Is an online skin cancer toolkit an effective way to educate primary care physicians about skin cancer diagnosis and referral?

Introduction: Early detection of melanoma skin cancer improves survival rates. Training family physicians in dermoscopy with the triage amalgamated dermoscopic algorithm (TADA) has high sensitivity and specificity for identifying malignant skin neoplasms. In this study we evaluated the effectiveness of TADA training among medical students, compared with practicing clinicians. Methods: We incorporated the TADA framework into 90-minute workshops that taught dermoscopy to family physicians, primary care residents, and first- and second-year medical students. The workshop reviewed the clinical and dermoscopic features of benign and malignant skin lesions and included a hands-on interactive session using a dermatoscope. All participants took a 30-image pretest and a different 30-image posttest. Results: Forty-six attending physicians, 25 residents, and 48 medical students participated in the workshop. Mean pretest scores were 20.1, 20.3, and 15.8 for attending physicians, resident physicians and students, respectively (P<.001); mean posttest scores were 24.5, 25.9, and 24.1, respectively (P=.11). Pre/posttest score differences were significant (P<.001) for all groups. The medical students showed the most gain in their pretest and posttest scores. Conclusion: After short dermoscopy workshop, medical students perform as well as trained physicians in identifying images of malignant skin lesions. Dermoscopy training may be a valuable addition to the medical school curriculum as this skill can be used by primary care physicians as well as multiple specialists including dermatologists, gynecologists, otolaryngologists, plastic surgeons, and ophthalmologists, who often encounter patients with concerning skin lesions.

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Significant decline in cancer diagnostic testing in U.S. CMS population during the COVID-19 pandemic.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.6536 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 6536-6536

Author(s):

Dave Smart ◽

Peter Riccelli ◽

Keith Kerr ◽

Jordan Clark ◽

Susanne Munksted Fosvig ◽

...

Keyword(s):

Primary Care ◽

Cancer Diagnosis ◽

Primary Care Physicians ◽

Diagnostic Testing ◽

Delayed Diagnosis ◽

Cancer Control ◽

Unintended Consequences ◽

Initial Diagnosis ◽

Test Volume ◽

The Us

6536 Background: The COVID-19 pandemic has caused >400,000 infection related deaths in the US to January 2021. Actions taken to limit COVID-19 infection and mortality could potentially lead to unintended consequences, precipitating excess mortality due to other causes. One such cause is delayed cancer diagnosis. Significant decreases in presentation for cancer diagnosis at the primary care level have been noted in the UK. This study aimed to look for evidence of a similar effect in the US. Methods: CMS claims data from JAN18-JUN20 associated with primary diagnosis across 11 cancers (bladder, breast, cervical, colorectal, endometrial, lung, ovarian, pancreatic, prostate, sarcoma and thyroid) were analyzed for use of surgical pathology (SP), a procedure associated with initial diagnosis, and immunohistochemistry (IHC). Test volumes varied widely by test and cancer so were normalized to enable comparison across indications. This was done by dividing the month-on-month difference for the period JAN19-JUN19 vs JAN20-JUN20 by the median monthly test volume for the period JAN18-DEC19 (“pre-COVID period”). Extent and duration of declines in test rates and number of missing patients as the sum of these declines were then determined. The ratio of IHC to SP testing was taken to determine any decline in likely post-initial diagnosis testing. Results: There were significant (>10%) declines in test volumes for SP for all 11 cancers at some time in Q1-Q2 2020. Table. Extent, duration and return to pre-COVID levels for SP testing across 11 cancers Median extent and duration of the decline was 56% (range 41.1%-80.4%) and 2 months (range 1- >4). This equates to 32,192 missing diagnoses across all cancers. SP test volumes for all cancers except lung and breast had returned to around pre-COVID levels by JUN20. There was no significant (>10%) increase in normalized SP test volume after the COVID dip for any cancer. While SP showed decreased test volumes across all cancers at some point during the first half of 2020, test volume ratios of IHC to SP showed increases for most cancers in the same time period. Conclusions: These data highlight that the decline in patients presenting to their primary care physicians with suspicion of cancer for diagnostic investigation was linked to COVID-19 prevention strategies. No evidence for increased, “catch up” testing to address presentational/diagnostic backlog was observed. Thus, it is predicted that these patients may subsequently present with a more advanced cancer. Potential excess morbidity, mortality and cost associated with absent or delayed diagnosis should be factored into cancer control programs going forward.[Table: see text]

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Dermoscopy Improves Accuracy of Primary Care Physicians to Triage Lesions Suggestive of Skin Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2005.05.0864 ◽

2006 ◽

Vol 24 (12) ◽

pp. 1877-1882 ◽

Cited By ~ 125

Author(s):

Giuseppe Argenziano ◽

Susana Puig ◽

Iris Zalaudek ◽

Francesco Sera ◽

Rosamaria Corona ◽

...

Keyword(s):

Primary Care ◽

Skin Cancer ◽

Primary Care Physicians ◽

Randomized Study ◽

Skin Lesions ◽

Skin Cancer Screening ◽

Predictive Values ◽

Naked Eye ◽

Pigmented Lesions ◽

Malignant Skin Tumors

Purpose Primary care physicians (PCPs) constitute an appropriate target for new interventions and educational campaigns designed to increase skin cancer screening and prevention. The aim of this randomized study was to determine whether the adjunct of dermoscopy to the standard clinical examination improves the accuracy of PCPs to triage lesions suggestive of skin cancer. Patients and Methods PCPs in Barcelona, Spain, and Naples, Italy, were given a 1-day training course in skin cancer detection and dermoscopic evaluation, and were randomly assigned to the dermoscopy evaluation arm or naked-eye evaluation arm. During a 16-month period, 73 physicians evaluated 2,522 patients with skin lesions who attended their clinics and scored individual lesions as benign or suggestive of skin cancer. All patients were re-evaluated by expert dermatologists at clinics for pigmented lesions. Referral accuracy of both PCP groups was calculated by their scores, which were compared to those tabulated for dermatologists. Results Referral sensitivity, specificity, and positive and negative predictive values were 54.1%, 71.3%, 11.3%, and 95.8%, respectively, in the naked-eye arm, and 79.2%, 71.8%, 16.1%, and 98.1%, respectively, in the dermoscopy arm. Significant differences were found in terms of sensitivity and negative predictive value (P = .002 and P = .004, respectively). Histopathologic examination of equivocal lesions revealed 23 malignant skin tumors missed by PCPs performing naked-eye observation and only six by PCPs using dermoscopy (P = .002). Conclusion The use of dermoscopy improves the ability of PCPs to triage lesions suggestive of skin cancer without increasing the number of unnecessary expert consultations.

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The success of the Rapid Diagnostic Clinic (RDC) detecting new cancers in patients with non-localizing symptoms.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.29_suppl.303 ◽

2020 ◽

Vol 38 (29_suppl) ◽

pp. 303-303

Author(s):

Jan Sindhar ◽

Sabine Martin ◽

Loay Rahman ◽

Sifan Zheng ◽

Yaseen Mukadam ◽

...

Keyword(s):

Primary Care ◽

Cancer Diagnosis ◽

Primary Care Physicians ◽

Early Stage ◽

Recovery Phase ◽

Referral Criteria ◽

Anti Cancer ◽

Set Up ◽

The Uk

303 Background: Rapid Diagnostic Clinics (RDC) are being set up across the UK allow primary care physicians to refer patients with symptoms concerning for cancer that do not fulfil tumour-specific two week wait urgent referral criteria. Guy’s RDC was established to address the high cancer related mortality in our network. There is little data assessing the effectiveness of RDC models is available in a British population. Methods: We evaluated all patients referred to Guy’s RDC pilot scheme between December 2016-June 2019 (n=1,341) to assess the rate and type of cancer diagnosed and clinical outcomes. Results: Of 1341 patients, 96 cancers were diagnoses (7.2%). Most common were lung (16%), haematological (13%) and colorectal (12%). A third were at early stage (I-II) and 40% received radical treatment. Median time to cancer diagnosis 28 days (IQR 15-47) and treatment 56 days (IQR 32-84). 75% of patients were suitable for anti-cancer treatment: surgery (26%), systemic (24%) and radiotherapy (14%). We plan to present updated data on > 2000 patients referred until June 2020. Overall 6% of patients were diagnosed with pre-malignant conditions. Conclusions: RDCs provide a streamlined pathway for complex vague symptoms patients which are challenging for primary care. The 7% rate of cancer diagnosis exceeds many tumour specific urgent pathways which supports the need for rapid tailored diagnostics. The detection of pre-malignant conditions in 6% allows surveillance and intervention to potentially improve long-term outcomes. RDCs are likely to be pivotal in the cancer recovery phase of the COVID-19 pandemic.

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Pediatric lymphadenopathy: Which patients need evaluation by an oncologist?

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e13605 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e13605-e13605

Author(s):

Kathryn A. Six ◽

Orlando Esparza ◽

Gabriel Daniels ◽

Inmaculada B. Aban ◽

Matthew A. Kutny ◽

...

Keyword(s):

Primary Care ◽

Lymph Node ◽

Cancer Diagnosis ◽

Primary Care Physicians ◽

Maximal Dimension ◽

Single Institution ◽

Starting Point ◽

Study Results ◽

Lymph Node Size ◽

Node Size

e13605 Background: While lymphadenopathy may be the first sign of cancer in children, it can also be a manifestation of non-malignant illness. Lymphadenopathy is a common reason for referral to a pediatric oncologist, which can result in significant anxiety for parents. Understanding which patients require an oncology referral for lymphadenopathy is key in order to streamline healthcare utilization for this common clinical entity. Methods: In this single institution study, we retrospectively reviewed the medical records of patients referred to pediatric oncology for lymphadenopathy between 2012 and 2020. A logistic regression model was fitted to examine the association between the maximum size of the lymph nodes and cancer diagnosis. We also obtained estimates of odds ratio and area under the ROC curve. Sensitivity and specificity were estimated using exact Clopper-Pearson method for proportion. SAS v9.4 was used to perform statistical analyses. Institutional IRB approved the study. Results: A total of 91 patients aged 1 to 19 years (median 14 years) were included. There was a statistically significant association between lymph node size and a diagnosis of malignancy. For every centimeter increase in maximal dimension of lymph node(s), there was an estimated 2.2-times increase in the odds of cancer (CI 95% 1.5-3.3; p = 0.0002). The estimated area under the curve for this model was 0.8 (95% CI 0.7-0.9) indicating that lymph node size correlated very well with cancer risk. We evaluated the model to find a threshold for lymph node size that provided a high sensitivity for screening purposes. A cut-off of 2 centimeters resulted in an estimated sensitivity of 0.95 (95%CI 0.7-0.99) and specificity of 0.6 (95%CI 0.5-0.7). Conclusions: This study provides preliminary evidence that the estimated odds of a cancer diagnosis doubles for each centimeter increase in lymph node size. This single institution retrospective study suggests that in patients with lymphadenopathy, the maximum lymph node size may be a predictor of malignancy. Our results demonstrate that the sensitivity for cancer increases at a lymph node size of two centimeters or larger. Navigating when to monitor a patient with lymphadenopathy in the primary care setting versus referring to the oncologist can be a challenge for primary care physicians. Our results are consistent with the practice that using a two centimeter cutoff is a good starting point for referrals; however, these results will need to be verified with a larger sample size before they are adopted into clinical guidelines. Further study is underway to evaluate lymphadenopathy referrals to both surgery and oncology in order to reduce potential bias that may be associated with oncology referrals, which may have a predilection for malignancy. This study underlines the importance of a physical examination by the primary care physician as the crucial step in determining if a patient requires an oncology referral.

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