Diagnostic ability of general practitioners and dermatologists in discriminating pigmented skin lesions

Artificial Intelligence Algorithms for Benign vs. Malignant Dermoscopic Skin Lesion Image Classification

In recent decades, the incidence of melanoma has grown rapidly. Hence, early diagnosis is crucial to improving clinical outcomes. Here, we propose and compare a classical image analysis-based machine learning method with a deep learning one to automatically classify benign vs. malignant dermoscopic skin lesion images. The same dataset of 25,122 publicly available dermoscopic images was used to train both models, while a disjointed test set of 200 images was used for the evaluation phase. The training dataset was randomly divided into 10 datasets of 19,932 images to obtain an equal distribution between the two classes. By testing both models on the disjoint set, the deep learning-based method returned accuracy of 85.4 ± 3.2% and specificity of 75.5 ± 7.6%, while the machine learning one showed accuracy and specificity of 73.8 ± 1.1% and 44.5 ± 4.7%, respectively. Although both approaches performed well in the validation phase, the convolutional neural network outperformed the ensemble boosted tree classifier on the disjoint test set, showing better generalization ability. The integration of new melanoma detection algorithms with digital dermoscopic devices could enable a faster screening of the population, improve patient management, and achieve better survival rates.

An Intelligent Diagnostic Model for Melasma Based on Deep Learning and Multimode Image Input

INTRODUCTION

The diagnosis of melasma is often based on the naked-eye judgment of physicians. However, this is a challenge for inexperienced physicians and non-professionals, and incorrect treatment might have serious consequences. Therefore, it is important to develop an accurate method for melasma diagnosis. The objective of this study is to develop and validate an intelligent diagnostic system based on deep learning for melasma images.

METHODS

A total of 8010 images in the VISIA system, comprising 4005 images of patients with melasma and 4005 images of patients without melasma, were collected for training and testing. Inspired by four high-performance structures (i.e., DenseNet, ResNet, Swin Transformer, and MobileNet), the performances of deep learning models in melasma and non-melasma binary classifiers were evaluated. Furthermore, considering that there were five modes of images for each shot in VISIA, we fused these modes via multichannel image input in different combinations to explore whether multimode images could improve network performance.

RESULTS

The proposed network based on DenseNet121 achieved the best performance with an accuracy of 93.68% and an area under the curve (AUC) of 97.86% on the test set for the melasma classifier. The results of the Gradient-weighted Class Activation Mapping showed that it was interpretable. In further experiments, for the five modes of the VISIA system, we found the best performing mode to be "BROWN SPOTS." Additionally, the combination of "NORMAL," "BROWN SPOTS," and "UV SPOTS" modes significantly improved the network performance, achieving the highest accuracy of 97.4% and AUC of 99.28%.

CONCLUSIONS

In summary, deep learning is feasible for diagnosing melasma. The proposed network not only has excellent performance with clinical images of melasma, but can also acquire high accuracy by using multiple modes of images in VISIA.

Educational Interventions to Support Primary Care Provider Performance of Diagnostic Skin Cancer Examinations: A Systematic Literature Review

To our knowledge, there is no available standardized educational curriculum designed to promote the incorporation of skin cancer examinations and procedures into general practice. To explore the contemporary training landscape, we conducted a systematic review of educational interventions designed to support skin cancer diagnostic examinations by primary care providers (PCPs). Our review uniquely encompasses all PCPs, including practicing physicians, residents, and advanced practice practitioners (APPs). The objective of this study is to review and synthesize worldwide data on educational interventions addressing PCP performance of skin cancer diagnostic examinations. A systematic review was performed in MEDLINE, Cochrane, EMBASE, and Scopus for English language articles worldwide published from 2000 onwards. Articles were screened for eligibility, and possibly overlapping datasets were resolved. Data extracted included curriculum content, delivery format, and educational outcomes. This review followed the PRISMA guidelines. A total of 63 studies were selected for data inclusion with one addressing training for resident physicians, 4 for APPs, and the remainder for practicing physicians. Educational interventions included in this review reflect the pre-SARS-CoV-2 pandemic educational environment: half provided live/synchronous instruction of about 5-h duration on average, and a quarter featured interactive components. Less than a quarter of interventions included practice change as a specific reported outcome. Without sustainable practice change, the anticipated long-term benefits of early cancer detection in patients remain limited. Previous and existing educational interventions designed to support skin cancer detection by PCPs demonstrate heterogeneous curriculum content, delivery methods, and educational outcomes. An ideal intervention would teach consensus-derived clinical competencies, provide meaningful learner feedback, and measure outcomes, such as knowledge/competency, confidence/attitudes, and practice change, using validated instruments.

Short- and Long-Term Evaluation of General Practitioners' Competences After a Training in Melanoma Diagnosis: Refresher Training Sessions May Be Needed

General practitioners (GPs) are first-line clinicians in melanoma diagnosis. It is, therefore, important to ensure that they maintain their melanoma diagnostic accuracy over time. The objective of this study was to assess the short- and long-term competences of GPs after a training session in naked-eye melanoma diagnosis. An interventional prospective study was conducted whereby, over a 6-month period, GPs attended a 1-h melanoma diagnostic training session. To assess their acquired competences, GPs were asked to fill in a questionnaire on basic melanoma knowledge and to evaluate 10 clinical images of pigmented skin lesions prior to training, immediately after and 1 year later. In total, 89 GPs completed the questionnaire prior and immediately after training. As expected, the number of GPs who appropriately managed [Formula: see text] 50% of the melanoma cases increased after training (P < 0.001). One year after training, only 27 (30%) of the 89 GPs completed the questionnaire. This number of participants was too low to obtain significant figures but the GPs' mean overall score of appropriately managed clinical cases was much lower than in the immediate post-test. In conclusion, although this short training improved the GPs' diagnostic accuracy and management of melanoma in the short-term, participating GPs do not seem to have maintained these competences in the long-term. Further studies are needed to assess whether refresher training sessions are able to sustain acquired diagnostic and management skills.

Sensitivity and Specificity for Skin Cancer Diagnosis in Primary Care Providers: a Systematic Literature Review and Meta-analysis of Educational Interventions and Diagnostic Algorithms

BACKGROUND

In areas without convenient access to dermatology care, primary care providers (PCPs) serve as an important patient resource for early skin cancer detection. To determine the most effective strategy for skin cancer detection training in PCPs, we conducted a systematic review of educational interventions and performed a meta-analysis on sensitivity and specificity outcomes in PCPs.

OBJECTIVES

To summarize data on skin cancer sensitivity and specificity outcomes for PCP-targeted training programs and diagnostic algorithms. Our PCP cohort included practicing physicians, trainee physicians, and advanced practice practitioners.

METHODS

A literature search was performed in MEDLINE, Embase, Web of Science, and the Cochrane Library for relevant English-language articles published worldwide from 2000 onward. Results were screened for eligibility, and overlapping datasets were reconciled. Data extracted included the educational intervention, diagnostic algorithm, and outcomes of interest (sensitivity and specificity). Outcomes were pooled across interventions that taught the same diagnostic algorithm. A bivariate model was fit to compare different interventions/algorithms. This review followed the PRISMA guidelines.

RESULTS

In total, 21 articles were included in this review, encompassing over 58,610 assessments of skin lesions by about 1529 participants worldwide. Training programs that implemented the triage-amalgamated dermoscopic algorithm (TADA) demonstrated high pooled sensitivity (91.7%) and high pooled specificity (81.4%) among PCPs.

CONCLUSIONS AND RELEVANCE

Overall, this systematic review and meta-analysis showed that dermoscopy training in PCPs was generally associated with gains in skin cancer sensitivity without loss of specificity. Clinically, this correlates with fewer skin cancers overlooked by PCPs and fewer excisions of benign lesions.

Verrucous Melanoma of the Scalp Initially Misdiagnosed as Seborrheic Keratosis

Verrucous melanoma (VM) is a rare entity that presents diagnostic difficulty on both clinical and histopathologic grounds. Clinically, this tumor can be mistaken for a benign non-melanocytic lesion, particularly seborrheic keratosis (SK), as they both share several similarities, such as the homogenous pigmentation, the verrucous surface, and the roughly well-defined borders. In our patient’s case, her verrucous lesion was initially misdiagnosed as SK by a general practitioner two months prior to her admission. Upon physical examination, the lesion was indeed suggestive of SK but a VM was not discarded. Biopsy revealed melanoma. Standard treatment of SK often includes electrodesiccation or cryotherapy, which potentially might worsen and delay the diagnosis of melanoma with subsequent implications for therapeutic management and prognosis. We report this case to increase awareness and knowledge about VM, which may lead to earlier diagnosis and improved outcomes.

Skin Cancer Education Interventions for Primary Care Providers: A Scoping Review

Primary care physicians (PCPs) are often the first line of defense against skin cancers. Despite this, many PCPs do not receive a comprehensive training in skin conditions. Educational interventions aimed at skin cancer screening instruction for PCPs offer an opportunity to detect skin cancer at earlier stages and subsequent improved morbidity and mortality. A scoping review was conducted to collect data about previously reported skin cancer screening interventions for PCPs. A structured literature search found 51 studies describing 37 unique educational interventions. Curriculum elements utilized by the interventions were divided into categories that would facilitate comparison including curriculum components, delivery format, delivery timing, and outcome measures. The interventions varied widely in design, including literature-based interventions, live teaching sessions, and online courses with durations ranging from 5 min to 24 months. While several interventions demonstrated improvements in skin cancer knowledge and competency by written exams, only a few revealed positive clinical practice changes by biopsy review or referral analysis. Examining successful interventions could aid in developing a skin cancer detection curriculum for PCPs that can produce positive clinical practice and population-based changes in the management of skin cancer.

Melanoma Diagnostic Practices of French-Speaking Belgian General Practitioners and the Prospective Study of Their Pigmented Skin Lesion Diagnostic Accuracy and Management

General practitioners (GPs) are among the main actors involved in early melanoma diagnosis. However, melanoma diagnostic accuracy and management are reported to be insufficient among GPs in Europe. The primary aim of this observational prospective study was to shed light on melanoma diagnostic practices among French-speaking Belgian GPs. The second aim was to specifically analyse these GPs' pigmented skin lesion diagnostic accuracy and management. GPs from the five French-speaking districts of Belgium were asked to complete a questionnaire, before taking part in a melanoma diagnostic training session. First, we assessed the GPs' current melanoma diagnostic practices. Then, their pigmented skin lesion diagnostic accuracy and management were evaluated, through basic theoretical questions and clinical images. These results were subsequently analysed, according to the GPs' sociodemographic characteristics and medical practice type. In total, 89 GPs completed the questionnaire. Almost half of the GPs (43%; CI = [33;54]) were confronted with a suspicious skin lesion as the main reason for consultation once every 3 months, while 33% (CI = [24;43]) were consulted for a suspicious lesion as a secondary reason once a month. Prior to training, one-third of the GPs exhibited suboptimal diagnostic accuracy in at least one of six "life-threatening" clinical cases among two sets of 10 clinical images of pigmented skin lesions, which can lead to inadequate patient management (i.e. incorrect treatment and/or inappropriate reinsurance). This study underlines the need to train GPs in melanoma diagnosis. GPs' pigmented skin lesion diagnostic accuracy and management should be improved to increase early melanoma detection.

Classification of Non-tumorous Facial Pigmentation Disorders Using Generative Adversarial Networks and Improved SMOTE

The diagnosis of non-tumorous facial pigmentation disorders is crucial since facial pigmentations can serve as a health indicator for other more serious diseases. The computer-based classification of non-tumorous facial pigmentation disorders using images / photographs allows automated diagnosis of such disorders. However, the classification performance of existing methods is still not satisfactory due to the limited real-world images available for research. In this paper, we proposed a novel approach to applying generative adversarial network (GAN) with improved synthetic minority over-sampling technique (Improved SMOTE) to enhance the image dataset with more varieties. With the application of Improved SMOTE, more data is provided to train GAN models. By utilizing the GAN to perform data augmentation, more diverse and effective training images can be generated for developing classification model using deep neural networks via transfer learning. A significant increase in the classification accuracy (>4%) was achieved by the proposed method compared to the state-of-the-art method.

Training general practitioners in melanoma diagnosis: a scoping review of the literature

BACKGROUND

General practitioners (GPs) play a key role in early melanoma detection. To help GPs deal with suspicious skin lesions, melanoma diagnostic training programmes have been developed. However, it is unclear whether these programmes guarantee the acquisition of skills that will be applied by GPs in their daily clinical practice and maintained over time.

OBJECTIVES

This scoping review aimed to examine and compare educational programmes designed to train GPs in melanoma diagnosis using clinical (naked eye) examination alone or dermoscopy±clinical examination, and sought to inform on the long-term sustainability of the GPs' acquired skills.

ELIGIBILITY CRITERIA

Studies eligible for inclusion evaluated educational programmes for teaching diagnosis of melanoma to GPs. MEDLINE, EMBASE and Cochrane databases were searched for relevant articles from 1995 to May 2020.

RESULTS

Forty-five relevant articles were found assessing 31 educational programmes. Most programmes that improved the diagnostic accuracy and long-term performances of the GPs, that is, increase in confidence, decrease in dermatologist referral for benign skin lesions and improvement in the benign/malignant ratio of excised skin lesions, trained the GPs in clinical diagnosis, followed by dermoscopy. To maintain long-term performances, these programmes provided refresher training material.

CONCLUSION

This review shows that studies generally report positive outcomes from the training of GPs in melanoma diagnosis. However, refresher training material seemed necessary to maintain the acquired skills. The optimal form and ideal frequency for these updates have yet to be defined.

Basal Cell Carcinoma Surgery in general practice: Is there a role for the local General Practitioner?

Basal cell carcinoma (BCC) is a common disease of the skin caused principally by prolonged solar radiation exposure. It is normally a malignancy with favorable prognostic features and is potentially curable by standard excision. In White populations with high disease incidence, general practitioners (GPs) play a vital role in diagnosing and managing BCC, including surgical excision. Dedicated care at the primary care level by adequately trained GPs is conceivably cost effective for the health system and more convenient for the patient. In Asia and other parts of the world with low incidence, this valuable role of GPs may appear to be inconsequential. In this regard, any justification for the involvement of local GPs in BCC surgery is debatable. This article aims to provide a clinical update on essential information relevant to BCC surgery and advance understanding of the intricate issues of making a treatment decision at the primary care level.

CASE REPORT

Madam Tan, a 71-year-old Malaysian Chinese lady, otherwise healthy, presented to her local GP with a complaint of a nodule over the left cheek that had been there for more than a decade. Her concern was that the lesion was growing and had become conspicuous. She had spent most of her life as a farmer working in her orchard.Upon examination, she had an obvious dome-shaped nodule over the left cheek measuring approximately 1.8 cm in diameter. The lesion was firm, pigmented, well-demarcated, and slightly ulcerated at the top. Clinically, she was diagnosed with a pigmented nodular basal cell carcinoma of the left cheek. Examination of the systems was unremarkable.She requested that the consulting GP remove the growth. The cost for specialist treatment and waiting time at the local hospital were her concerns.

CLINICAL QUESTIONS

Can the basal cell skin cancer be excised safely and effectively in the local primary care setting? What are the crucial preoperative concerns?

Value of Teledermoscopy in Primary Healthcare Centers: Preliminary Results of the TELESPOT Project in Belgium

INTRODUCTION

Teledermoscopy using smartphone-based applications is becoming more and more important in a setting of increasing frequency of skin cancer and difficult access to specialized care. The TELESPOT project aimed to provide rapid diagnosis and speed up patient flow between primary healthcare centers and a tertiary care center in Belgium. The aim of the present study is to describe the development of an in-house smartphone-based dermoscopy application, evaluate its real-life value in a series of primary healthcare centers, and present preliminary diagnostic data.

METHODS

Modified Likert scales were used to assess patient and general practitioner (GP) satisfaction rates for the system. Furthermore, a total of 105 photographic and dermoscopic images were acquired in a series of 80 patients at participating centers.

RESULTS

Overall, patient and GP satisfaction levels were 89% and 94%, respectively. High-priority management was recommended in 7.6% of cases (8/105: 3 basal cell carcinoma, 1 primary cutaneous B-cell lymphoma, 1 Spitz melanocytic nevus, 1 congenital nevus, 1 in situ melanoma, and 1 invasive melanoma, proven by histology).

CONCLUSIONS

The primary healthcare centers were highly satisfied with the TELESPOT project in terms of user-friendliness, efficacy, and reliability as well as in providing a reinforced image of first-line medicine efforts in combating skin cancer.

Screening for reducing morbidity and mortality in malignant melanoma

BACKGROUND

Screening for malignant melanoma has the potential to reduce morbidity and mortality from the disease through earlier detection, as prognosis is closely associated with the thickness of the lesion at the time of diagnosis. However, there are also potential harms from screening people without skin lesion concerns, such as overdiagnosis of lesions that would never have caused symptoms if they had remained undetected. Overdiagnosis results in harm through unnecessary treatment and the psychosocial consequences of being labelled with a cancer diagnosis. For any type of screening, the benefits must outweigh the harms. Screening for malignant melanoma is currently practised in many countries, and the incidence of the disease is rising sharply, while mortality remains largely unchanged.

OBJECTIVES

To assess the effects on morbidity and mortality of screening for malignant melanoma in the general population.

SEARCH METHODS

We searched the following databases up to May 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registries, checked the reference lists of included and other relevant studies for further references to randomised controlled trials (RCTs), used citation tracking (Web of Science) for key articles, and asked trialists about additional studies and study reports.

SELECTION CRITERIA

RCTs, including cluster-randomised trials, of screening for malignant melanoma compared with no screening, regardless of screening modality or setting, in any type of population and in any age group where people were not suspected of having malignant melanoma. We excluded studies in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome) and studies performed exclusively in people with previous melanomas.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcomes of this review were total mortality, overdiagnosis of malignant melanoma, and quality of life/psychosocial consequences.

MAIN RESULTS

We included two studies with 64,391 participants. The first study was a randomised trial of an intervention developed to increase the rate of performance of thorough skin self-examination. The intervention group received instructional materials, including cues and aids, a 14-minute instruction video, and a brief counselling session, and at three weeks a brief follow-up telephone call from a health educator, aimed at increasing performance of thorough skin self-examination. The control group received a diet intervention with similar follow-up. The trial included 1356 people, who were recruited from 11 primary care practices in the US between 2000 and 2001. Participant mean age was 53.2 years and 41.7% were men. This study did not report on any of our primary outcomes or the following secondary outcomes: mortality specific to malignant melanoma, false-positive rates (skin biopsies/excisions with benign outcome), or false-negative rates (malignant melanomas diagnosed between screening rounds and up to one year after the last round). All participants were asked to complete follow-up telephone interviews at 2, 6, and 12 months after randomisation.The second study was a pilot study for a cluster-RCT of population-based screening for malignant melanoma in Australia. This pilot trial included 63,035 adults aged over 30 years. The three-year programme involved community education, an education and support component for medical practitioners, and the provision of free skin screening services. The mean age of people attending the skin screening clinics (which were held by primary care physicians in workplaces, community venues, and local hospitals, and included day and evening sessions) was 46.5 years, and 51.5% were men. The study included whole communities, targeting participants over 30 years of age, but information on age and gender of the whole study population was not reported. Study duration was three years (1998 to 2001), and outcomes were measured at the screening clinics during these three years. There was no further follow-up for any outcomes. The control group received no programme. The ensuing, planned cluster randomised trial in 560,000 adults was never carried out due to lack of funding. At the time of this review, there are no published or unpublished data on our prespecified outcomes available, and no results for mortality outcomes from the pilot study are to be expected.The risk of bias in these studies was high for performance bias (blinding study personnel and participants) and high or unclear for detection bias (blinding of outcome assessment). Risk of bias in the other domains was either unclear or low. We were unable to assess the certainty of the evidence for our primary outcomes as planned due to lack of data.

AUTHORS' CONCLUSIONS

Adult general population screening for malignant melanoma is not supported or refuted by current evidence from RCTs. It therefore does not fulfil accepted criteria for implementation of population screening programmes. This review did not investigate the effects of screening people with a history of malignant melanoma or in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome). To determine the benefits and harms of screening for malignant melanoma, a rigorously conducted randomised trial is needed, which assesses overall mortality, overdiagnosis, psychosocial consequences, and resource use.

[Recognition and initial management of melanoma by general practitioners: A survey in a rural French area with low medical density]

INTRODUCTION

Cutaneous cancers are very common, easily visible on skin. The general practitioner (GP) is in the front line to manage the lesions. He has to recognize malignancy and refer most often to the specialist for excision, or consider that the lesion is benign and in ambiguous cases, offer clinical monitoring. The current low medical density in the Centre Val de Loire area makes access to general practitioners (GP) and dermatologists harder. The aim of this study was to evaluate GPs' everyday practice in cutaneous cancers screening in general, and particularly in melanoma screening, in a rural region of France.

METHODS

We sent a questionnaire on November 24th 2015 to all GPs of the Cher department (204 questionnaires), to assess their knowledge and practice of melanoma. The questionnaire comprised 2 parts: the first part was composed of 23 items with a majority of questions focused on melanoma and the second part consisted of clinical cases including 5 benign cutaneous tumors, 4 melanomas and 1 pigmented basal cell carcinoma. GP's were asked to answer in each case: diagnosis, degree of certainty (from 0 to 10), practical attitude (excision, referral to dermatologist or surgeon or surveillance). Their answers were anonymous. The primary endpoint was whether medical decision regarding each case was appropriate, i.e. removal of malignant lesion or referral for removal, and reassurance or surveillance in benign lesions.

RESULTS

The response rate was 35% (72 responses). Thirty-eight GPs (53%) had an appropriate management facing the 5 malignant lesions, 18 GP (25%) had an appropriate management in 4 out of 5 cases. The ABCDE rule was known by 58% of responders, the ugly duckling sign of 19%. GPs did not feel comfortable with melanoma: on a growing scale (from 0=not comfortable at all to 10=very comfortable) the average was 4.2 with a median at 5 (range 0-10). They expressed a strong need for training on this topic: on a scale increasing from 0 to 10, the average was 7.9 for a median to 8 (range 3-10). Knowledge about melanoma risk factors, and the level of ease dealing with screening of melanoma was not significantly associated with a better management. The main difficulties were lack of time and the increasing difficulty of access to dermatologist. Fast and easy access by teledermatology was solicited by 89% of GPs.

CONCLUSION

GPs had often appropriate management of skin cancer. The major obstacles to skin's cancer screening were the lack of time and difficult access to dermatologists. The setting-up of an easier access with teledermatology was requested by 89% of responders, and should improve early detection of melanoma.

Early Detection of Skin Cancer by Family Physicians: A Pilot Project

Background:

Malignant melanoma is rising quickly in incidence and mortality rates. Family physicians (FPs) have been reported to lack confidence in diagnosing skin cancers. Objective: The aim of this study was to determine whether an educational intervention can improve FPs' abilities to diagnose skin cancers.

Methods:

The design was a prospective, randomized trial which included a skin cancer questionnaire, a video intervention, and a skin biopsy review.

Results:

Pre-intervention, FPs answered 57% of the questions correctly on the skin cancer questionnaire. Post-intervention, the video intervention group scored higher than did the control group. The video intervention group removed 10% fewer benign lesions and almost 3 times more malignant lesions compared with their pre-intervention biopsy rate. No findings were statistically significant.

Conclusion:

An educational intervention may improve FPs' knowledge and diagnosis of skin cancer. Our results may guide future studies with larger sample sizes in developing a skin cancer continuing medical education (CME) course for FPs.

Time to Diagnosis of Melanoma: Same Trend in Different Continents

Background:

Patients and physicians both play an important role in the diagnosis of malignant melanoma.

Objective:

The purpose of this study was to assess important factors of delay in diagnosis at different centers and on three continents.

Methods:

Between October 2001 and October 2002, patients with histologically confirmed invasive melanoma were included in the study and given an established questionnaire. Recorded patients and tumor characteristics included age, sex, anatomic location, Breslow thickness, patients' awareness of the lesion and time with suspicion, and physicians' time (delay) before the operation.

Results:

The study included 985 patients (486 males, 499 females): 253 from Germany, 464 from Sweden, 58 from Brazil, and 210 from Australia. More females detected their lesions by themselves. The change to a darker color (21 %) and enlargement of the area of the lesion (19%) were the major signs. The highest knowledge among patients that early detection may improve the outcome was found in Sweden and Australia. At each center, the media (newspaper, magazine, radio, and television) provided the best sources of information about melanoma. Twenty to 33% of all physicians initially consulted missed the melanoma diagnosis, independent of their specialty.

Conclusions:

There are still factors for the delay in melanoma diagnosis in different countries and continents, but the differences are rather small. The results should be included in planning prevention campaigns in this specific field and in the education of medical students, physicians of all specialties, and other health professionals.

A multifaceted intervention: no increase in general practitioners' competence to diagnose skin cancer (minSKIN) - randomized controlled trial

BACKGROUND

General practitioners (GPs) play crucial roles in early detection of skin cancer. A pilot-study found a positive short-term effect of a 1-day dermatologic education programme on GPs' diagnostic competence.

OBJECTIVE

To determine effects of a multifaceted intervention, including technical equipment and continuing feedback by a dermatologist, on GPs' diagnostic skills regarding skin cancer.

METHODS

Randomized controlled trial with 78 GPs of the Canton of Zurich, Switzerland.

INTERVENTION

GPs in intervention group received a 1-day training, a Lumio (magnifying glass with polarized light, 3Gen), a Nikon digital camera and - during 1 year - feedback on skin lesion pictures sent to the dermatologist. GPs in control group only received the 1-day training.

MAIN OUTCOME AND MEASURES

PRIMARY OUTCOME

structured assessment of GP's diagnostic skills in correctly diagnosing images of skin lesions regarding skin cancer. At baseline prior to intervention (T0), after the full-day training course in both groups (T1), and after 1 year of continuing feedback (T2) to the intervention group.

MEASURES

Non-parametric unpaired (Wilcoxon-Mann-Whitney) tests were used to compare numbers of correctly classified skin lesions between both groups at T2 and for the change between T1 and T2.

RESULTS

At T0, both groups classified a median of 23 skin lesions of the 36 images correctly. This value rose to 28 for both groups at T1 and fell to 24 for both groups at T2. No difference between control and intervention group at T2. Furthermore, we compared differences in the sum scores per GP between T1 and T2 for each group. Also in this comparison, no difference between control and intervention group was found.

CONCLUSION AND RELEVANCE

No long-term effect of the multifaceted intervention was found on the competence to diagnose skin cancer by GPs. The positive short-term effect of the 1-day dermatologic education programme did not persist over 12 months.

High-definition optical coherence tomography imaging of melanocytic lesions: a pilot study

High-definition optical coherence tomography (HD-OCT) is a non-invasive in vivo imaging technique with cellular resolution based on the principle of conventional optical coherence tomography. The objective of this study was to evaluate HD-OCT for its ability to identify architectural patterns and cytologic features of melanocytic lesions. All lesions were examined by one observer clinically and using dermoscopy. Cross-sectional HD-OCT images were compared with histopathology. En face HD-OCT images were compared with reflectance confocal microscopy (RCM). Twenty-six melanocytic lesions of 26 patients were imaged. Identification of architectural patterns in cross-sectional mode and cytologic features of pigmented cells in the epidermis, dermo-epidermal junction, papillary dermis, and superficial reticular dermis in the en face mode was possible by HD-OCT. HD-OCT provides morphological imaging with sufficient resolution and penetration depth to discriminate architectural patterns and cytologic features of pigmented cells in epidermis and dermis. The method appears to offer the possibility of additional three-dimensional structural information complementary to that of RCM, albeit at a slightly lower lateral resolution. The diagnostic potential of HD-OCT regarding malignant melanoma is not high enough for ruling out a diagnosis of malignant melanoma.

Agreement between Dermatologists and Primary Care Practitioners in the Diagnosis of Malignant Melanoma: Review of the Literature

Background:

The incidence of melanoma continues to rise in the developed world. It is therefore essential for primary care practitioners (PCPs) to be able to discriminate between malignant and benign cutaneous findings, as most patients present to PCPs first for examination of suspicious lesions.

Objective:

To compare dermatologists and PCPs in the diagnosis of malignant melanoma.

Methods:

Prospective studies published from January 1950 to August 2010 in MEDLINE, EMBASE, CINAHL, and CancerLit databases were examined. Relevant medical search terms, discussed amongst the authors, were entered into the databases. Only articles comparing dermatologists and PCPs in the diagnosis of malignant melanoma were selected.

Results:

Dermatologists were reported as having sensitivities, specificities, and diagnostic accuracies ranging from 0.74 to 1.00, 0.56 to 0.95, and 0.85 to 0.89, respectively. PCPs had sensitivities, specificities, and diagnostic accuracies ranging from 0.25 to 0.88, 0.26 to 0.71, and 0.49 to 0.80, respectively.

Conclusions:

PCPs should receive more training to improve their ability in the diagnosis of malignant melanoma.

Contexte:

La fréquence du mélanome est en hausse continue dans les pays développés. Dans ce contexte, il est essentiel que les médecins de premier recours (MPR) puissent distinguer les lésions cutanées malignes des lésions cutanées bénignes, étant donné que la plupart des patients consultent d'abord un MPR pour l'examen des lésions douteuses.

Objectif:

L'étude visait à comparer les dermatologues et les MPR dans le diagnostic du mélanome malin.

Méthode:

Nous avons procédé à un examen d'études prospectives, publiées de janvier 1950 à août 2010, dans les bases de données MEDLINE, EMBASE, CINAHL, et CancerLit. Les termes d'interrogation médicaux pertinents, ayant fait l'objet de discussion parmi les auteurs, ont été inscrits dans les bases de données. Seuls les articles dans lesquels il y avait une comparaison entre dermatologues et MPR dans le diagnostic du mélanome malin ont été sélectionnés.

Résultats:

La sensibilité, la spécificité, et la précision du diagnostic parmi les dermatologues variaient de 0.74 à 1.00, de 0.56 à 0.95, et de 0.85 à 0.89, respectivement, tandis que la sensibilité, la spécificité, et la précision du diagnostic parmi les MPR variaient 0.25 à 0.88, de 0.26 à 0.71, et de 0.49 à 0.80, respectivement.

Conclusion:

Les MPR devraient recevoir plus de formation afin d'améliorer leur capacité de diagnostic du mélanome malin.

Comparison of Dermatologists' and Nondermatologists' Diagnostic Accuracy for Malignant Melanoma

Background:

The incidence of malignant melanoma is increasing annually in Canada and patients present to nondermatologist groups (NDGs) first to have suspicious lesions examined.

Objective:

To determine the ability of Canadian NDGs in the recognition and management of melanoma.

Methods:

A survey of 25 malignant and benign skin lesion photographs was distributed to dermatologists and NDGs across Canada. Participants were asked to list whether the lesions were malignant or benign, and could answer ‘uncertain’ if needed. Dermatologists were subsequently asked if they would biopsy the lesion, whereas NDGs were asked if they would biopsy/refer.

Results:

Dermatologists achieved mean sensitivities, specificities, and diagnostic accuracies of 0.79, 0.77, and 0.71, respectively. They consistently decided to biopsy malignant lesions. NDGs attained mean scores of 0.61, 0.62, and 0.53, respectively, and selected to refer/biopsy the majority of lesions, malignant and benign.

Conclusions:

NDGs should receive more dermatologic training in the recognition of malignant melanoma.

Interventions to reduce primary care delay in cancer referral: a systematic review

BACKGROUND

Reducing delay in the primary care part of the cancer care pathway is likely to improve cancer survival. Identifying effective interventions in primary care would allow action by primary healthcare professionals and local commissioners to reduce delay.

AIM

To identify interventions that reduce primary care delay in the referral of patients with cancer to secondary care.

DESIGN AND SETTING

Systematic review in primary care.

METHOD

Eight electronic databases were searched using terms for primary care, cancer, and delay. Exclusion criteria included screening and the 2-week-wait referral system. Reference lists of relevant papers were hand searched. The quality of each paper was assessed using predefined criteria, and checked by a second reviewer.

RESULTS

Searches identified 1798 references, of which 22 papers were found to meet the criteria. Interventions concerning education, audit and feedback, decision support software and guideline use, diagnostic tools, and other specific skills training were identified. Most studies reported a positive effect on their specified outcomes, although no study measured a direct effect on reducing delay.

CONCLUSION

There was no evidence that any intervention directly reduced primary care delay in the diagnosis of cancer. Limited evidence suggests that complex interventions, including audit and feedback and specific skills training, have the potential to do so.

Skin cancer education for primary care physicians: a systematic review of published evaluated interventions

BACKGROUND

Early detection of melanoma may provide an opportunity to positively impact melanoma mortality. Numerous skin cancer educational interventions have been developed for primary care physicians (PCPs) to improve diagnostic accuracy. Standardized training is also a prerequisite for formal testing of melanoma screening in the primary care setting.

OBJECTIVE

We conducted a systematic review to determine the extent of evaluated interventions designed to educate PCPs about skin cancer, including melanoma.

DESIGN

Relevant studies in the English language were identified through systemic searches performed in MEDLINE, EMBASE, BIOSIS, and Cochrane through December 2010. Supplementary information was obtained from corresponding authors of the included studies when necessary.

APPROACH

Studies eligible for inclusion formally evaluated skin cancer education interventions and were designed primarily for PCPs. Excluded studies lacked a specified training intervention, used decision-making software, focused solely on risk factor identification, or did not directly educate or assess participants. Twenty studies met the selection criteria. Data were extracted according to intervention content and delivery format, and study outcomes.

KEY RESULTS

All interventions included instructions about skin cancer diagnosis, but otherwise varied in content. Curricula utilized six distinct educational techniques, usually incorporating more than one. Intervention duration varied from 12 min to over 6 h. Eight of the 20 studies were randomized trials. Most studies (18/20, 90%) found a significant improvement in at least one of the following five outcome categories: knowledge, competence, confidence, diagnostic performance, or systems outcomes. Competence was most commonly measured; no study evaluated all categories. Variability in study design, interventions, and outcome measures prevented correlation of outcomes with intervention characteristics.

CONCLUSIONS

Despite the development of many isolated educational interventions, few have been tested rigorously or evaluated under sufficient standardized conditions to allow for quantitative comparison. Improved and rigorously tested skin cancer educational interventions for PCPs with outcome measures focusing on changes in performance are needed.

Advances and short comings in the early diagnosis of melanoma

Malignant melanoma kills more people each year than any other skin cancer, with approximately 8000 lives lost and a cost of over 3 billion dollars annually in the US alone. Tumor depth is the most important prognostic factor in melanoma. Thus, early detection has the potential to diagnose melanoma when lesions are thinner, and to improve survival in primary melanomas. In this review, we discuss the implications, barriers, and advantages of melanoma screening, and describe the currently employed methods of detection, newly available modalities, and current areas of research. We also discuss the efficacy, advantages and disadvantages, and clinical practicality of each, and suggest various means of combining different methodologies as well as tailoring various strategies to individual patient needs.

[Effectiveness of primary care physicians and dermatologists in the diagnosis of skin cancer: a comparative study in the same geographic area]

BACKGROUND

skin cancer is the most common malignant tumor in white individuals. Early diagnosis and treatment are key factors in reducing morbidity. We performed a prospective observational study throughout 2008 to assess the ability of primary care physicians to diagnose nonmelanoma skin cancer.

METHODS

the study was undertaken in a single geographic area corresponding to the region served by a primary health care center. Patients who were referred to a dermatologist were included if the primary care physician indicated skin cancer in the differential diagnosis on the referral form. Patients were also included if the dermatologist suspected skin cancer even if the referral from primary care had not indicated it.

RESULTS

primary care physicians had a sensitivity of 0.45 and a specificity of 0.16 for the diagnosis of skin cancer, whereas dermatologists had a sensitivity of 0.97 and a specificity of 0.75. The α statistic as a measure of agreement was -0.56.

CONCLUSIONS

The ability of primary care physicians to diagnose skin cancer was appreciably lower than that of dermatologists. This may result in substantial delays in the provision of appropriate care for patients with skin cancer considering the role played by primary care physicians in screening for the disease in the Spanish national health system.

Accuracy of SIAscopy for pigmented skin lesions encountered in primary care: development and validation of a new diagnostic algorithm

Background

Diagnosing pigmented skin lesions in general practice is challenging. SIAscopy has been shown to increase diagnostic accuracy for melanoma in referred populations. We aimed to develop and validate a scoring system for SIAscopic diagnosis of pigmented lesions in primary care.

Methods

This study was conducted in two consecutive settings in the UK and Australia, and occurred in three stages: 1) Development of the primary care scoring algorithm (PCSA) on a sub-set of lesions from the UK sample; 2) Validation of the PCSA on a different sub-set of lesions from the same UK sample; 3) Validation of the PCSA on a new set of lesions from an Australian primary care population. Patients presenting with a pigmented lesion were recruited from 6 general practices in the UK and 2 primary care skin cancer clinics in Australia. The following data were obtained for each lesion: clinical history; SIAscan; digital photograph; and digital dermoscopy. SIAscans were interpreted by an expert and validated against histopathology where possible, or expert clinical review of all available data for each lesion.

Results

A total of 858 patients with 1,211 lesions were recruited. Most lesions were benign naevi (64.8%) or seborrhoeic keratoses (22.1%); 1.2% were melanoma. The original SIAscopic diagnostic algorithm did not perform well because of the higher prevalence of seborrhoeic keratoses and haemangiomas seen in primary care. A primary care scoring algorithm (PCSA) was developed to account for this. In the UK sample the PCSA had the following characteristics for the diagnosis of 'suspicious': sensitivity 0.50 (0.18-0.81); specificity 0.84 (0.78-0.88); PPV 0.09 (0.03-0.22); NPV 0.98 (0.95-0.99). In the Australian sample the PCSA had the following characteristics for the diagnosis of 'suspicious': sensitivity 0.44 (0.32-0.58); specificity 0.95 (0.93-0.97); PPV 0.52 (0.38-0.66); NPV 0.95 (0.92-0.96). In an analysis of lesions for which histological diagnosis was available (n = 111), the PCSA had a significantly greater Area Under the Curve than the 7-point checklist for the diagnosis of melanoma (0.83; 95% CI 0.71-0.95 versus 0.61; 95% CI 0.44-0.78; p = 0.02 for difference).

Conclusions

The PCSA could have a useful role in improving primary care management of pigmented skin lesions. Further work is needed to develop and validate the PCSA in other primary care populations and to evaluate the cost-effectiveness of GP management of pigmented lesions using SIAscopy.

Melanoma early detection

Recognizing early forms of melanoma may have significant impact on decreasing mortality from this malignancy. As a result, multiple efforts have focused on developing new and improving current early detection strategies. These include educating patients about the importance of performing skin self-examination, increasing rates of complete skin examinations by physicians in the context of routine care, initiating mass screening campaigns, creating specialized skin cancer clinics, and developing better diagnostic tools through advances in technology. In this article, the current state of these efforts is reviewed.

Strategies for early melanoma detection: Approaches to the patient with nevi

Given its propensity to metastasize and the lack of effective therapies for most patients with advanced disease, early detection of melanoma is a clinical imperative. Although there are no noninvasive techniques for the definitive diagnosis of melanoma, and the "gold standard" remains biopsy with histologic examination, a variety of modalities may facilitate early melanoma diagnosis and the detection of new and changing nevi. This article reviews the general clinical principles of early melanoma detection and various modalities that are currently available or on the horizon, providing the clinician with an up to date understanding of management strategies for their patients with numerous or atypical nevi.

LEARNING OBJECTIVE

After completing this learning activity, participants should understand the clinical importance of early melanoma detection, appreciate the challenges of early melanoma diagnosis and which patients are at highest risk, know the general principles of early melanoma detection, be familiar with current and emerging modalities that may facilitate early melanoma diagnosis and the detection of new and changing nevi, know the advantages and limitations of each modality, and be able to practice a combined approach to the patient with numerous or clinically atypical nevi.

Digital dermoscopic monitoring of atypical nevi in patients at risk for melanoma

BACKGROUND

Atypical nevi are a common risk factor for melanoma.

OBJECTIVES

The objective was to determine the utility of monitoring dermoscopic photographs of atypical nevi in a high-risk population.

METHODS

Over a 4.5-year period, digital dermoscopic photographs were taken of clinically atypical nevi at initial and follow-up visits, such that side-by-side comparisons could be made.

RESULTS

A total of 5,945 lesions were monitored in 297 patients over 3 to 52 months (median, 22 months), and 324 lesions were biopsied. Photographic (dermoscopic) changes were noted in 96 of 5,945 (1.6%) lesions, which included 64 dysplastic nevi (67%), 25 common nevi (26%), and 1 melanoma (1.0%). Of 6 melanomas biopsied during the follow-up period, only 1 was detected by dermoscopic photographic change at follow-up.

CONCLUSIONS

Most clinically atypical melanocytic nevi are stable over time, and lesions exhibiting dermoscopic changes are most likely to be dysplastic nevi. Although dermoscopy is a useful tool for clinical examination, the sensitivity of dermoscopic monitoring is limited by melanomas that may arise in normal skin or in clinically benign nevi that were not initially photographed.

Screening, early detection, and trends for melanoma: Current status (2000-2006) and future directions

In the past 5 years, there have been notable strides toward the earlier recognition and discovery of melanoma, including new technologies to complement and augment the clinical examination and new insights to help clinicians recognize early melanoma. However, incidence and mortality rates throughout most of the developed world have risen over the past 25 years, while education and screening, potentially the best means for reducing the disease, continue to be severely underutilized. Much progress needs to be made to reach middle-aged and older men and persons of lower socioeconomic status who suffer a disproportionate burden of death from melanoma. Worldwide melanoma control must also be a priority, and comprehensive educational and screening programs should be directed to Northern Ireland and a number of Eastern European nations, whose 5-year survival rates range between 53% and 60%, mirroring those of the United States and Australia more than 40 years ago.

LEARNING OBJECTIVE

After completing this learning activity, participants should be aware of the most recent melanoma epidemiologic data, both in the United States and internationally; worldwide early detection and screening programs; clinical strategies to recognize and improve the detection of early melanoma; the latest technologies for early detection of melanoma; and public and professional education programs designed to enhance early detection.

Prospective study to assess general practitioners' dermatological diagnostic skills in a referral setting

A prospective study was conducted to assess general practitioners' diagnostic skills in a referral setting. The primary objective was to identify general practitioners' strengths and weaknesses in diagnosing a broad spectrum of skin conditions. The diagnoses of 315 skin conditions made by 165 general practitioners were compared with a reference standard. The reference standard was made up of 73 histopathological diagnoses, 119 dermatologists' clinical diagnoses and 123 dermatologists' diagnoses plus follow up. The diagnoses assigned by referring general practitioners were consistent with dermatologists' clinical diagnoses and histology (where available) in 57% of cases. General practitioners made the correct diagnosis in 44% of cases when compared with histopathology. General practitioners were generally good at diagnosing conditions such as acne, warts, rosacea, molluscum contagiosum, vitiligo and skin tags. The proportion of correct diagnoses for premalignant and malignant skin tumours was 47%, and that of skin rashes requiring a diagnosis was 44%. Further education of general practitioners would help to improve their diagnostic skills in certain skin conditions.

Clinical presentations of cutaneous melanoma

Cutaneous melanoma is responsible for the majority of skin cancer deaths. Early and accurate detection are the most important means to improve patient survival. This article reviews the common clinical presentations of head and neck cutaneous melanoma, and discusses lesions that might be clinically mistaken for melanoma.

Breslow depth of cutaneous melanoma: impact of factors related to surveillance of the skin, including prior skin biopsies and family history of melanoma

BACKGROUND

Because the early detection of cutaneous melanoma can dramatically improve survival, identification and surveillance of persons at risk have received much attention.

OBJECTIVE

Our purpose was to examine the influences of personal or family history, patterns of detection, and prior skin biopsies (considered to be a measurement of surveillance by medical personnel) on the Breslow depth of cutaneous melanomas.

METHODS

A retrospective cohort analysis of 218 patients with a history of at least one invasive cutaneous melanoma who visited the Yale Pigmented Lesion Clinic between January 1995 and January 1996 was performed. Data on patterns of detection, melanocytic nevi, and skin biopsies before and after the initial diagnosis of melanoma were collected, and patients with a family history of melanoma were compared with sporadic patients.

RESULTS

Initial melanomas discovered by dermatologists were more likely to be 0.75 mm or less in depth than those found by other physicians (P = .03). Although patients detected 45% of the initial primary melanomas (98/218), dermatologists discovered 80% of the second primary tumors (33/41; P = .001). A personal history of melanoma was predictive of a thinner Breslow depth (P = .01), but a family history of melanoma was not. Having a biopsy of any type or combination of types of skin lesion(s) performed in the 5 years, 2 years, or 1 year before the first diagnosis of melanoma did not predict a melanoma of thinner Breslow depth among either familial or sporadic patients. The mean number of skin biopsies performed per patient was 8 times higher in the 5-year period after (5.6) versus the 5-year period before (0.7) the initial diagnosis of melanoma, with a peak in the first year after the diagnosis (2.3 vs 0.25 in the prior year). In 27 patients, one or more skin biopsies were performed in the year before the initial diagnosis of melanoma; 41% of these biopsies (23/56) were of lesions in normally exposed sites (eg, the face, neck, and forearms) compared with 22% of the melanomas (6/27).

LIMITATIONS

Since an invasive melanoma (with the possible exception of a nodular melanoma) would likely have been present for at least a year, plausible explanations for why evidence of previous dermatologic care did not appear to result in earlier detection include performance of a limited rather than a total body skin examination as well as subtle clinical features of early melanomas. However, this study cannot give weight to these explanations because at the time new Pigmented Lesion Clinic patients were not routinely asked about previous total body skin examinations.

CONCLUSIONS

The disappointing trends seen in this study, with neither the well-established risk factor of a family history of melanoma nor previously having a skin biopsy predicting thinner melanomas, highlight the need to establish criteria defining the subset of patients for whom appropriate management requires periodic total body skin examination.

Melanoma detection in British Columbia, Canada

BACKGROUND

In several studies, delays in malignant melanoma (MM) diagnosis have been correlated with increased tumor thickness, increased morbidity, and increased mortality.

OBJECTIVE

We sought to assess how MM is detected in British Columbia, Canada, and to understand the role of patient education and other factors on diagnostic delays.

METHODS

A self-administered questionnaire was distributed to 176 consecutive patients with histologically confirmed MM.

RESULTS

The total median delay was 4 months. There was no correlation between tumor thickness and delay times. Lesions found incidentally by physicians were less invasive (median Breslow thickness 0.59 vs 1.0 mm, P=.006) than those found by patients. The majority of patients had some knowledge of MM and recognized the importance of early detection. Nearly one fourth of respondents were unaware MM could develop from a melanocytic nevus. In general, MM knowledge did not affect total delay.

CONCLUSION

Patients in British Columbia, Canada, report relatively short delays in diagnosis of MM. Delays were not correlated with increased tumor thickness or with patient knowledge regarding melanoma before diagnosis.

Melanoma within the seborrheic keratosis

Seborrheic keratoses (SKs) are common benign nonmelanocytic epidermal tumors with characteristic clinical features, which are thought to allow a straightforward diagnosis in most situations. As a result, it is an accepted practice to destroy them without histopathologic confirmation. However, systematic reviews of histologic specimens reveal an erroneous clinical diagnosis or associated malignant tumors in a number of cases, including malignant melanomas. We describe a patient with a clinically typical-appearing SK, which was biopsied and histologically proven to be a malignant melanoma arising in the SK. Our report is a reminder that the reliability of clinical diagnosis of SKs needs to be questioned. In addition, a biopsy of SKs is not only warranted but necessary in order to identify a malignant melanoma that would otherwise be misdiagnosed or even completely missed.