Melanoma is a major public health problem in the United States. The central irony in the melanoma epidemic is that most fatal melanomas were visible on the surface of the skin in a curable phase of their evolution, yet no one either noticed or responded to them in time. Given evidence suggesting that monthly skin self-examination can save lives, we sought to evaluate an intervention to encourage this practice, both for its efficacy as well as its possible effect on increasing the number and cost of skin surgeries.
Full body skin examination by clinicians has been addressed by groups such as the U.S. Preventive Services Task Force that concluded “the evidence is insufficient to recommend for or against routine screening for skin cancer using a total-body skin examination for the early detection of cutaneous melanoma” although it did note that “clinicians should remain alert for skin lesions with malignant features noted in the context of physical examinations performed for other purposes”, and that “all of these organizations [whose recommendations were reviewed] advise public or patient education to change behaviors … including … skin self-examination”16
We do note that the evidence supporting the efficacy of TSSE for reducing morbidity and mortality from melanoma, although substantial, does not include randomized trials, and is limited in quality and quantity. We also note that TSSE differs from many other screening tests because the test itself does not require a professional examiner or expensive equipment and is free of significant cost and discomfort. The adverse effects associated with TSSE, such as skin surgeries, are not as severe as with other screening procedures, so one may consider that the standard of proof required for action should be correspondingly lower.
Reports of predictors of SSE have been published,9, 17-25
and reports of accuracy of those self-examinations.26-28
Two randomized trials of SSE interventions have also been reported. Oliveria et al intervened with high risk patients (five or more clinically dysplastic nevi) seeking care at a specialized clinic who received physician and nurse education on the conduct of SSE. The experimental intervention involved provision of a book of photographs covering all of the participants' skin and appropriate instructions on its use for SSE. A higher proportion of the intervention group reported at least 3 SSEs in the 4 months after intervention compared to controls (61% vs. 37%, p
Aitken et al. randomized 18 communities in Queensland, Australia, half of which received an intervention consisting of (1) community education regarding SSE and professional skin examination for early detection of melanoma delivered by seminars and by a self-help guide that was delivered to all members of the community, (2) physician education, and (3) free skin screening clinics. Although at the end of the 3-year intervention period, the residents of the intervention communities were more likely than residents of the control communities to report that their doctor had advised them to conduct a SSE (26% vs 19%) and had shown them how to do so (16% vs 9%), there was no difference in the proportion that reported conducting SSE despite an increase in professional examinations.30
Both of the above studies asked about thorough SSE with a single question.
We found that our intervention was quite successful at increasing the practice of TSSE, and that increase was sustained for the year of follow-up. Along with that was a sustained increase in the availability of a key tool for TSSE, the wall mirror. We also found that a smaller increase in TSSE occurred in the “diet” comparison group (without a change in the availability of a wall mirror), which we attribute to two factors. First, prior to initiating recruitment in their offices, the primary care clinicians from whose practices we recruited the study population were all educated with our Basic Skin Cancer Triage curriculum which includes education on TSSE. The physicians did not know the group assignments of the participants, but they could have spread a TSSE message to a wide range of patients. Second, all participants in both groups were questioned about conduct of TSSE and related issues during the study. Both of these factors may have influenced their TSSE performance.
The fact that self-efficacy and the two attitudinal variables were predictive of greater TSSE regardless of group membership implies that these areas merit additional attention in future interventions, whether separately or as added emphases in a revised version of this intervention's materials.
Skin surgeries were more often performed in the “skin examination” group than in the “diet” group during the 6 months after intervention, but not prior to or more than 6 months after intervention, and these additional surgeries were not associated with additional malignant diagnoses. This is a noteworthy finding because of its implications for campaigns directed at increasing TSSE. If the sustained increase in performance of TSSE were associated with a sustained increase in surgeries for benign conditions, it might indicate that there is a significant adverse long-term consequence in morbidity and cost to the TSSE intervention. However, our data suggest that the increase in surgeries is transient. We suspect that when people first examine their skin more closely they initially may seek medical attention for innocuous lesions that may have been present and unchanged, but also unnoticed, for many years. The medical attention may lead to surgical intervention that in retrospect is unnecessary. However, it appears that after 6 months of scrutinizing the skin they become sufficiently familiar with their skin lesions that observing these no longer arouses concern or provokes surgical interventions. Hence in the long run, there is increased scrutiny of the skin and thus presumably melanomas will be detected earlier - but the extra expense and morbidity of needless surgery is avoided.
Only 2% of surgeries revealed malignancies or severe dysplasias, half of which were basal cell carcinomas (BCCs). Delay in treatment of BCC, unless the delay is very long, generally has little or no impact on morbidity, and no impact on mortality.31
One may therefore suspect that the excess surgeries during the first 6 months after intervention had little or no long-term beneficial impact on the lives of these patients. We did not examine medical records to determine the circumstances for each surgery performed during follow-up.
A major limitation of this study was its reliance on self-report of TSSE performance. We did not consider it feasible to verify TSSE performance by direct observation of this activity, since it typically occurs in the privacy of one's home when one is undressed. Also, our intervention did involve multiple components, and we cannot determine from our data which of these accounts for the intervention's success. Less intensive interventions may also be effective; we chose the more intensive approach to demonstrate that we can successfully intervene on this practice, which we have done. Due to funding constraints, we did not follow these patients long enough to determine the duration of the effect of this intervention on TSSE performance beyond one year, although this would have been desirable. Strengths of our effort include study of a population that was not restricted to very high risk individuals (since most melanomas do not develop among individuals recognized to be at very high risk). Therefore, our results are potentially quite broadly applicable and may have substantial impact on the overall societal burden of melanoma. We were also careful to use a definition of TSSE that involved sufficient detail that it excluded those who might say they thoroughly examine their skin even though they failed to scrutinize important areas for melanoma early detection.
The intervention we performed leads to a sustained increase in TSSE performance and a transient increase in skin surgeries. We hope that this performance of TSSE, in combination with public and professional awareness of warning signs for melanoma, will substantially reduce death from this disease.