Response to Shore et al.: Lessons From an Exemplary Physician in a Private Setting

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 core curriculum.

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.