Serial Screening for Melanoma: Measures and Strategies That Have Consistently Achieved Early Detection and Cure
March 2011 | Volume 10 | Issue 3 | Original Article | 244 | Copyright © 2011
Ronald N. Shore MD, Paula Shore MEd†, Noel M. Monahan MHSc PA-C, James Sundeen MD
Ronald N. Shore, MD PA, Rockville, Maryland (Dr. Shore, Ms. Shore, Ms. Monahan): Department of Dermatology, Johns Hopkins University, Baltimore, Maryland (Dr. Shore), and GenPath, Clarksburg, Maryland (Dr. Sundeen); Deceased
Objective: To determine the effectiveness of a serial screening program in achieving early detection and preventing death in patients
at increased risk for melanoma.
Design: Retrospective study.
Setting: Private dermatology practice.
Patients: The study included all patients at increased risk for melanoma who were screened in the program during the 17-year period, July 1, 1992-June 30, 2009 (=1108 patients per year).
Main Outcome Measures: Survival and indicators of early detection.
Results: All melanomas that developed in program participants during the 17-year period were detected early and there were no deaths, metastases, recurrences, nor need for sentinel node biopsies. An analysis of melanoma cases seen in five recent years revealed additional evidence of consistent early detection: 80 percent of the lesions were in situ, no lesions were greater than 0.15 mm in Breslow depth, and all lesions were in the radial growth phase, a stage almost always associated with cure. Four measures, often absent in mass screening programs, contributed to very early detection and cure: thorough serial examinations, biopsying suspicious lesions (particularly pigmented lesions that were highly irregular and/or approaching black in color), recalling patients every six months to detect all melanomas in the radial growth phase, and educating patients on the need to return. Conclusion: An office-based surveillance program that includes serial full skin examinations and ongoing recalls appears capable of detecting melanoma at a very early stage when cures can be realized in almost every case. Therefore, when patients present with recognized risk factors for melanoma, dermatologists should seriously consider recommending and performing such serial screening procedures.
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Although there has been a significant increase in the occurrence of malignant melanoma (MM) in the last several decades, screening of patients at increased risk by dermatologists in the office setting is far from standard.1 Furthermore, there is no consensus in the profession as to which particular patients should be examined, how often this should be done, who should do it, how it should be done and, indeed, if it is even worthwhile.
During the 1980s, the first author of this paper began performing full skin examinations (FSEs) on patients perceived to be at increased risk of MM and other skin cancers. Patients were recalled every six months for repeat examinations in an attempt to detect new MMs while they were still in the earliest stage, the radial growth phase (RGP), which has been associated with cure in virtually all cases.2 In 1992 a more complex recall system was instituted to follow up on patients at increased risk who had not returned regularly.
As the years passed, it became apparent that the screening program was performing exactly as intended--not a single patient who returned for regular screening died of MM nor any other skin cancer. In contrast, other patients presented to the practice on their initial visit with MMs in more advanced stages, and some of these did not survive.
The results of the screening program, while very gratifying, raised a most profound question: At a time when major health policy organizations cannot agree if skin screening is even of value,3,4 how was it possible for this program to be so successful? The remainder of this paper reviews the details of the program, analyzes the effects of various components, and identifies those measures that contributed to its success.
This review was based on data from patient records, recall program records, and superbill forms (charge sheets for provided services) from the private dermatology practice of Ronald N.