Screening for Melanoma: One Man’s Opinion

Posted by Mark Abramowicz, M.D.

An upcoming issue of Treatment Guidelines from The Medical Letter will be devoted to Screening Tests for Cancer; that article will include sections on the colon, breast, prostate, lung, cervix and ovary. It may not include the skin, because screening for skin malignancies doesn’t require any special test until you are ready to do a biopsy. A few months ago, we wrote an article on screening for melanoma that elicited some reactions that surprised me.

Melanoma starts thin and grows thick. Remove it when it’s thin, and survival approaches 100%. Wait until it’s thick, and it may have spread locally or become metastatic. Once metastatic, there is no effective treatment and survival approaches zero.

So look for it when it’s thin, right? And that’s all you have to do is to look for it. No X-rays, no mammograms, no bowel preps, no rectal exam, no pelvic, nothing. Just look. No, no, no, say some, it’s not that simple. We don’t know that screening would save lives; you have to prove it. And OK, even if you could prove that (put 10,000 people with light complexions in prison to keep them on protocol, screen half every year and wait 20 years), how many lives would you save? I mean, is it cost-effective?

And who will do the screening? Backs to the wall on the question of screening at all, the accountants will say that the patients should screen themselves. The problem with that is, even if patients somehow knew what a melanoma looked like, melanomas can appear in some places that may not be so easy to self-examine, like the back, the vulva and between the buttocks. And then there’s the scalp and the eye. It’s ridiculous.

So maybe the internist or family physician should do the screening. They cost a lot less than dermatologists. But not many of us non-dermatologists feel confident enough about ruling out a melanoma that we would bet our patients’ lives on our abilities. So why not send them all to dermatologists? That’s where I go. That’s where I insist that my slightly freckled wife and children go. When I read in the newspaper that one of my colleagues died of metastatic melanoma, I wonder if he screened himself or asked his internist to do it for him. I’m sure most people don’t think about that. But I do.

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Comments

  1. Tim Weisbord says:

    I would like an opinion on managment of a positive prostate biopsy….Gleason 3.

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