Why Not Screen for Melanoma?

We will soon publish our tenth article in the last 4 years on yet another drug for the treatment of unresectable or metastatic melanoma. All of these drugs are obscenely expensive. None of them cures the disease. Melanoma detected early is nearly 100% curable. Unresectable or metastatic melanoma is usually fatal. Early detection of melanoma does not require exposure to x-rays like mammography or a CT-scan of the lung, propofol anesthesia and the risk of bowel perforation like colonoscopy, or the risk of sepsis like a needle biopsy of the prostate. But the US Preventive Services Task Force apparently once again is going to find the evidence insufficient to recommend a routine whole-body examination for melanoma and other skin cancers.

The last USPSTF recommendation against screening for melanoma came in 2009. A draft recommendation now on the USPSTF website, scheduled to be finalized this year, concludes as before that “…the current evidence is insufficient to assess the balance of benefits and harms of visual skin cancer screening in adults.”

Most patients discover their own melanomas, but detection by a physician, particularly a dermatologist, is more likely to find thinner, more curable tumors. Melanoma occurs frequently on the back, especially in men, and can occur in areas even more difficult for patients to self-examine, like the vulva and between the buttocks. A skin cancer screening project in the Schleswig-Holstein region of Germany in 2003-2004 offered visual screening to all adults. Even though only 20% of the adult population chose to be screened, by 2008-2009 mortality from melanoma in Schleswig-Holstein had fallen by 48%. At the same time in 4 surrounding regions and in the rest of Germany, melanoma mortality rates remained stable.

The USPSTF discusses the German study, but emphasizes that the absolute reduction in mortality was only 1 death per 100,000 persons screened. But it was a 48% reduction, and they only screened 20% of the population. About 10,000 people die from melanoma in the US every year. If that number fell to 5200, would that outweigh the harm of some negative skin biopsies? Is the evidence really insufficient to answer that question?

Enter your email address to follow this blog and receive notifications of new posts by email.

Comments

  1. Norman Levine says:

    As a dermatologist, I perform many screening exams and occasionally do uncover a melanoma that the patient failed to identify beforehand. Thus, screening exams do serve a purpose. However, the magnitude of risk varies greatly between those with a previous melanoma, those with multiple family members with melanoma, those with fair skin and a history of bad sunburns and the rest of the population without these risk factors. Perhaps screening exam frequency could be stratified depending on the likelihood of detecting a melanoma. Screening a 25-year old dark skinned person routinely for melanoma may not be an efficient way to husband our limited resources.

  2. Elaine Silver MD says:

    What possible harms could there be to visually examining the skin? I agree that screening should be related to risk assessment but that goes for any preventive action. You don’t usually screen 75 year old women for STDs. (I say usually).

  3. George Gottlieb, MD says:

    Screening 100,000 people would probably require 3 people working full time. If they were techs who earned $50,000/yr, it would cost $150,000 to prevent one death. Stratifying by risk, as suggested by Drs Levine and Silver, is the only way to make screening cost effective.

  4. Mom sense says:

    My daughter had stage II melanoma in her 20s (was never a sun bather) and diligently covers her skin when outdoors but must have yearly exams and frequent biopsies which she pays the full cost of. Yet people continue to smoke and they get their exams and tests fully covered for free. People who’ve had melanoma have a much greater reoccurance risk than the general public and should get yearly exams for free. I guess if you’re a smoker, the govt has your back but not for those with melanoma.

Leave a Reply:

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s