Mortality rates for nearly all cancers with known
screening tests such as cancer of the prostate, cervix,
breast and colon have dropped in the past generation.
1 Melanoma kills, and, tragically, the mortality rates of melanoma
for middle-aged and older individuals, particularly men,
continue to rise precipitously.2 There are far too many missed
opportunities for careful screening of the skin as many of these
same individuals see their physicians regularly for other health
concerns.3 Clearly, new strategies, including expert screening
of high-risk patients, are a major focus of mortality reduction.
Downshifting the tumor depth to a diagnosis of melanoma in
situ or less than 1 mm must be the key goal, as recent studies
have shown mortality rates of less than three percent for melanoma
diagnosed at less than 1 mm, and more than three times
higher for melanomas diagnosed between 1.01 mm and 2 mm.4
The American Academy of Dermatology (AAD) has many
programs designed to screen for and prevent melanoma. A
mainstay of the latter is an extensive public education effort.
Sun avoidance, sun protection and self-examination are key
messages. Dr. Ronald Shore is to be congratulated for his expertly
designed and common-sense approach to melanoma
detection.5 His expert attention to detail in implementing it is
commendable. Finally, without the additional step of reviewing
his experience and reporting it we would not benefit from it.
In this assessment of melanomas detected among his large patient
panel, coupled with an extensive literature review, Shore
et al. make a strong and compelling case to serially screen atrisk
patients and biopsy “highly dysplastic” lesions. His results
are striking—among all patients whose melanoma was first
detected by Shore, nearly all were in situ. He has also made
an important contribution to the limited understanding of the
natural history of melanoma. As part of his serial examinations,
melanoma in situ and two very thin invasive melanomas (when
one reviews the profile of patients B-J) were detected an average
of nine months after a prior normal examination. As noted
by Shore et al., this is the third study of its kind in which not one
advanced stage melanoma was found among patients vigilantly
followed by dermatologists committed to superb care and
systematic data collection and reporting.
Shore’s lessons may inspire new practice for dermatologists
and even non-dermatologist physicians. Because 85 percent of
Americans will never see a dermatologist, the comprehensive
head-to-toe, front and back examination must be taught to all
primary care physicians. Few learn this skill in medical school or primary care residency programs.6,7Currently practicing
primary care physicians (PCP) should benefit from web-based
training programs that will soon emerge. Chart reminders that
alert PCPs to ask patients every six months about their smoking
status and nutritional status should be adapted to ask about
and request checks for abnormal moles in high-risk patients.
The patient’s positive response to questions about changing
moles should warrant a referral to a dermatologist.
So, how can this model of ideal practice in Shore’s office be
scaled up? First, organizations that promote the teaching of
dermatology residents should collaborate with Shore to incorporate
his basic principles and office-based strategies into their
To this end, trainees might ask what it takes to integrate comprehensive
screening for skin cancer into one’s practice. How
much time must be devoted to the thorough examination and
setting up of a practice devoted to early detection? Does it take
away from other aspects of patient care? Does this require additional
time from nursing and other staff? Are patients willing
to undress? Answers to these practical questions and others
could be bundled in the form of a manual or toolkit that might
pave the way for easier adoption.
Second, journals and publications routinely distributed to currently
practicing dermatologists could report tips on the “nuts
and bolts” of an ideal detection practice or make such a manual
readily accessible online. Third, dermatologists could form
informal practice-based networks with a goal of replicating
Shore’s experience while adapting it to their unique practices.
A network of United States (U.S.) dermatologists committed to
the central tenets of Shore’s work-serial screening, patient reminders
and exemplary data collection would have a profound
impact on the common goal of reducing melanoma deaths.
In this era of disease prevention and cost containment, many
dermatologists find it nonsensical that a visual screening of
the skin is not accepted by most agencies as a recommended
aspect of responsible early disease detection. Dr. Shore’s experience
in a solo suburban private practice demonstrates how an
individual doctor, without NIH or pharmaceutical sponsorship,
can make an impact. We are hopeful that his example provides
additional data that may eventually lead to a responsible public
health recommendation for a risk-based assessment and regular
follow-up examinations for those found to be at risk for our
most deadly dermatologic disease.