Although the United States Preventive Services Task Force [1] (USPSTF) does not endorse skin self-examination (SSE) due to inadequate evidence that it prevents skin cancer, SSE by patients has been associated with reduced tumor stage at initial diagnosis [1-3]. The American Academy of Dermatology recommends routine SSE, regardless of melanoma risk factors (RFs), without specifying frequency. There is a knowledge gap about the optimal frequency at which SSE should be performed and how melanoma RFs impact recommendations. In this study, we surveyed pigmented lesion expert dermatologists within the Melanoma Prevention Working Group (MPWG) to assess their recommendations on optimal SSE practices.
An Institutional Review Board–approved survey was emailed to 56 board-certified dermatologists who are active members of the MPWG, between August and November 2023. We received 36 responses (64%) and assessed demographics and SSE recommendations. The deidentified data were analyzed qualitatively.
Most respondents work in academics (75%) and have practiced for over 10 years (72%). Twenty (56%) participants recommend SSE to all patients, irrespective of melanoma RFs, while 15 (42%) only recommend SSE to patients with RFs. The most important RFs identified were history of melanoma (100%), family history of melanoma (93%), and increased number of total body nevi (93%) (Table 1). These findings align with RFs outlined in a consensus statement on optimal screening practices for melanoma which identified high-risk individuals as those with a personal and/or family history of melanoma [4].
For patients with at least one melanoma RF, nearly all respondents (97%) recommend SSE. The most common frequency chosen was once a month (47%), and 64% recommend SSE within a timeframe of 1-to-3 months (Figure 1). For patients with no melanoma RFs, most respondents (78%) still advise SSE, though no consensus on frequency was found. Notably, 27 (75%) respondents believe primary care providers (PCPs) should be involved in teaching patients SSE. Furthermore, 22 (61%) respondents support using a teaching resource for teaching patients SSE performance, with all (100%) agreeing that the American Academy of Dermatology’s SSE template should be utilized. [5]
Self-efficacy for SSE, defined as one’s confidence to perform a skin check, is a positive predictor of performance [3,6]. A prospective study showed that perceived physician support for SSE and patient education on how to perform SSE were significantly associated with increased self-efficacy in melanoma patients [3]. Dermatologists, therefore, play a key role in actively encouraging SSE and providing education to increase its utilization. PCPs can also be involved in educating patients on SSE practices, a position held by most respondents. A targeted approach to SSE recommendations based on RFs has the potential to reduce melanoma morbidity.
Although the response rate was adequate, limitations include the small membership of MPWG, response bias, and limited generalizability to non-pigmented lesion specialists.
To our knowledge, this is the first survey of pigmented lesion expert dermatologists regarding their SSE recommendations. Despite the USPSTF’s negative endorsement, the experts in our study overwhelmingly recommend SSE. In particular, the most common SSE frequency chosen for patients with melanoma RFs was once a month, and the majority recommend performance of SSE within a 1-to-3-month timeframe. For experts opposed to monthly examinations, cited concerns included the potential to increase patient anxiety due to frequency. Conversely, experts supporting monthly exams highlighted the benefits of detecting rapidly growing lesions and establishing regular self-examination habits.
For patients without RFs, our experts still recommend SSE, but a consensus on frequency was not reached. This survey provides valuable evidence in support of SSE and can serve as a guide for the frequency at which SSE should be performed. Furthermore, this study highlights the knowledge gap in recommending SSE to patients without melanoma RFs, indicating a need for future research. These results provide a unique perspective that may inform patient educational initiatives and secondary prevention strategies for melanoma that can be reinforced by community dermatologists.
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Table 1 SSE Recommendations and Beliefs
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Routine SSE Recommendation (n= 36)
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(n)
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(%)
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Recommend to all regardless of melanoma RFs
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20
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56%
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Only recommend based upon RFs
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15
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42%
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Other*
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1
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2%
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RFs that influence recommendation for SSE (n= 15) (multiple selections allowed)
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Prior history of melanoma
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15
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100%
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Family history of melanoma
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14
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93%
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Increased number of total body nevi
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14
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93%
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History of atypical nevi
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13
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87%
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Immunosuppression
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13
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87%
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Prior history of non-melanoma skin cancers
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12
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80%
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Lighter Fitzpatrick skin types (I or II)
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9
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60%
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SSE Frequency Recommendation with 1 or more melanoma RFs (n= 36)
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Once a month
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17
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47%
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Every 3 months
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5
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14%
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Every 6 months
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6
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17%
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Recommend but do not specify frequency
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6
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17%
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Do NOT recommend to these patients
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1
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2%
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Other: Every 6-8 weeks
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1
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3%
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SSE Frequency Recommendation with NO melanoma RFs (n= 36)
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Once a month
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7
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19%
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Every 3 months
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3
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8%
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Every 6 months
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2
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6%
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Every year
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6
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17%
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Recommend but do not specify frequency
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10
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28%
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Do NOT recommend to these patients
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8
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22%
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Do you believe there are possible harms with recommending SSE? (n= 36)
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Yes, the harms outweigh the benefits
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1
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3%
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Yes, the benefits outweigh the harms
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18
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50%
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No
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17
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47%
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If YES to possible harms, what are the greatest harms? (n= 19) (multiple selections allowed)
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Increased cancer worry
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17
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90%
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Over-biopsy of benign lesions
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11
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58%
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Excess costs associated with biopsies of benign lesions
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10
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53%
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Other
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3
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16%
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Do you believe PCPs should be involved in teaching SSE? (n= 36)
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Yes
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27
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75%
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No
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9
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25%
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*Do not recommend routine SSE to pediatric patients or those with a limited life expectancy