This study used data from a nationally representative sample to examine the sex-stratified prevalence and correlates of having a total skin examination in the past year among white individuals aged 50 years and over. By focusing on this population at increased risk of dying from melanoma, the study results highlight subgroups who may benefit most from interventions to promote skin cancer screening. Identifying correlates of screening provides information on factors that may promote or hinder receipt of a physician routine total skin examination. Consistent with prior research,13, 14
overall rates of having a skin examination in the past year were very low (16% among men and 13% among men) and leave considerable room for improvement. Of note, the skin examination screening rates were considerably lower than the screening rates for breast (54%), prostate (43%), and colorectal cancers (51%) found in the current study. This is likely due to multiple physician, patient-related, and systems factors, including inconsistent skin examination screening recommendations, physicians' perceived lack of time for performing an examination, lack of relevant training, lack of patient demand for examinations, intake forms that rarely highlight the need for a skin examination, and inadequate reimbursement.9, 19, 20
There is equivocal evidence from prior studies regarding potential differences in total skin examination rates between men and women.13, 14, 21
We found men to have a significantly higher skin examination rate than women (16% and 13%, respectively), although the absolute difference in screening rates was small. Lower rates of skin examination screening were observed among those with a lower level of education. Given the poorer disease prognosis for individuals who are diagnosed with melanoma and have a lower socioeconomic status22
(who are more likely to have a lower level of education), comprehensive efforts to increase total skin examination rates are needed across population subgroups.
Results of the bivariate analyses indicated that reported skin examination screening rates were lower among both men and women with poorer healthcare access and coverage. However, these associations were no longer statistically significant in the multivariable analyses, suggesting that they were accounted for by other variables such as education level. Having a personal history of skin cancer was linked with a greater likelihood of having a skin examination in the past year for both men and women. However, from one third to more than half of these individuals did not have an examination in the past year, pointing out the need for regular ascertainment, documentation, prompting, and education regarding personal history of skin cancer. Having a family history of skin cancer was also linked with a higher skin examination screening rate among men and women, although the rates were considerably lower than those for individuals with a personal history of skin cancer. Physicians should routinely recommend that their patients with a personal history of skin cancer discuss the importance of skin cancer screening with their family members. However, the vast majority of melanoma diagnoses occur in individuals without a family history of skin cancer.
Individuals who reported not having a past year skin examination were more likely not to have been screened for colorectal, breast (among women), and prostate (among men) cancers. This may reflect general healthcare access barriers such as lack of insurance or underinsurance. These results also suggest the importance of physicians assessing patients' receipt of multiple cancer screenings, for example by including a comprehensive set of relevant questions on intake forms. Such assessments, and subsequent physician recommendations to undergo screening, may also be conducted as part of a cancer-related checkup during a general health examination,12
particularly for patients with well-established risk factors for melanoma.23
The use of chart prompts may also remind physicians to encourage patients at higher risk for melanoma to engage in skin self-examination and to report changes to existing moles or the development of new moles. Achieving widespread receipt of screening for multiple cancers will require systematic, coordinated efforts at all levels of the healthcare system, including providers, practices, and managed care organizations.
Although self-reports of total skin examinations have been found to have high sensitivity,24
participants' reported receipt of total skin examinations in the current study may not correspond with actual examinations performed by a physician. Further, participants were only asked about total skin examinations performed by a dermatologist or other physician, and thus skin examinations performed by other healthcare providers (such as nurses or advanced practice clinicians) are not captured. The cross-sectional nature of the study design precludes determination of the causal nature of observed associations.
Rates of having a total skin examination in the past year were low across all age/sex subgroups examined in this study. Physicians should be particularly aware of the need to consider skin cancer screening examinations for their male, elderly patients as well as individuals with less education. Lack of screening for skin cancer was associated with lack of screening for other cancers. There are likely multiple barriers to skin examination screening for physicians and their patients. Further research is needed to develop and test interventions that both increase patient awareness of the importance of periodic total skin examinations and promote physician delivery of such examinations.