputable that skin screening by a dermatologist or a trained dermatology nurse practitioner can detect skin cancer in its many forms. Whether the USPSTF statement is specifically directed toward melanoma or all skin cancers is unclear. The most common form of skin cancer, basal cell carcinoma (BCC), is the least aggressive and rarely results in death. Therefore, if we look at only mortality in relation to screening for all types of skin cancer, the mortality rate is expected to be low. However, BCC still results in monetary cost, both in terms of treatment and lost productivity and cost to the individual in terms of pain, scarring, or loss of function. Certain BCCs can cause extensive tissue destruction requiring more complex surgery. Squamous cell carcinoma, the second most common type of skin cancer, can metastasize, but the mortality rate is significantly lower than that of melanoma. Melanoma is curable if detected early, but a delay in diagnosis lessens the odds of survival. With 76,400 melanomas expected to be diagnosed in 2016 resulting in 10,000 deaths (Howlader et al., 2016), the questions become, "Who will detect these and would the predicted number of deaths be reduced if more melanomas were detected earlier?". Even highly trained and skilled dermatology providers cannot be 100% certain of a diagnosis without pathological examination. Despite dermoscopy and other optical tools now available, biopsies are required to get a definitive diagnosis.
Will a general practitioner who has not been specifically trained to accurately detect skin cancers be more apt to do or recommend more biopsies? Perhaps. Will they be more apt to refer to a dermatologist or dermatology nurse practitioner? Hopefully. How much additional training would the general practitioner need if they are required to screen every patient they see? Who will pay for the training, and will the required screening result in greater reimbursement for the visit? If it is required and not done, will there be penalties? Beyond the economic factors, how much liability could the practitioner assume if a screening is done but a discreet lesion is not detected?
The USPSTF conclusion and subsequent "I" (insufficient evidence to recommend or not recommend) grade for whole-body skin screening may be the correct empirically based ruling. However, as dermatology nurses who are passionate about preventing skin cancer and improving patient outcomes, it is difficult to accept. Certainly, more research needs to be done to answer many questions and to show that total body skin screening results in more benefit than harm. Ethics was the theme of the Dermatology Nurses' Association's 2016 Annual Convention. As nurses and patient advocates, we should feel the ethical need to do all we can to make sure the public has the very best care. No one should be denied the benefit of a total body skin screening based on the USPSTF's findings. The insufficient evidence grading does not mean that screening should not be done. The USPSTF's finding on skin screening is an issue that should be a call to action and begs for quality nursing research. Now is the time for dermatology nurses to lead the charge. In the meantime, the most important thing that we can do is to educate our patients and the public about skin cancer prevention and detection. We do that every day, and many of our partner organizations do the same, but sadly, we are not reaching everyone. We challenge our membership to be creative, seek funding for both research and patient education initiatives, and put your ideas into action.
Maura Flynn
Katrina Nice Masterson
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