Non-Dermatologists Miss Many Cancerous Skin Lesions

A new study by Yale School of Medicine finds that many cancerous skin lesions are missed in exams by non-specialists, and that only a total body skin exam (TBSE) by a dermatologist can ensure they will be detected. In addition, the findings suggest the increasingly common use of teledermatology (in which non-specialists communicate skin conditions to a dermatologist long-distance via audio, video and data techniques) has the potential to miss many cancerous lesions. The study appears in the Archives of Dermatology.

More than one million skin cancers are diagnosed each year in the United States, and one in five Americans will develop skin cancer in their lifetime. Non-specialists, especially primary care physicians, are often the first to see skin lesions, initiating referral to dermatologists.

The research team studied the records of 400 patients referred by non-specialists to the dermatology service at the Veterans Affairs Connecticut Healthcare System. The patients each had one lesion considered suspicious for malignancy.

Of the 149 lesions that proved to be malignant, 41 percent were incidental — meaning that they were not originally detected by the non-specialist but were picked up in the total body skin exam. Among these incidental lesions discovered by the dermatology service, six turned out to be malignant melanomas — the most deadly form of skin cancer.

Senior author Daniel G. Federman, MD, professor of internal medicine at Yale School of Medicine and Firm Chief, Primary Care, at the Veterans Affairs Health Care System in West Haven, Connecticut, said, “Our research demonstrates how important it is to perform a total body skin exam, because the earlier a lesion is diagnosed, there is a more likely chance of complete recovery.”

The authors also caution about the use of teledermatology, which was originally utilized in rural areas but has gained momentum even in highly populated areas over the past decade. It’s associated with decreased time to diagnosis and surgical treatment. But because it utilizes digital images instead of total body skin exams conducted in-person, the reviewing dermatologist may not see malignancies or other lesions of concern outside the field of the digital image.

“Teledermatology clearly has a role in areas where patients do not have access to dermatologists,” Federman explained. “Our findings suggest non-dermatologists should receive more training in the diagnosis of skin cancer, and both non-dermatologists and dermatologists should perform a full body skin examination if they find a suspicious skin lesion during a patient encounter. “

First author was Kate V. Viola, MD, formerly of Yale School of Medicine and currently of the Albert Einstein College of Medicine and Montefiore Medical Center. Other authors are Whitney L. Tolpinrud and Cary P. Gross, MD, of Yale School of Medicine; Suguru Imaeda, MD, of Yale School of Medicine and the Veterans Affairs Health Care System; and Robert S. Kirsner, MD of the University of Miami School of Medicine.

The study was funded by the Robert Wood Johnson Clinical Scholars Program at Yale, and West Haven Veterans Affairs.