Melanoma

Among patients with stage I or II cutaneous melanoma, women have been found to have a consistent 30% advantage over men in overall survival, disease-specific survival, rate of distant metastasis, rate of lymph node metastasis, and rate of relapse, a study published online April 30 in the Journal of Clinical Oncology has shown.

"The 30% advantage extends to the whole spectrum of melanoma disease behavior," reported Dr. Arjen Joosse of Erasmus University Medical Center, Rotterdam, the Netherlands, and his associates.

Women with melanoma are known to have higher survival rates than men, but the details of the difference had never been thoroughly explored. Some experts have proposed that men have more advanced disease at diagnosis because they are less aware of melanoma, less likely to be screened, and less likely to seek medical care for a suspect lesion. Others contend that biologic differences between the sexes account for survival differences, and point to estrogen as a likely contributor.

Dr. Joosse and his colleagues examined the issue by analyzing the pooled results of four large, randomized phase III clinical trials of localized melanoma performed by the European Organisation for Research and Treatment of Cancer (EORTC). The trials, which investigated different therapies for the disease, involved detailed medical records and "meticulous" follow-up of 2,672 patients (48% men and 52% women).

"Women exhibited an independent, significant, and consistent advantage of approximately 30%" for overall survival, relapse-free survival, disease-specific survival, time to in-transit metastasis, lymph node metastasis, and distant metastasis, the investigators reported (J. Clin. Oncol. 2012 April 30 [doi:10.1200/JCO.2011.38.0584]).

This sex-based difference persisted across numerous prognostic subgroups of patients, regardless of the location of the initial lesion, Breslow thickness, the presence or absence of ulceration, and whether the patient underwent sentinel node biopsy or elective lymph node dissection. If the hypothesis about sex differences in melanoma detection, screening, and diagnostic delays were true, there should be marked differences in the discrepancy between men and women across such subgroups; but no such differences were found.

Moreover, because women showed both a longer delay before relapse and a higher cure rate, compared with men, "it seems that whatever the cause of the female advantage may be, it causes both a delay in progression and a larger subset of melanomas being cured in women, compared with men," the researchers wrote.

To explore the hypothesis that estrogen might be the source of women’s survival advantage, the investigators classified the female patients by age to approximate their menopausal status.

Postmenopausal women (defined as those aged 60 years and older) retained the 30% advantage in overall survival, relapse-free survival, time to lymph node metastasis, and time to distant metastasis, compared with premenopausal women (aged 45 and younger). The advantage for disease-specific survival declined significantly in this analysis, but that may be a chance finding because of the small sample sizes and low event rates in these subgroups.

Thus, estrogen alone cannot account for the sex-based differences in survival. Other factors that may be involved include androgen receptors in melanoma cells; differences in oxidative stress between men and women; differences between the sexes in vitamin D metabolism, because vitamin D levels appear to affect melanoma prognosis; and differences in immune homeostasis, since melanoma is thought to be immunogenic.

Unravelling the underlying cause of the survival difference between men and women could point the way to targeted therapies, the investigators noted.

They added that the 30% survival advantage in their study is consistent with a 30% advantage in 5 of the 7 published studies in the literature that included 10,000 or more patients.

The study investigators reported no relevant financial disclosures.

Among patients with stage I or II cutaneous melanoma, women have been found to have a consistent 30% advantage over men in overall survival, disease-specific survival, rate of distant metastasis, rate of lymph node metastasis, and rate of relapse, a study published online April 30 in the Journal of Clinical Oncology has shown.

"The 30% advantage extends to the whole spectrum of melanoma disease behavior," reported Dr. Arjen Joosse of Erasmus University Medical Center, Rotterdam, the Netherlands, and his associates.

Women with melanoma are known to have higher survival rates than men, but the details of the difference had never been thoroughly explored. Some experts have proposed that men have more advanced disease at diagnosis because they are less aware of melanoma, less likely to be screened, and less likely to seek medical care for a suspect lesion. Others contend that biologic differences between the sexes account for survival differences, and point to estrogen as a likely contributor.

Dr. Joosse and his colleagues examined the issue by analyzing the pooled results of four large, randomized phase III clinical trials of localized melanoma performed by the European Organisation for Research and Treatment of Cancer (EORTC). The trials, which investigated different therapies for the disease, involved detailed medical records and "meticulous" follow-up of 2,672 patients (48% men and 52% women).

"Women exhibited an independent, significant, and consistent advantage of approximately 30%" for overall survival, relapse-free survival, disease-specific survival, time to in-transit metastasis, lymph node metastasis, and distant metastasis, the investigators reported (J. Clin. Oncol. 2012 April 30 [doi:10.1200/JCO.2011.38.0584]).

This sex-based difference persisted across numerous prognostic subgroups of patients, regardless of the location of the initial lesion, Breslow thickness, the presence or absence of ulceration, and whether the patient underwent sentinel node biopsy or elective lymph node dissection. If the hypothesis about sex differences in melanoma detection, screening, and diagnostic delays were true, there should be marked differences in the discrepancy between men and women across such subgroups; but no such differences were found.

Moreover, because women showed both a longer delay before relapse and a higher cure rate, compared with men, "it seems that whatever the cause of the female advantage may be, it causes both a delay in progression and a larger subset of melanomas being cured in women, compared with men," the researchers wrote.

To explore the hypothesis that estrogen might be the source of women’s survival advantage, the investigators classified the female patients by age to approximate their menopausal status.

Postmenopausal women (defined as those aged 60 years and older) retained the 30% advantage in overall survival, relapse-free survival, time to lymph node metastasis, and time to distant metastasis, compared with premenopausal women (aged 45 and younger). The advantage for disease-specific survival declined significantly in this analysis, but that may be a chance finding because of the small sample sizes and low event rates in these subgroups.

Thus, estrogen alone cannot account for the sex-based differences in survival. Other factors that may be involved include androgen receptors in melanoma cells; differences in oxidative stress between men and women; differences between the sexes in vitamin D metabolism, because vitamin D levels appear to affect melanoma prognosis; and differences in immune homeostasis, since melanoma is thought to be immunogenic.

Unravelling the underlying cause of the survival difference between men and women could point the way to targeted therapies, the investigators noted.

They added that the 30% survival advantage in their study is consistent with a 30% advantage in 5 of the 7 published studies in the literature that included 10,000 or more patients.

The study investigators reported no relevant financial disclosures.

Among patients with stage I or II cutaneous melanoma, women have been found to have a consistent 30% advantage over men in overall survival, disease-specific survival, rate of distant metastasis, rate of lymph node metastasis, and rate of relapse, a study published online April 30 in the Journal of Clinical Oncology has shown.

"The 30% advantage extends to the whole spectrum of melanoma disease behavior," reported Dr. Arjen Joosse of Erasmus University Medical Center, Rotterdam, the Netherlands, and his associates.

Women with melanoma are known to have higher survival rates than men, but the details of the difference had never been thoroughly explored. Some experts have proposed that men have more advanced disease at diagnosis because they are less aware of melanoma, less likely to be screened, and less likely to seek medical care for a suspect lesion. Others contend that biologic differences between the sexes account for survival differences, and point to estrogen as a likely contributor.

Dr. Joosse and his colleagues examined the issue by analyzing the pooled results of four large, randomized phase III clinical trials of localized melanoma performed by the European Organisation for Research and Treatment of Cancer (EORTC). The trials, which investigated different therapies for the disease, involved detailed medical records and "meticulous" follow-up of 2,672 patients (48% men and 52% women).

"Women exhibited an independent, significant, and consistent advantage of approximately 30%" for overall survival, relapse-free survival, disease-specific survival, time to in-transit metastasis, lymph node metastasis, and distant metastasis, the investigators reported (J. Clin. Oncol. 2012 April 30 [doi:10.1200/JCO.2011.38.0584]).

This sex-based difference persisted across numerous prognostic subgroups of patients, regardless of the location of the initial lesion, Breslow thickness, the presence or absence of ulceration, and whether the patient underwent sentinel node biopsy or elective lymph node dissection. If the hypothesis about sex differences in melanoma detection, screening, and diagnostic delays were true, there should be marked differences in the discrepancy between men and women across such subgroups; but no such differences were found.

Moreover, because women showed both a longer delay before relapse and a higher cure rate, compared with men, "it seems that whatever the cause of the female advantage may be, it causes both a delay in progression and a larger subset of melanomas being cured in women, compared with men," the researchers wrote.

To explore the hypothesis that estrogen might be the source of women’s survival advantage, the investigators classified the female patients by age to approximate their menopausal status.

Postmenopausal women (defined as those aged 60 years and older) retained the 30% advantage in overall survival, relapse-free survival, time to lymph node metastasis, and time to distant metastasis, compared with premenopausal women (aged 45 and younger). The advantage for disease-specific survival declined significantly in this analysis, but that may be a chance finding because of the small sample sizes and low event rates in these subgroups.

Thus, estrogen alone cannot account for the sex-based differences in survival. Other factors that may be involved include androgen receptors in melanoma cells; differences in oxidative stress between men and women; differences between the sexes in vitamin D metabolism, because vitamin D levels appear to affect melanoma prognosis; and differences in immune homeostasis, since melanoma is thought to be immunogenic.

Unravelling the underlying cause of the survival difference between men and women could point the way to targeted therapies, the investigators noted.

They added that the 30% survival advantage in their study is consistent with a 30% advantage in 5 of the 7 published studies in the literature that included 10,000 or more patients.

The study investigators reported no relevant financial disclosures.

WAIKOLOA, HAWAII – The dermoscopic features that reliably distinguish malignant mucosal lesions are a combination of structureless areas within the lesion along with blue, gray, or white color, a multicenter study conducted by the International Dermoscopy Society has shown.

This combination of dermoscopic findings yielded 100% sensitivity for histopathologically confirmed melanoma and 93% sensitivity for any malignancy, lead investigator Dr. Andreas Blum reported at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

He noted that while the key points in dermoscopic differentiation between malignant and benign and pigmented and nonpigmented lesions of the skin, nail apparatus, and scalp are well established, the important features to look for in dermoscopic evaluation of lesions of the oral mucosa and genitalia haven’t been well characterized. That was the impetus for the international observational study.

Consensus regarding dermoscopy of mucosal lesions has lagged for a couple of reasons, explained Dr. Blum, professor of dermatology at the University of Tübingen (Germany). One is that pigmented mucosal lesions are uncommon. And another is that manipulating the dermoscope in mucosal areas can be a challenge.

The study took place at 14 specialized skin cancer clinics in 10 countries. It included 140 patients with pigmented mucosal lesions, of which 126 ultimately proved benign, while 11 were melanomas, 2 were squamous cell carcinoma in situ lesions, and 1 was a metastasis (Arch. Dermatol. 2011;147:1181-7).

The investigators scored the dermoscopic patterns they saw as dots, globules, or clods, circles, lines, or structureless using a pattern analysis method developed by Dr. Harald Kittler.

The key study finding was that in a univariate analysis, lesions that were blue, white, or gray in color under the dermoscope and that contained structureless zones had a 100% sensitivity for melanoma, a 93% sensitivity for any malignancy, and an 83% specificity for being benign.

"When you see structureless areas – and only part of the lesion needs to be structureless – with blue, gray, or white zones, then you know something has gone wrong and it’s time to do a biopsy or excision," he said.

Recognizing structureless areas might be at times a difficult call for less-experienced physicians to make, the investigators also analyzed the data based solely upon a lesion’s color. Blue, gray, or white still had a sensitivity of 100% for melanoma and 93% for any malignancy, but the specificity dropped to 64%.

"So if you’re unsure about whether you’re seeing a structureless area, based upon color only, you’ll reliably detect melanomas and other malignancies, but you’ll end up doing unnecessary biopsies for benign lesions," Dr. Blum explained.

He credited Dr. Alfred W. Kopf of New York University with a suggestion that has made dermoscopic evaluation of mucosal lesions much more practical. To avoid contaminating the lens of the dermoscope, simply wrap the head of the device in plastic food wrap that has been coated on both sides with mineral oil.

Session chair Dr. Ashfaq A. Marghoob, a coinvestigator in the international study, offered a cautionary tale. He said that he has had two teenage patients with vulvar pigmented lesions that looked clinically like a clear-cut melanoma, and dermoscopically like melanoma, and the pathology report on the biopsy specimen came back as melanoma. Yet an alert gynecologic surgical oncologist contacted him and said he thought the white area surrounding the pigmented lesion looked like lichen sclerosus et atrophicus. It turned out the surgeon was right.

"I saw the patients again, and lo and behold it was as obvious as could be. I had missed the LS & A [lichen sclerosus et atrophicus], because I was so focused on the pigmented lesion that I just hadn’t realized it was there. It turns out that if you have LS & A, you can develop pigmented lesions within it that look like melanoma clinically, that look like melanoma under dermoscopy, and look like melanoma histologically," said Dr. Marghoob, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

The surgery planned for one of these young patients entailed removal of the clitoral area, so timely recognition that she actually had LS & A and not melanoma spared her from a life-changing mistake.

"We’ve now been following her for 5 years, and she’s absolutely fine with no change in the pigmented lesion," he noted.

The lesson he said he’d like to share: "A vulvar melanoma in somebody under the age of 50 is almost unheard of, and I’d strongly consider LS & A instead, checking with a Wood’s light."

Neither Dr. Blum nor Dr. Marghoob reported having any relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – The dermoscopic features that reliably distinguish malignant mucosal lesions are a combination of structureless areas within the lesion along with blue, gray, or white color, a multicenter study conducted by the International Dermoscopy Society has shown.

This combination of dermoscopic findings yielded 100% sensitivity for histopathologically confirmed melanoma and 93% sensitivity for any malignancy, lead investigator Dr. Andreas Blum reported at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

He noted that while the key points in dermoscopic differentiation between malignant and benign and pigmented and nonpigmented lesions of the skin, nail apparatus, and scalp are well established, the important features to look for in dermoscopic evaluation of lesions of the oral mucosa and genitalia haven’t been well characterized. That was the impetus for the international observational study.

Consensus regarding dermoscopy of mucosal lesions has lagged for a couple of reasons, explained Dr. Blum, professor of dermatology at the University of Tübingen (Germany). One is that pigmented mucosal lesions are uncommon. And another is that manipulating the dermoscope in mucosal areas can be a challenge.

The study took place at 14 specialized skin cancer clinics in 10 countries. It included 140 patients with pigmented mucosal lesions, of which 126 ultimately proved benign, while 11 were melanomas, 2 were squamous cell carcinoma in situ lesions, and 1 was a metastasis (Arch. Dermatol. 2011;147:1181-7).

The investigators scored the dermoscopic patterns they saw as dots, globules, or clods, circles, lines, or structureless using a pattern analysis method developed by Dr. Harald Kittler.

The key study finding was that in a univariate analysis, lesions that were blue, white, or gray in color under the dermoscope and that contained structureless zones had a 100% sensitivity for melanoma, a 93% sensitivity for any malignancy, and an 83% specificity for being benign.

"When you see structureless areas – and only part of the lesion needs to be structureless – with blue, gray, or white zones, then you know something has gone wrong and it’s time to do a biopsy or excision," he said.

Recognizing structureless areas might be at times a difficult call for less-experienced physicians to make, the investigators also analyzed the data based solely upon a lesion’s color. Blue, gray, or white still had a sensitivity of 100% for melanoma and 93% for any malignancy, but the specificity dropped to 64%.

"So if you’re unsure about whether you’re seeing a structureless area, based upon color only, you’ll reliably detect melanomas and other malignancies, but you’ll end up doing unnecessary biopsies for benign lesions," Dr. Blum explained.

He credited Dr. Alfred W. Kopf of New York University with a suggestion that has made dermoscopic evaluation of mucosal lesions much more practical. To avoid contaminating the lens of the dermoscope, simply wrap the head of the device in plastic food wrap that has been coated on both sides with mineral oil.

Session chair Dr. Ashfaq A. Marghoob, a coinvestigator in the international study, offered a cautionary tale. He said that he has had two teenage patients with vulvar pigmented lesions that looked clinically like a clear-cut melanoma, and dermoscopically like melanoma, and the pathology report on the biopsy specimen came back as melanoma. Yet an alert gynecologic surgical oncologist contacted him and said he thought the white area surrounding the pigmented lesion looked like lichen sclerosus et atrophicus. It turned out the surgeon was right.

"I saw the patients again, and lo and behold it was as obvious as could be. I had missed the LS & A [lichen sclerosus et atrophicus], because I was so focused on the pigmented lesion that I just hadn’t realized it was there. It turns out that if you have LS & A, you can develop pigmented lesions within it that look like melanoma clinically, that look like melanoma under dermoscopy, and look like melanoma histologically," said Dr. Marghoob, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

The surgery planned for one of these young patients entailed removal of the clitoral area, so timely recognition that she actually had LS & A and not melanoma spared her from a life-changing mistake.

"We’ve now been following her for 5 years, and she’s absolutely fine with no change in the pigmented lesion," he noted.

The lesson he said he’d like to share: "A vulvar melanoma in somebody under the age of 50 is almost unheard of, and I’d strongly consider LS & A instead, checking with a Wood’s light."

Neither Dr. Blum nor Dr. Marghoob reported having any relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – The dermoscopic features that reliably distinguish malignant mucosal lesions are a combination of structureless areas within the lesion along with blue, gray, or white color, a multicenter study conducted by the International Dermoscopy Society has shown.

This combination of dermoscopic findings yielded 100% sensitivity for histopathologically confirmed melanoma and 93% sensitivity for any malignancy, lead investigator Dr. Andreas Blum reported at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

He noted that while the key points in dermoscopic differentiation between malignant and benign and pigmented and nonpigmented lesions of the skin, nail apparatus, and scalp are well established, the important features to look for in dermoscopic evaluation of lesions of the oral mucosa and genitalia haven’t been well characterized. That was the impetus for the international observational study.

Consensus regarding dermoscopy of mucosal lesions has lagged for a couple of reasons, explained Dr. Blum, professor of dermatology at the University of Tübingen (Germany). One is that pigmented mucosal lesions are uncommon. And another is that manipulating the dermoscope in mucosal areas can be a challenge.

The study took place at 14 specialized skin cancer clinics in 10 countries. It included 140 patients with pigmented mucosal lesions, of which 126 ultimately proved benign, while 11 were melanomas, 2 were squamous cell carcinoma in situ lesions, and 1 was a metastasis (Arch. Dermatol. 2011;147:1181-7).

The investigators scored the dermoscopic patterns they saw as dots, globules, or clods, circles, lines, or structureless using a pattern analysis method developed by Dr. Harald Kittler.

The key study finding was that in a univariate analysis, lesions that were blue, white, or gray in color under the dermoscope and that contained structureless zones had a 100% sensitivity for melanoma, a 93% sensitivity for any malignancy, and an 83% specificity for being benign.

"When you see structureless areas – and only part of the lesion needs to be structureless – with blue, gray, or white zones, then you know something has gone wrong and it’s time to do a biopsy or excision," he said.

Recognizing structureless areas might be at times a difficult call for less-experienced physicians to make, the investigators also analyzed the data based solely upon a lesion’s color. Blue, gray, or white still had a sensitivity of 100% for melanoma and 93% for any malignancy, but the specificity dropped to 64%.

"So if you’re unsure about whether you’re seeing a structureless area, based upon color only, you’ll reliably detect melanomas and other malignancies, but you’ll end up doing unnecessary biopsies for benign lesions," Dr. Blum explained.

He credited Dr. Alfred W. Kopf of New York University with a suggestion that has made dermoscopic evaluation of mucosal lesions much more practical. To avoid contaminating the lens of the dermoscope, simply wrap the head of the device in plastic food wrap that has been coated on both sides with mineral oil.

Session chair Dr. Ashfaq A. Marghoob, a coinvestigator in the international study, offered a cautionary tale. He said that he has had two teenage patients with vulvar pigmented lesions that looked clinically like a clear-cut melanoma, and dermoscopically like melanoma, and the pathology report on the biopsy specimen came back as melanoma. Yet an alert gynecologic surgical oncologist contacted him and said he thought the white area surrounding the pigmented lesion looked like lichen sclerosus et atrophicus. It turned out the surgeon was right.

"I saw the patients again, and lo and behold it was as obvious as could be. I had missed the LS & A [lichen sclerosus et atrophicus], because I was so focused on the pigmented lesion that I just hadn’t realized it was there. It turns out that if you have LS & A, you can develop pigmented lesions within it that look like melanoma clinically, that look like melanoma under dermoscopy, and look like melanoma histologically," said Dr. Marghoob, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

The surgery planned for one of these young patients entailed removal of the clitoral area, so timely recognition that she actually had LS & A and not melanoma spared her from a life-changing mistake.

"We’ve now been following her for 5 years, and she’s absolutely fine with no change in the pigmented lesion," he noted.

The lesson he said he’d like to share: "A vulvar melanoma in somebody under the age of 50 is almost unheard of, and I’d strongly consider LS & A instead, checking with a Wood’s light."

Neither Dr. Blum nor Dr. Marghoob reported having any relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Improved early detection of fast-growing, lethal melanomas will require out-of-the-box thinking, such as providing dermatoscopes for patients to use at home and educating hairdressers and other nondermatologists on how to detect melanoma.

"At least three companies are now designing dermatoscopes for patient use. Patients will be able to buy the dermatoscope at a pharmacy and do self-examination or examine their spouse. That, I think, is going to be a reality within the next 5 years," Dr. Ashfaq A. Marghoob predicted at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Photo: Dean Bertoncelj/iStockphoto

A key feature of these devices will be the capability of hooking into a smart phone for wireless transmission of suspicious images to a skin cancer expert for assessment.

Dr. Marghoob and his coworkers first proposed dermoscopy as a tool with untapped potential for skin self-examination in selected patients in an article last year (Arch. Dermatol. 2011;147:53-8).

But patient empowerment is only part of what’s needed in order to improve early detection of the fast-growing killer subtype of melanoma. Dr. Marghoob and his coworkers are now conducting a prospective study to evaluate the impact of a 20-minute education session for hair care professionals about how they can aid in detecting skin cancers on the scalp, neck, and face.

This study was a direct outgrowth of a survey the investigators conducted at a Houston convention of barbers and hairstylists. Forty-nine percent of respondents indicated they were highly receptive to participating in a skin cancer education program. During the preceding month, 37% of respondents had looked at more than half of their customers’ scalps for suspicious lesions, 29% had looked at more than half of their customers’ necks, and 15% had checked more than half of their customers’ faces (Arch. Dermatol. 2011;147:1159-65).

Melanoma of the scalp and neck accounted for 10% of all melanoma deaths in the United States from 1973 to 2003. Barbers and hairstylists are in a unique position to detect skin cancers in those locations because they typically see their customers on a regular basis, spend a fair amount of time with them at each visit, have good rapport, and often discuss health issues.

The larger goal underlying this project, Dr. Marghoob explained, is to develop a cadre of expertly trained lay community workers to examine areas of the skin that are difficult for people to see for themselves and which often go overlooked by physicians. In addition to hair professionals, other workers ideally suited to serve as lay skin cancer educators and examiners include massage therapists, manicurists, cosmetologists, and electrologists.

Dr. Marghoob has also been involved in efforts to teach dermoscopy to primary care physicians and other nondermatologist physicians, including ob.gyns., pediatricians, and plastic surgeons. Moreover, he recently conducted a study in which second-year medical students were issued dermatoscopes and trained in their use.

"We found they get better at diagnosing skin cancer and are paying more attention to the skin. All we really want them to do is really look at the skin while they’re doing a physical examination," he said.

He has also been encouraging internists and family physicians to take advantage of opportunistic skin screening situations. For example, when they’re listening to the lungs and heart with a stethoscope, he urges primary care physicians to have patients take their shirt off so they can take a close look at the truncal skin rather than simply slip the bell of the scope underneath the shirt.

Another potentially fruitful means of improving upon the gains achieved in early detection of skin cancer would be targeted screening of older men, a high-risk group for fast-growing nodular melanomas, Dr. Marghoob added.

He reported having no financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Improved early detection of fast-growing, lethal melanomas will require out-of-the-box thinking, such as providing dermatoscopes for patients to use at home and educating hairdressers and other nondermatologists on how to detect melanoma.

"At least three companies are now designing dermatoscopes for patient use. Patients will be able to buy the dermatoscope at a pharmacy and do self-examination or examine their spouse. That, I think, is going to be a reality within the next 5 years," Dr. Ashfaq A. Marghoob predicted at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Photo: Dean Bertoncelj/iStockphoto

A key feature of these devices will be the capability of hooking into a smart phone for wireless transmission of suspicious images to a skin cancer expert for assessment.

Dr. Marghoob and his coworkers first proposed dermoscopy as a tool with untapped potential for skin self-examination in selected patients in an article last year (Arch. Dermatol. 2011;147:53-8).

But patient empowerment is only part of what’s needed in order to improve early detection of the fast-growing killer subtype of melanoma. Dr. Marghoob and his coworkers are now conducting a prospective study to evaluate the impact of a 20-minute education session for hair care professionals about how they can aid in detecting skin cancers on the scalp, neck, and face.

This study was a direct outgrowth of a survey the investigators conducted at a Houston convention of barbers and hairstylists. Forty-nine percent of respondents indicated they were highly receptive to participating in a skin cancer education program. During the preceding month, 37% of respondents had looked at more than half of their customers’ scalps for suspicious lesions, 29% had looked at more than half of their customers’ necks, and 15% had checked more than half of their customers’ faces (Arch. Dermatol. 2011;147:1159-65).

Melanoma of the scalp and neck accounted for 10% of all melanoma deaths in the United States from 1973 to 2003. Barbers and hairstylists are in a unique position to detect skin cancers in those locations because they typically see their customers on a regular basis, spend a fair amount of time with them at each visit, have good rapport, and often discuss health issues.

The larger goal underlying this project, Dr. Marghoob explained, is to develop a cadre of expertly trained lay community workers to examine areas of the skin that are difficult for people to see for themselves and which often go overlooked by physicians. In addition to hair professionals, other workers ideally suited to serve as lay skin cancer educators and examiners include massage therapists, manicurists, cosmetologists, and electrologists.

Dr. Marghoob has also been involved in efforts to teach dermoscopy to primary care physicians and other nondermatologist physicians, including ob.gyns., pediatricians, and plastic surgeons. Moreover, he recently conducted a study in which second-year medical students were issued dermatoscopes and trained in their use.

"We found they get better at diagnosing skin cancer and are paying more attention to the skin. All we really want them to do is really look at the skin while they’re doing a physical examination," he said.

He has also been encouraging internists and family physicians to take advantage of opportunistic skin screening situations. For example, when they’re listening to the lungs and heart with a stethoscope, he urges primary care physicians to have patients take their shirt off so they can take a close look at the truncal skin rather than simply slip the bell of the scope underneath the shirt.

Another potentially fruitful means of improving upon the gains achieved in early detection of skin cancer would be targeted screening of older men, a high-risk group for fast-growing nodular melanomas, Dr. Marghoob added.

He reported having no financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Improved early detection of fast-growing, lethal melanomas will require out-of-the-box thinking, such as providing dermatoscopes for patients to use at home and educating hairdressers and other nondermatologists on how to detect melanoma.

"At least three companies are now designing dermatoscopes for patient use. Patients will be able to buy the dermatoscope at a pharmacy and do self-examination or examine their spouse. That, I think, is going to be a reality within the next 5 years," Dr. Ashfaq A. Marghoob predicted at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Photo: Dean Bertoncelj/iStockphoto

A key feature of these devices will be the capability of hooking into a smart phone for wireless transmission of suspicious images to a skin cancer expert for assessment.

Dr. Marghoob and his coworkers first proposed dermoscopy as a tool with untapped potential for skin self-examination in selected patients in an article last year (Arch. Dermatol. 2011;147:53-8).

But patient empowerment is only part of what’s needed in order to improve early detection of the fast-growing killer subtype of melanoma. Dr. Marghoob and his coworkers are now conducting a prospective study to evaluate the impact of a 20-minute education session for hair care professionals about how they can aid in detecting skin cancers on the scalp, neck, and face.

This study was a direct outgrowth of a survey the investigators conducted at a Houston convention of barbers and hairstylists. Forty-nine percent of respondents indicated they were highly receptive to participating in a skin cancer education program. During the preceding month, 37% of respondents had looked at more than half of their customers’ scalps for suspicious lesions, 29% had looked at more than half of their customers’ necks, and 15% had checked more than half of their customers’ faces (Arch. Dermatol. 2011;147:1159-65).

Melanoma of the scalp and neck accounted for 10% of all melanoma deaths in the United States from 1973 to 2003. Barbers and hairstylists are in a unique position to detect skin cancers in those locations because they typically see their customers on a regular basis, spend a fair amount of time with them at each visit, have good rapport, and often discuss health issues.

The larger goal underlying this project, Dr. Marghoob explained, is to develop a cadre of expertly trained lay community workers to examine areas of the skin that are difficult for people to see for themselves and which often go overlooked by physicians. In addition to hair professionals, other workers ideally suited to serve as lay skin cancer educators and examiners include massage therapists, manicurists, cosmetologists, and electrologists.

Dr. Marghoob has also been involved in efforts to teach dermoscopy to primary care physicians and other nondermatologist physicians, including ob.gyns., pediatricians, and plastic surgeons. Moreover, he recently conducted a study in which second-year medical students were issued dermatoscopes and trained in their use.

"We found they get better at diagnosing skin cancer and are paying more attention to the skin. All we really want them to do is really look at the skin while they’re doing a physical examination," he said.

He has also been encouraging internists and family physicians to take advantage of opportunistic skin screening situations. For example, when they’re listening to the lungs and heart with a stethoscope, he urges primary care physicians to have patients take their shirt off so they can take a close look at the truncal skin rather than simply slip the bell of the scope underneath the shirt.

Another potentially fruitful means of improving upon the gains achieved in early detection of skin cancer would be targeted screening of older men, a high-risk group for fast-growing nodular melanomas, Dr. Marghoob added.

He reported having no financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – The improvement in melanoma survival over the past 4 decades can be attributed to effective public education campaigns, increased patient awareness, and improved physician skills and diagnostic tools, according to Dr. Ashfaq A. Marghoob.

It has been nothing short of phenomenal, he said, especially considering it can’t be credited to major therapeutic advances because up until a couple years ago there weren’t any.

Bruce Jancin/IMNG Medical Media

Survival at 5 years for all-stage melanomas of the skin climbed from less than 60% in 1970 to 91% in 2011, he said at the Hawaii Dermatology Seminar sponsored by the Skin Disease Education Foundation (SDEF). But while this is a triumph deserving of celebration, the statistics are somewhat deceiving, said Dr. Marghoob, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

He is among a growing number of experts who believe that many thin melanomas detected through screening efforts are slow-growing, indolent skin cancers that sometimes regress and in any event will never become thick or dangerous – never result in death – within the range of current life expectancy. He noted that there is ample precedence, namely, indolent forms of prostate cancer, lymphoma, and breast cancer.

Dr. Marghoob was part of an international team that demonstrated the existence of a slow-growing subtype of melanoma. In a series of 103 melanomas excised after a median follow-up of 20 months, most of the lesions were still in situ or in an early invasive stage. Only three lesions were 1-mm thick or more. There was no correlation between tumor thickness and follow-up time (Br. J. Dermatol. 2010;162:267-73). Growing support exists among epidemiologists for the concept that there are three distinct, unrelated melanoma subtypes (Br. J. Dermatol. 2007;157:338-43). One subtype consists of thin, slow-growing melanomas – the kind that have been steadily increasing in incidence for decades. These are associated with intermittent sun exposure and often arise on the trunk among numerous background nevi. These melanomas are amenable to detection via screening or periodic surveillance. But they only rarely metastasize.

A second type of slow-growing melanoma often occurs on the head and neck of individuals with continuous sun exposure. The incidence of this subtype of melanoma is slowly increasing.

The third and most concerning melanoma subtype consists of thick, fast-growing lesions occurring in individuals with many nevi, but that are not associated with sun exposure. The incidence of these fast-growing, high-lethality melanomas has remained steady over time because they often escape detection as a result of their accelerated growth rate. Improved early detection is a high priority, and it will require creative new approaches, he said.

But in terms of celebrating rising 5-year melanoma survival rates, a contributory landmark event, in Dr. Marghoob’s view, was the increased awareness about melanoma after introduction of the ABCD mnemonic, devised chiefly for primary care physicians and the general public. This was later enhanced by the "ugly duckling" campaign, which taught physicians and patients that melanomas are generally recognizable as outlier lesions.

Multiple studies have shown that skin cancer specialists using visual examination alone – incorporating the ABCDs and ugly duckling concept – can typically diagnose melanoma with a sensitivity of 70% and specificity of 75%. The number needed to treat (NNT) or benign-to-malignant biopsy ratio is 1:12-15.

With the aid of total body photography for assistance in patient follow-up, the NNT improves to 10.

Dermoscopy has been another important advance. It enables physicians to pick up melanomas not detectable by any other method. Skin cancer specialists who supplement visual examination with dermoscopy typically have 90% sensitivity and 86% specificity for the diagnosis of melanoma. The NNT improves to 4-7, Dr. Marghoob continued.

Recent studies indicate these numbers get even better with the use of confocal microscopy during skin examination.

Using a review of his own practice to illustrate the strong trend for improved diagnosis, Dr. Marghoob noted that in 1998 his NNT was 12.5. He adopted dermoscopy in 1999, and in 2000, when he was using dermoscopy routinely, his NNT improved to 7. During both 2006 and 2007 it was 3, he said.

"We have gotten better at diagnosing melanoma and we will continue to improve," he concluded.

He reported having no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – The improvement in melanoma survival over the past 4 decades can be attributed to effective public education campaigns, increased patient awareness, and improved physician skills and diagnostic tools, according to Dr. Ashfaq A. Marghoob.

It has been nothing short of phenomenal, he said, especially considering it can’t be credited to major therapeutic advances because up until a couple years ago there weren’t any.

Bruce Jancin/IMNG Medical Media

Survival at 5 years for all-stage melanomas of the skin climbed from less than 60% in 1970 to 91% in 2011, he said at the Hawaii Dermatology Seminar sponsored by the Skin Disease Education Foundation (SDEF). But while this is a triumph deserving of celebration, the statistics are somewhat deceiving, said Dr. Marghoob, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

He is among a growing number of experts who believe that many thin melanomas detected through screening efforts are slow-growing, indolent skin cancers that sometimes regress and in any event will never become thick or dangerous – never result in death – within the range of current life expectancy. He noted that there is ample precedence, namely, indolent forms of prostate cancer, lymphoma, and breast cancer.

Dr. Marghoob was part of an international team that demonstrated the existence of a slow-growing subtype of melanoma. In a series of 103 melanomas excised after a median follow-up of 20 months, most of the lesions were still in situ or in an early invasive stage. Only three lesions were 1-mm thick or more. There was no correlation between tumor thickness and follow-up time (Br. J. Dermatol. 2010;162:267-73). Growing support exists among epidemiologists for the concept that there are three distinct, unrelated melanoma subtypes (Br. J. Dermatol. 2007;157:338-43). One subtype consists of thin, slow-growing melanomas – the kind that have been steadily increasing in incidence for decades. These are associated with intermittent sun exposure and often arise on the trunk among numerous background nevi. These melanomas are amenable to detection via screening or periodic surveillance. But they only rarely metastasize.

A second type of slow-growing melanoma often occurs on the head and neck of individuals with continuous sun exposure. The incidence of this subtype of melanoma is slowly increasing.

The third and most concerning melanoma subtype consists of thick, fast-growing lesions occurring in individuals with many nevi, but that are not associated with sun exposure. The incidence of these fast-growing, high-lethality melanomas has remained steady over time because they often escape detection as a result of their accelerated growth rate. Improved early detection is a high priority, and it will require creative new approaches, he said.

But in terms of celebrating rising 5-year melanoma survival rates, a contributory landmark event, in Dr. Marghoob’s view, was the increased awareness about melanoma after introduction of the ABCD mnemonic, devised chiefly for primary care physicians and the general public. This was later enhanced by the "ugly duckling" campaign, which taught physicians and patients that melanomas are generally recognizable as outlier lesions.

Multiple studies have shown that skin cancer specialists using visual examination alone – incorporating the ABCDs and ugly duckling concept – can typically diagnose melanoma with a sensitivity of 70% and specificity of 75%. The number needed to treat (NNT) or benign-to-malignant biopsy ratio is 1:12-15.

With the aid of total body photography for assistance in patient follow-up, the NNT improves to 10.

Dermoscopy has been another important advance. It enables physicians to pick up melanomas not detectable by any other method. Skin cancer specialists who supplement visual examination with dermoscopy typically have 90% sensitivity and 86% specificity for the diagnosis of melanoma. The NNT improves to 4-7, Dr. Marghoob continued.

Recent studies indicate these numbers get even better with the use of confocal microscopy during skin examination.

Using a review of his own practice to illustrate the strong trend for improved diagnosis, Dr. Marghoob noted that in 1998 his NNT was 12.5. He adopted dermoscopy in 1999, and in 2000, when he was using dermoscopy routinely, his NNT improved to 7. During both 2006 and 2007 it was 3, he said.

"We have gotten better at diagnosing melanoma and we will continue to improve," he concluded.

He reported having no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – The improvement in melanoma survival over the past 4 decades can be attributed to effective public education campaigns, increased patient awareness, and improved physician skills and diagnostic tools, according to Dr. Ashfaq A. Marghoob.

It has been nothing short of phenomenal, he said, especially considering it can’t be credited to major therapeutic advances because up until a couple years ago there weren’t any.

Bruce Jancin/IMNG Medical Media

Survival at 5 years for all-stage melanomas of the skin climbed from less than 60% in 1970 to 91% in 2011, he said at the Hawaii Dermatology Seminar sponsored by the Skin Disease Education Foundation (SDEF). But while this is a triumph deserving of celebration, the statistics are somewhat deceiving, said Dr. Marghoob, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

He is among a growing number of experts who believe that many thin melanomas detected through screening efforts are slow-growing, indolent skin cancers that sometimes regress and in any event will never become thick or dangerous – never result in death – within the range of current life expectancy. He noted that there is ample precedence, namely, indolent forms of prostate cancer, lymphoma, and breast cancer.

Dr. Marghoob was part of an international team that demonstrated the existence of a slow-growing subtype of melanoma. In a series of 103 melanomas excised after a median follow-up of 20 months, most of the lesions were still in situ or in an early invasive stage. Only three lesions were 1-mm thick or more. There was no correlation between tumor thickness and follow-up time (Br. J. Dermatol. 2010;162:267-73). Growing support exists among epidemiologists for the concept that there are three distinct, unrelated melanoma subtypes (Br. J. Dermatol. 2007;157:338-43). One subtype consists of thin, slow-growing melanomas – the kind that have been steadily increasing in incidence for decades. These are associated with intermittent sun exposure and often arise on the trunk among numerous background nevi. These melanomas are amenable to detection via screening or periodic surveillance. But they only rarely metastasize.

A second type of slow-growing melanoma often occurs on the head and neck of individuals with continuous sun exposure. The incidence of this subtype of melanoma is slowly increasing.

The third and most concerning melanoma subtype consists of thick, fast-growing lesions occurring in individuals with many nevi, but that are not associated with sun exposure. The incidence of these fast-growing, high-lethality melanomas has remained steady over time because they often escape detection as a result of their accelerated growth rate. Improved early detection is a high priority, and it will require creative new approaches, he said.

But in terms of celebrating rising 5-year melanoma survival rates, a contributory landmark event, in Dr. Marghoob’s view, was the increased awareness about melanoma after introduction of the ABCD mnemonic, devised chiefly for primary care physicians and the general public. This was later enhanced by the "ugly duckling" campaign, which taught physicians and patients that melanomas are generally recognizable as outlier lesions.

Multiple studies have shown that skin cancer specialists using visual examination alone – incorporating the ABCDs and ugly duckling concept – can typically diagnose melanoma with a sensitivity of 70% and specificity of 75%. The number needed to treat (NNT) or benign-to-malignant biopsy ratio is 1:12-15.

With the aid of total body photography for assistance in patient follow-up, the NNT improves to 10.

Dermoscopy has been another important advance. It enables physicians to pick up melanomas not detectable by any other method. Skin cancer specialists who supplement visual examination with dermoscopy typically have 90% sensitivity and 86% specificity for the diagnosis of melanoma. The NNT improves to 4-7, Dr. Marghoob continued.

Recent studies indicate these numbers get even better with the use of confocal microscopy during skin examination.

Using a review of his own practice to illustrate the strong trend for improved diagnosis, Dr. Marghoob noted that in 1998 his NNT was 12.5. He adopted dermoscopy in 1999, and in 2000, when he was using dermoscopy routinely, his NNT improved to 7. During both 2006 and 2007 it was 3, he said.

"We have gotten better at diagnosing melanoma and we will continue to improve," he concluded.

He reported having no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – An organized program of population-based total body skin examination screening for skin cancer has been shown to significantly reduce melanoma mortality.

"This is quite astounding. It is very impressive to see that a total body skin exam can reduce mortality. It forces us all to think about whether we should do this in a very, very large population, as we now do in Germany," said Dr. Andreas Blum, professor of dermatology at the University of Tübingen (Germany).

He presented highlights of the SCREEN (Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany) project, in which all residents of the state of Schleswig-Holstein were eligible for a standardized total body skin exam during a 1-year study period. This was to date the world’s largest systematic population-based skin cancer screening program, he said.

Nineteen percent of the Schleswig-Holstein adult population – more than 360,000 citizens – participated. A total of 3,103 skin cancers were found, including 585 melanomas, for a rate of 1.6 melanomas per 1,000 persons screened. Basal cell carcinomas were detected at a rate of 5.4 malignancies per 1,000, and squamous cell carcinomas at 1.1 per 1,000 people screened. Five lesion excisions had to be performed to detect one malignancy.

Using the incidence of melanoma in Schleswig-Holstein during the 2 years prior to the SCREEN project as a baseline, the incidence of melanoma during the SCREEN project increased by 16% in men and by 38% in women.

The key study finding was a significant decrease in melanoma mortality documented 5 years after SCREEN ended. The observed melanoma mortality rate in men was 0.79 per 100,000 population, compared with an expected 2.0 per 100,000. Among women, the observed mortality was 0.66 per 100,000, compared with an expected 1.3 per 100,000. Thus, the observed mortality because of earlier detection of melanoma in the screened area was less than 50% of expected, Dr. Blum said at the Hawaii Dermatology Seminar sponsored by the Skin Disease Education Foundation (SDEF).

The screening project had a two-tiered structure. Most participants were first screened by a primary care physician or other nondermatologist. In the event of suspicious findings and/or skin cancer risk factors, the participant was referred to a dermatologist who performed the biopsies. All participating physicians first had to attend an 8-hour training course. Of note, 116 of the 118 dermatologists in Schleswig-Holstein participated in SCREEN, as did nearly two-thirds of eligible nondermatologists (J. Am. Acad. Dermatol. 2012;66:201-11).

Following up on the unprecedented success of the SCREEN project, German dermatologists next proposed a randomized controlled trial in order to provide the highest-level evidence that mass skin cancer screening reduces melanoma mortality. However, government health officials found SCREEN persuasive and nixed the idea of a large and costly randomized trial. Instead, Germany has launched a national skin cancer screening program, according to Dr. Blum. All 45 million Germans aged 35 years and older are now eligible to be screened for skin cancer once every 2 years; whether the health care system can cope with the demand remains to be seen.

Another recent project evaluating the benefits of total body skin examination for skin cancer screening also reported favorable results, he noted.

Investigators in a multicenter study screened more than 14,000 patients with a total body skin exam. Participants were consecutive adults presenting with a localized dermatologic problem, such as a skin infection, that wouldn’t ordinarily result in a total body skin exam. The total body skin exams detected 40 patients (0.3%) with melanoma. Five benign lesions were excised for each melanoma detected. Another 2.1% of patients had at least one nonmelanoma skin cancer detected by total body skin exam. On average, 400 patients had to be examined by total body skin exam in order to find 1 melanoma (J. Am. Acad. Dermatol. 2012;66:212-9).

"I see around 150 new patients per week, so that means every third week I see a new melanoma," Dr. Blum said.

Total body skin examination has long been a controversial issue. The U.S. Preventive Services Task Force found insufficient evidence to recommend screening adults for skin cancer (Ann. Intern. Med. 2009;150:188-93). That stance will now need to be revisited in light of these two large projects, said Dr. Blum.

He predicted that the cost involved in routine total body skin examinations is likely to be a critical source of controversy. Using the National Cancer Institute’s estimate that 12.5% of melanomas are fatal, and assuming the cost of a total body skin exam to be $50, he estimated that routine total body skin exams in the SCREEN project cost $240,000 per melanoma death avoided.

In his own specialized skin cancer clinic, where he sees a more select patient population, Dr. Blum estimated that routine total body skin examination costs about $65,000 per melanoma death avoided. And when he plugged in the numbers provided by his colleague Dr. Ashfaq A. Marghoob, pertaining to the skin cancer clinic at Memorial Sloan-Kettering Cancer Center in New York, Dr. Blum once again came up with a figure of roughly $65,000 per melanoma death avoided.

"The range is quite high. I think the cost debate will continue," Dr. Blum predicted.

He reported having no financial conflicts.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – An organized program of population-based total body skin examination screening for skin cancer has been shown to significantly reduce melanoma mortality.

"This is quite astounding. It is very impressive to see that a total body skin exam can reduce mortality. It forces us all to think about whether we should do this in a very, very large population, as we now do in Germany," said Dr. Andreas Blum, professor of dermatology at the University of Tübingen (Germany).

He presented highlights of the SCREEN (Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany) project, in which all residents of the state of Schleswig-Holstein were eligible for a standardized total body skin exam during a 1-year study period. This was to date the world’s largest systematic population-based skin cancer screening program, he said.

Nineteen percent of the Schleswig-Holstein adult population – more than 360,000 citizens – participated. A total of 3,103 skin cancers were found, including 585 melanomas, for a rate of 1.6 melanomas per 1,000 persons screened. Basal cell carcinomas were detected at a rate of 5.4 malignancies per 1,000, and squamous cell carcinomas at 1.1 per 1,000 people screened. Five lesion excisions had to be performed to detect one malignancy.

Using the incidence of melanoma in Schleswig-Holstein during the 2 years prior to the SCREEN project as a baseline, the incidence of melanoma during the SCREEN project increased by 16% in men and by 38% in women.

The key study finding was a significant decrease in melanoma mortality documented 5 years after SCREEN ended. The observed melanoma mortality rate in men was 0.79 per 100,000 population, compared with an expected 2.0 per 100,000. Among women, the observed mortality was 0.66 per 100,000, compared with an expected 1.3 per 100,000. Thus, the observed mortality because of earlier detection of melanoma in the screened area was less than 50% of expected, Dr. Blum said at the Hawaii Dermatology Seminar sponsored by the Skin Disease Education Foundation (SDEF).

The screening project had a two-tiered structure. Most participants were first screened by a primary care physician or other nondermatologist. In the event of suspicious findings and/or skin cancer risk factors, the participant was referred to a dermatologist who performed the biopsies. All participating physicians first had to attend an 8-hour training course. Of note, 116 of the 118 dermatologists in Schleswig-Holstein participated in SCREEN, as did nearly two-thirds of eligible nondermatologists (J. Am. Acad. Dermatol. 2012;66:201-11).

Following up on the unprecedented success of the SCREEN project, German dermatologists next proposed a randomized controlled trial in order to provide the highest-level evidence that mass skin cancer screening reduces melanoma mortality. However, government health officials found SCREEN persuasive and nixed the idea of a large and costly randomized trial. Instead, Germany has launched a national skin cancer screening program, according to Dr. Blum. All 45 million Germans aged 35 years and older are now eligible to be screened for skin cancer once every 2 years; whether the health care system can cope with the demand remains to be seen.

Another recent project evaluating the benefits of total body skin examination for skin cancer screening also reported favorable results, he noted.

Investigators in a multicenter study screened more than 14,000 patients with a total body skin exam. Participants were consecutive adults presenting with a localized dermatologic problem, such as a skin infection, that wouldn’t ordinarily result in a total body skin exam. The total body skin exams detected 40 patients (0.3%) with melanoma. Five benign lesions were excised for each melanoma detected. Another 2.1% of patients had at least one nonmelanoma skin cancer detected by total body skin exam. On average, 400 patients had to be examined by total body skin exam in order to find 1 melanoma (J. Am. Acad. Dermatol. 2012;66:212-9).

"I see around 150 new patients per week, so that means every third week I see a new melanoma," Dr. Blum said.

Total body skin examination has long been a controversial issue. The U.S. Preventive Services Task Force found insufficient evidence to recommend screening adults for skin cancer (Ann. Intern. Med. 2009;150:188-93). That stance will now need to be revisited in light of these two large projects, said Dr. Blum.

He predicted that the cost involved in routine total body skin examinations is likely to be a critical source of controversy. Using the National Cancer Institute’s estimate that 12.5% of melanomas are fatal, and assuming the cost of a total body skin exam to be $50, he estimated that routine total body skin exams in the SCREEN project cost $240,000 per melanoma death avoided.

In his own specialized skin cancer clinic, where he sees a more select patient population, Dr. Blum estimated that routine total body skin examination costs about $65,000 per melanoma death avoided. And when he plugged in the numbers provided by his colleague Dr. Ashfaq A. Marghoob, pertaining to the skin cancer clinic at Memorial Sloan-Kettering Cancer Center in New York, Dr. Blum once again came up with a figure of roughly $65,000 per melanoma death avoided.

"The range is quite high. I think the cost debate will continue," Dr. Blum predicted.

He reported having no financial conflicts.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – An organized program of population-based total body skin examination screening for skin cancer has been shown to significantly reduce melanoma mortality.

"This is quite astounding. It is very impressive to see that a total body skin exam can reduce mortality. It forces us all to think about whether we should do this in a very, very large population, as we now do in Germany," said Dr. Andreas Blum, professor of dermatology at the University of Tübingen (Germany).

He presented highlights of the SCREEN (Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany) project, in which all residents of the state of Schleswig-Holstein were eligible for a standardized total body skin exam during a 1-year study period. This was to date the world’s largest systematic population-based skin cancer screening program, he said.

Nineteen percent of the Schleswig-Holstein adult population – more than 360,000 citizens – participated. A total of 3,103 skin cancers were found, including 585 melanomas, for a rate of 1.6 melanomas per 1,000 persons screened. Basal cell carcinomas were detected at a rate of 5.4 malignancies per 1,000, and squamous cell carcinomas at 1.1 per 1,000 people screened. Five lesion excisions had to be performed to detect one malignancy.

Using the incidence of melanoma in Schleswig-Holstein during the 2 years prior to the SCREEN project as a baseline, the incidence of melanoma during the SCREEN project increased by 16% in men and by 38% in women.

The key study finding was a significant decrease in melanoma mortality documented 5 years after SCREEN ended. The observed melanoma mortality rate in men was 0.79 per 100,000 population, compared with an expected 2.0 per 100,000. Among women, the observed mortality was 0.66 per 100,000, compared with an expected 1.3 per 100,000. Thus, the observed mortality because of earlier detection of melanoma in the screened area was less than 50% of expected, Dr. Blum said at the Hawaii Dermatology Seminar sponsored by the Skin Disease Education Foundation (SDEF).

The screening project had a two-tiered structure. Most participants were first screened by a primary care physician or other nondermatologist. In the event of suspicious findings and/or skin cancer risk factors, the participant was referred to a dermatologist who performed the biopsies. All participating physicians first had to attend an 8-hour training course. Of note, 116 of the 118 dermatologists in Schleswig-Holstein participated in SCREEN, as did nearly two-thirds of eligible nondermatologists (J. Am. Acad. Dermatol. 2012;66:201-11).

Following up on the unprecedented success of the SCREEN project, German dermatologists next proposed a randomized controlled trial in order to provide the highest-level evidence that mass skin cancer screening reduces melanoma mortality. However, government health officials found SCREEN persuasive and nixed the idea of a large and costly randomized trial. Instead, Germany has launched a national skin cancer screening program, according to Dr. Blum. All 45 million Germans aged 35 years and older are now eligible to be screened for skin cancer once every 2 years; whether the health care system can cope with the demand remains to be seen.

Another recent project evaluating the benefits of total body skin examination for skin cancer screening also reported favorable results, he noted.

Investigators in a multicenter study screened more than 14,000 patients with a total body skin exam. Participants were consecutive adults presenting with a localized dermatologic problem, such as a skin infection, that wouldn’t ordinarily result in a total body skin exam. The total body skin exams detected 40 patients (0.3%) with melanoma. Five benign lesions were excised for each melanoma detected. Another 2.1% of patients had at least one nonmelanoma skin cancer detected by total body skin exam. On average, 400 patients had to be examined by total body skin exam in order to find 1 melanoma (J. Am. Acad. Dermatol. 2012;66:212-9).

"I see around 150 new patients per week, so that means every third week I see a new melanoma," Dr. Blum said.

Total body skin examination has long been a controversial issue. The U.S. Preventive Services Task Force found insufficient evidence to recommend screening adults for skin cancer (Ann. Intern. Med. 2009;150:188-93). That stance will now need to be revisited in light of these two large projects, said Dr. Blum.

He predicted that the cost involved in routine total body skin examinations is likely to be a critical source of controversy. Using the National Cancer Institute’s estimate that 12.5% of melanomas are fatal, and assuming the cost of a total body skin exam to be $50, he estimated that routine total body skin exams in the SCREEN project cost $240,000 per melanoma death avoided.

In his own specialized skin cancer clinic, where he sees a more select patient population, Dr. Blum estimated that routine total body skin examination costs about $65,000 per melanoma death avoided. And when he plugged in the numbers provided by his colleague Dr. Ashfaq A. Marghoob, pertaining to the skin cancer clinic at Memorial Sloan-Kettering Cancer Center in New York, Dr. Blum once again came up with a figure of roughly $65,000 per melanoma death avoided.

"The range is quite high. I think the cost debate will continue," Dr. Blum predicted.

He reported having no financial conflicts.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Look for a major cut in reimbursement for the treatment of actinic keratoses when the matter comes up for review by the American Medical Association Relative Value Scale Update Committee in January, according to Dr. Brett M. Coldiron.

"It’s going to be bad, bad. The best-case scenario our team has worked out is a 25% cut," Dr. Coldiron said at the Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF).

Bruce Jancin/IMNG Medical Media

It’s entirely possible that the committee will instead recommend closer to a 50% slash in its report to the Center for Medicare and Medicaid Services, added Dr. Coldiron, who has represented dermatology on the Relative Value Scale Update Committee (RUC) or served in an advisory capacity for the past 19 years.

"That first AK relative value rating was based on numbing [the AK], curetting it twice, electrodesiccation, and [the rating estimated] 47 minutes of nursing time. It’s an extraordinary rating ... [times have changed], and now it’s finally up for review," explained Dr. Coldiron, president of the American College of Mohs Surgery and a 2013 member of the board of directors for the American Academy of Dermatology.

Dermatologists perform 86% of all AK treatments in the United States. And the number of procedures in which they bill Medicare for treating 15 or more AKs jumped by 185% from 1995 to 2006, to nearly 734,000 procedures per year.

Meanwhile, the number of Mohs surgery procedures billed to Medicare has increased by a whopping 400%, skin biopsies by dermatologists have increased by 82%, destructions by 68%, and excisions by 22%.

"Those are extraordinary increases, and you have to realize that they’re underestimates because they don’t include billing under Medicare private plans, which take up about 20% of Medicare dollars," he said.

All the Mohs surgery–related codes will come up for RUC review in April 2013. Dr. Coldiron anticipates reimbursement to be cut by about 20%.

He provided the audience with a colorful behind-the-scenes account of the RUC review process.

"The RUC is the Super Bowl of AMA committees, where everybody sits around a table and tries to strip money away from another specialty," he explained. "The RUC is 26 sharks in a tank with nothing to eat but each other. And we’re a small specialty with a ‘Bite Me’ sign on us. We’re less than 1% of all physicians. We have a seat on RUC because we were there from the beginning. But we have many specialty-specific codes which they can target, and we have rapidly increasing utilization."

What’s it like to stand up for dermatology at a RUC review before adversaries representing 25 other medical specialties? "I present the codes and they shoot questions; they just pound on you, sometimes for days. It’s very uncomfortable. They try to figure out what a code is really worth. It’s not much fun at all," said Dr. Coldiron, a dermatologist at the University of Cincinnati.

This intense battle is fueled by jealousy on the part of other specialties, he said. "Dermatology has done better than anybody else in RUC during the past 20 years. Our share of the Medicare pie has gone from about 2% to 3% of the whole Medicare pool, and they’re all aware of this."

He suspects many of his fellow dermatologists will respond to the coming cut in payment for AK therapy by saying, "Well, I used to bill for 10 AKs when I did 15, now I’m going to bill for all 15 of them." That’s a bad idea, in his view. If utilization suddenly shoots up, reimbursement will simply get cut again. And sharp increases in utilization will attract unwanted attention from the Recovery Audit Contractors (RACs). On a contingency basis, Medicare pays RACS 9%-13% of the money recovered through RAC audits for inappropriate billing.

The anticipated cuts in reimbursement for codes covering AK therapy, Mohs surgery, and medical pathology represent a particularly serious threat to academic dermatology, since most departments derive a substantial portion of their funding from those clinical services. Moreover, academic dermatologists have already been hit harder than others by the loss of consultation codes in the Medicare fee schedule, which translates to an estimated $7,000 per year in lost income for most.

The RUC cuts in reimbursement for AK treatment and Mohs surgery will hurt. But they are by no means the biggest threat facing dermatology, in Dr. Coldiron’s view. That distinction belongs to the Independent Payment Advisory Panel (IPAP) empowered by the Patient Protection and Affordable Care Act. The panel’s job will be to identify overused, overpaid, or useless services and cut Medicare payment rates for providers of those services. Their decisions cannot be reversed except by a two-thirds majority of Congress.

"This is serious for us and all small specialties because anything could happen. Why cover Mohs surgery at all? After all, it’s not covered in Great Britain or France, and they’ve got pretty good health care. Why cover acne – isn’t that cosmetic? Why pay pathologists for seborrheic keratoses? There are all kinds of possibilities here that we need to be prepared for," he cautioned.

He predicted that dermatology and other small specialties will get hit first and hardest by health care cost containment efforts. The RUC doesn’t like dermatology. Nor do Medicare officials and some key members of Congress. Neither does the Medicare Payment Advisory Commission (MedPAC), an independent federal body created to help Congress address complicated health policy issues.

"MedPAC likes primary care. They’re getting a bad attitude after 19 years of no increase for primary care. They want all procedure-oriented specialists to be paid the same as the cognitives," Dr. Coldiron said.

He added that fundamental misconceptions regarding dermatology abound. "They think that what dermatologists do is not important, that it’s cosmetic. And that our increase in Relative Value Units is due to waste, abuse, and minor procedure codes that pay too much. If dermatology disappeared there would be few tears shed," according to Dr. Coldiron.

These critics focus on the fact that dermatology, having reinvented itself as a skin surgical specialty, has become the most procedurally oriented of all specialties. Indeed, in the Medicare database, 73% of dermatologists’ income comes from procedures; ophthalmology is a distant second at 56%.

Dermatology’s critics are unwilling to recognize that the main reason for the big jump in dermatologic procedures during the last 2 decades is the ongoing skin cancer epidemic, Dr. Coldiron continued. He was a coinvestigator in a major study that documented a 75% jump in the age-adjusted rate of skin cancer procedures in the Medicare fee-for-service population between 1992 and 2006 (Arch. Dermatol. 2010;146:283-7).

By 2008, the estimated annual incidence of nonmelanoma skin cancer in the United States stood at nearly 3.7 million cases, far higher than previously recognized (Semin. Cutan. Med. Surg. 2011;30:3-5). Today the incidence is close to 4 million cases per year, he added.

"That’s the result of a lot of baby boomers lying out in the sun. The problem is that the government doesn’t want to pay for it. They would rather pretend it doesn’t exist," Dr. Coldiron concluded.

He reported having no financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Look for a major cut in reimbursement for the treatment of actinic keratoses when the matter comes up for review by the American Medical Association Relative Value Scale Update Committee in January, according to Dr. Brett M. Coldiron.

"It’s going to be bad, bad. The best-case scenario our team has worked out is a 25% cut," Dr. Coldiron said at the Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF).

Bruce Jancin/IMNG Medical Media

It’s entirely possible that the committee will instead recommend closer to a 50% slash in its report to the Center for Medicare and Medicaid Services, added Dr. Coldiron, who has represented dermatology on the Relative Value Scale Update Committee (RUC) or served in an advisory capacity for the past 19 years.

"That first AK relative value rating was based on numbing [the AK], curetting it twice, electrodesiccation, and [the rating estimated] 47 minutes of nursing time. It’s an extraordinary rating ... [times have changed], and now it’s finally up for review," explained Dr. Coldiron, president of the American College of Mohs Surgery and a 2013 member of the board of directors for the American Academy of Dermatology.

Dermatologists perform 86% of all AK treatments in the United States. And the number of procedures in which they bill Medicare for treating 15 or more AKs jumped by 185% from 1995 to 2006, to nearly 734,000 procedures per year.

Meanwhile, the number of Mohs surgery procedures billed to Medicare has increased by a whopping 400%, skin biopsies by dermatologists have increased by 82%, destructions by 68%, and excisions by 22%.

"Those are extraordinary increases, and you have to realize that they’re underestimates because they don’t include billing under Medicare private plans, which take up about 20% of Medicare dollars," he said.

All the Mohs surgery–related codes will come up for RUC review in April 2013. Dr. Coldiron anticipates reimbursement to be cut by about 20%.

He provided the audience with a colorful behind-the-scenes account of the RUC review process.

"The RUC is the Super Bowl of AMA committees, where everybody sits around a table and tries to strip money away from another specialty," he explained. "The RUC is 26 sharks in a tank with nothing to eat but each other. And we’re a small specialty with a ‘Bite Me’ sign on us. We’re less than 1% of all physicians. We have a seat on RUC because we were there from the beginning. But we have many specialty-specific codes which they can target, and we have rapidly increasing utilization."

What’s it like to stand up for dermatology at a RUC review before adversaries representing 25 other medical specialties? "I present the codes and they shoot questions; they just pound on you, sometimes for days. It’s very uncomfortable. They try to figure out what a code is really worth. It’s not much fun at all," said Dr. Coldiron, a dermatologist at the University of Cincinnati.

This intense battle is fueled by jealousy on the part of other specialties, he said. "Dermatology has done better than anybody else in RUC during the past 20 years. Our share of the Medicare pie has gone from about 2% to 3% of the whole Medicare pool, and they’re all aware of this."

He suspects many of his fellow dermatologists will respond to the coming cut in payment for AK therapy by saying, "Well, I used to bill for 10 AKs when I did 15, now I’m going to bill for all 15 of them." That’s a bad idea, in his view. If utilization suddenly shoots up, reimbursement will simply get cut again. And sharp increases in utilization will attract unwanted attention from the Recovery Audit Contractors (RACs). On a contingency basis, Medicare pays RACS 9%-13% of the money recovered through RAC audits for inappropriate billing.

The anticipated cuts in reimbursement for codes covering AK therapy, Mohs surgery, and medical pathology represent a particularly serious threat to academic dermatology, since most departments derive a substantial portion of their funding from those clinical services. Moreover, academic dermatologists have already been hit harder than others by the loss of consultation codes in the Medicare fee schedule, which translates to an estimated $7,000 per year in lost income for most.

The RUC cuts in reimbursement for AK treatment and Mohs surgery will hurt. But they are by no means the biggest threat facing dermatology, in Dr. Coldiron’s view. That distinction belongs to the Independent Payment Advisory Panel (IPAP) empowered by the Patient Protection and Affordable Care Act. The panel’s job will be to identify overused, overpaid, or useless services and cut Medicare payment rates for providers of those services. Their decisions cannot be reversed except by a two-thirds majority of Congress.

"This is serious for us and all small specialties because anything could happen. Why cover Mohs surgery at all? After all, it’s not covered in Great Britain or France, and they’ve got pretty good health care. Why cover acne – isn’t that cosmetic? Why pay pathologists for seborrheic keratoses? There are all kinds of possibilities here that we need to be prepared for," he cautioned.

He predicted that dermatology and other small specialties will get hit first and hardest by health care cost containment efforts. The RUC doesn’t like dermatology. Nor do Medicare officials and some key members of Congress. Neither does the Medicare Payment Advisory Commission (MedPAC), an independent federal body created to help Congress address complicated health policy issues.

"MedPAC likes primary care. They’re getting a bad attitude after 19 years of no increase for primary care. They want all procedure-oriented specialists to be paid the same as the cognitives," Dr. Coldiron said.

He added that fundamental misconceptions regarding dermatology abound. "They think that what dermatologists do is not important, that it’s cosmetic. And that our increase in Relative Value Units is due to waste, abuse, and minor procedure codes that pay too much. If dermatology disappeared there would be few tears shed," according to Dr. Coldiron.

These critics focus on the fact that dermatology, having reinvented itself as a skin surgical specialty, has become the most procedurally oriented of all specialties. Indeed, in the Medicare database, 73% of dermatologists’ income comes from procedures; ophthalmology is a distant second at 56%.

Dermatology’s critics are unwilling to recognize that the main reason for the big jump in dermatologic procedures during the last 2 decades is the ongoing skin cancer epidemic, Dr. Coldiron continued. He was a coinvestigator in a major study that documented a 75% jump in the age-adjusted rate of skin cancer procedures in the Medicare fee-for-service population between 1992 and 2006 (Arch. Dermatol. 2010;146:283-7).

By 2008, the estimated annual incidence of nonmelanoma skin cancer in the United States stood at nearly 3.7 million cases, far higher than previously recognized (Semin. Cutan. Med. Surg. 2011;30:3-5). Today the incidence is close to 4 million cases per year, he added.

"That’s the result of a lot of baby boomers lying out in the sun. The problem is that the government doesn’t want to pay for it. They would rather pretend it doesn’t exist," Dr. Coldiron concluded.

He reported having no financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Look for a major cut in reimbursement for the treatment of actinic keratoses when the matter comes up for review by the American Medical Association Relative Value Scale Update Committee in January, according to Dr. Brett M. Coldiron.

"It’s going to be bad, bad. The best-case scenario our team has worked out is a 25% cut," Dr. Coldiron said at the Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF).

Bruce Jancin/IMNG Medical Media

It’s entirely possible that the committee will instead recommend closer to a 50% slash in its report to the Center for Medicare and Medicaid Services, added Dr. Coldiron, who has represented dermatology on the Relative Value Scale Update Committee (RUC) or served in an advisory capacity for the past 19 years.

"That first AK relative value rating was based on numbing [the AK], curetting it twice, electrodesiccation, and [the rating estimated] 47 minutes of nursing time. It’s an extraordinary rating ... [times have changed], and now it’s finally up for review," explained Dr. Coldiron, president of the American College of Mohs Surgery and a 2013 member of the board of directors for the American Academy of Dermatology.

Dermatologists perform 86% of all AK treatments in the United States. And the number of procedures in which they bill Medicare for treating 15 or more AKs jumped by 185% from 1995 to 2006, to nearly 734,000 procedures per year.

Meanwhile, the number of Mohs surgery procedures billed to Medicare has increased by a whopping 400%, skin biopsies by dermatologists have increased by 82%, destructions by 68%, and excisions by 22%.

"Those are extraordinary increases, and you have to realize that they’re underestimates because they don’t include billing under Medicare private plans, which take up about 20% of Medicare dollars," he said.

All the Mohs surgery–related codes will come up for RUC review in April 2013. Dr. Coldiron anticipates reimbursement to be cut by about 20%.

He provided the audience with a colorful behind-the-scenes account of the RUC review process.

"The RUC is the Super Bowl of AMA committees, where everybody sits around a table and tries to strip money away from another specialty," he explained. "The RUC is 26 sharks in a tank with nothing to eat but each other. And we’re a small specialty with a ‘Bite Me’ sign on us. We’re less than 1% of all physicians. We have a seat on RUC because we were there from the beginning. But we have many specialty-specific codes which they can target, and we have rapidly increasing utilization."

What’s it like to stand up for dermatology at a RUC review before adversaries representing 25 other medical specialties? "I present the codes and they shoot questions; they just pound on you, sometimes for days. It’s very uncomfortable. They try to figure out what a code is really worth. It’s not much fun at all," said Dr. Coldiron, a dermatologist at the University of Cincinnati.

This intense battle is fueled by jealousy on the part of other specialties, he said. "Dermatology has done better than anybody else in RUC during the past 20 years. Our share of the Medicare pie has gone from about 2% to 3% of the whole Medicare pool, and they’re all aware of this."

He suspects many of his fellow dermatologists will respond to the coming cut in payment for AK therapy by saying, "Well, I used to bill for 10 AKs when I did 15, now I’m going to bill for all 15 of them." That’s a bad idea, in his view. If utilization suddenly shoots up, reimbursement will simply get cut again. And sharp increases in utilization will attract unwanted attention from the Recovery Audit Contractors (RACs). On a contingency basis, Medicare pays RACS 9%-13% of the money recovered through RAC audits for inappropriate billing.

The anticipated cuts in reimbursement for codes covering AK therapy, Mohs surgery, and medical pathology represent a particularly serious threat to academic dermatology, since most departments derive a substantial portion of their funding from those clinical services. Moreover, academic dermatologists have already been hit harder than others by the loss of consultation codes in the Medicare fee schedule, which translates to an estimated $7,000 per year in lost income for most.

The RUC cuts in reimbursement for AK treatment and Mohs surgery will hurt. But they are by no means the biggest threat facing dermatology, in Dr. Coldiron’s view. That distinction belongs to the Independent Payment Advisory Panel (IPAP) empowered by the Patient Protection and Affordable Care Act. The panel’s job will be to identify overused, overpaid, or useless services and cut Medicare payment rates for providers of those services. Their decisions cannot be reversed except by a two-thirds majority of Congress.

"This is serious for us and all small specialties because anything could happen. Why cover Mohs surgery at all? After all, it’s not covered in Great Britain or France, and they’ve got pretty good health care. Why cover acne – isn’t that cosmetic? Why pay pathologists for seborrheic keratoses? There are all kinds of possibilities here that we need to be prepared for," he cautioned.

He predicted that dermatology and other small specialties will get hit first and hardest by health care cost containment efforts. The RUC doesn’t like dermatology. Nor do Medicare officials and some key members of Congress. Neither does the Medicare Payment Advisory Commission (MedPAC), an independent federal body created to help Congress address complicated health policy issues.

"MedPAC likes primary care. They’re getting a bad attitude after 19 years of no increase for primary care. They want all procedure-oriented specialists to be paid the same as the cognitives," Dr. Coldiron said.

He added that fundamental misconceptions regarding dermatology abound. "They think that what dermatologists do is not important, that it’s cosmetic. And that our increase in Relative Value Units is due to waste, abuse, and minor procedure codes that pay too much. If dermatology disappeared there would be few tears shed," according to Dr. Coldiron.

These critics focus on the fact that dermatology, having reinvented itself as a skin surgical specialty, has become the most procedurally oriented of all specialties. Indeed, in the Medicare database, 73% of dermatologists’ income comes from procedures; ophthalmology is a distant second at 56%.

Dermatology’s critics are unwilling to recognize that the main reason for the big jump in dermatologic procedures during the last 2 decades is the ongoing skin cancer epidemic, Dr. Coldiron continued. He was a coinvestigator in a major study that documented a 75% jump in the age-adjusted rate of skin cancer procedures in the Medicare fee-for-service population between 1992 and 2006 (Arch. Dermatol. 2010;146:283-7).

By 2008, the estimated annual incidence of nonmelanoma skin cancer in the United States stood at nearly 3.7 million cases, far higher than previously recognized (Semin. Cutan. Med. Surg. 2011;30:3-5). Today the incidence is close to 4 million cases per year, he added.

"That’s the result of a lot of baby boomers lying out in the sun. The problem is that the government doesn’t want to pay for it. They would rather pretend it doesn’t exist," Dr. Coldiron concluded.

He reported having no financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Dr. Brett M. Coldiron is a sort of latter-day Paul Revere, travelling far and wide to spread the alarm to his fellow dermatologists – not of Redcoats a’coming, but of the need to prepare for looming economic hard times.

"I wasn’t invited to speak at your meeting, so I invited myself," he declared by way of introduction at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF), as he launched into an analysis of dermatology’s near-term financial future.

"I’m here to present your 5-year economic plan – what you can expect. I think you can plan your next 5 years based on these predictions. It’s not pretty; and it’s not kind," cautioned Dr. Coldiron, whose expertise regarding health care policy and reform has been forged through long-term involvement representing dermatology on the American Medical Association’s Relative Value Scale Update, Health Care Finance, and Government Health Care Policy committees.

His core message to his colleagues boiled down to this: "Don’t build palaces. It’s time to hunker down."

Dermatology is a heavily procedurally oriented, small specialty – less then 1% of all physicians – which has experienced dramatic growth in procedure volume over the past couple decades. As such, it is a high-priority target for congressional cost-cutting efforts. In the first 4 months of next year, Dr. Coldiron said he expects reimbursement for codes pertaining to actinic keratosis treatment to be cut by 25%-50%, along with a roughly 20% reduction in payment for Mohs surgery. And that’s just the beginning.

Dermatology and other small specialties will bear the brunt of any cost-savings attempts by Congress. Dermatology has powerful enemies in Congress, the Centers for Medicare and Medicaid Services, and the American Medical Association, who view dermatologists as overpaid, wasteful abusers of the system, explained Dr. Coldiron, who is president of the American College of Mohs Surgery and a 2013 member of the American Academy of Dermatology’s board of directors.

Among his predictions for the next 5 years:

• Hospitals and pharmacies, if squeezed too hard, will simply close. Insurers will move into other lines of business coverage. Pharmaceutical companies will reduce their research and development budgets. Thus, reducing physician income will be one of the few politically acceptable health care cost-cutting avenues available.

• There will be more bundling of minor procedures into evaluation and management fees.

• The government will attempt to force all physicians to accept Medicaid. "They’ll probably try to tie it to your acceptance of Medicare. Or maybe they’ll say, ‘We paid for 4 years of postgraduate education; now you owe us 4 years of taking Medicaid,’ " he said.

• The use of physician assistants and nurse practitioners will grow in dermatology. This will result in increased utilization and more intense billing audits along with reimbursement cuts aimed at cancelling out the economic impact of greater utilization.

• Cosmetic procedures and reconstructive surgery will remain safe havens. "They may try to pass a cosmetic procedure tax, but I think the fact that you have another source of income is very important," noted Dr. Coldiron, a dermatologist at the University of Cincinnati.

He recommended that dermatologists temper their income projections for the coming half-decade: "Don’t promise big salaries to new associates, only a percentage of income collected."

Also, read the fine print before jumping on board one of the accountable care organizations that are springing up. "This is government-driven managed care with capitation. What they’re going to do is extract from the specialists and give back to primary care. It’s kind of a loser’s game," he said.

Beyond the next 5 years, however, the outlook for dermatology is bright, Dr. Coldiron stressed.

"Be strong. We are not greedy specialists; we are a frontline specialty fighting an epidemic of skin cancer. We are needed by our patients and by the health care system. The pendulum will eventually swing back our way," he concluded.

Dr. Coldiron reported having no relevant financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Dr. Brett M. Coldiron is a sort of latter-day Paul Revere, travelling far and wide to spread the alarm to his fellow dermatologists – not of Redcoats a’coming, but of the need to prepare for looming economic hard times.

"I wasn’t invited to speak at your meeting, so I invited myself," he declared by way of introduction at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF), as he launched into an analysis of dermatology’s near-term financial future.

"I’m here to present your 5-year economic plan – what you can expect. I think you can plan your next 5 years based on these predictions. It’s not pretty; and it’s not kind," cautioned Dr. Coldiron, whose expertise regarding health care policy and reform has been forged through long-term involvement representing dermatology on the American Medical Association’s Relative Value Scale Update, Health Care Finance, and Government Health Care Policy committees.

His core message to his colleagues boiled down to this: "Don’t build palaces. It’s time to hunker down."

Dermatology is a heavily procedurally oriented, small specialty – less then 1% of all physicians – which has experienced dramatic growth in procedure volume over the past couple decades. As such, it is a high-priority target for congressional cost-cutting efforts. In the first 4 months of next year, Dr. Coldiron said he expects reimbursement for codes pertaining to actinic keratosis treatment to be cut by 25%-50%, along with a roughly 20% reduction in payment for Mohs surgery. And that’s just the beginning.

Dermatology and other small specialties will bear the brunt of any cost-savings attempts by Congress. Dermatology has powerful enemies in Congress, the Centers for Medicare and Medicaid Services, and the American Medical Association, who view dermatologists as overpaid, wasteful abusers of the system, explained Dr. Coldiron, who is president of the American College of Mohs Surgery and a 2013 member of the American Academy of Dermatology’s board of directors.

Among his predictions for the next 5 years:

• Hospitals and pharmacies, if squeezed too hard, will simply close. Insurers will move into other lines of business coverage. Pharmaceutical companies will reduce their research and development budgets. Thus, reducing physician income will be one of the few politically acceptable health care cost-cutting avenues available.

• There will be more bundling of minor procedures into evaluation and management fees.

• The government will attempt to force all physicians to accept Medicaid. "They’ll probably try to tie it to your acceptance of Medicare. Or maybe they’ll say, ‘We paid for 4 years of postgraduate education; now you owe us 4 years of taking Medicaid,’ " he said.

• The use of physician assistants and nurse practitioners will grow in dermatology. This will result in increased utilization and more intense billing audits along with reimbursement cuts aimed at cancelling out the economic impact of greater utilization.

• Cosmetic procedures and reconstructive surgery will remain safe havens. "They may try to pass a cosmetic procedure tax, but I think the fact that you have another source of income is very important," noted Dr. Coldiron, a dermatologist at the University of Cincinnati.

He recommended that dermatologists temper their income projections for the coming half-decade: "Don’t promise big salaries to new associates, only a percentage of income collected."

Also, read the fine print before jumping on board one of the accountable care organizations that are springing up. "This is government-driven managed care with capitation. What they’re going to do is extract from the specialists and give back to primary care. It’s kind of a loser’s game," he said.

Beyond the next 5 years, however, the outlook for dermatology is bright, Dr. Coldiron stressed.

"Be strong. We are not greedy specialists; we are a frontline specialty fighting an epidemic of skin cancer. We are needed by our patients and by the health care system. The pendulum will eventually swing back our way," he concluded.

Dr. Coldiron reported having no relevant financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Dr. Brett M. Coldiron is a sort of latter-day Paul Revere, travelling far and wide to spread the alarm to his fellow dermatologists – not of Redcoats a’coming, but of the need to prepare for looming economic hard times.

"I wasn’t invited to speak at your meeting, so I invited myself," he declared by way of introduction at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF), as he launched into an analysis of dermatology’s near-term financial future.

"I’m here to present your 5-year economic plan – what you can expect. I think you can plan your next 5 years based on these predictions. It’s not pretty; and it’s not kind," cautioned Dr. Coldiron, whose expertise regarding health care policy and reform has been forged through long-term involvement representing dermatology on the American Medical Association’s Relative Value Scale Update, Health Care Finance, and Government Health Care Policy committees.

His core message to his colleagues boiled down to this: "Don’t build palaces. It’s time to hunker down."

Dermatology is a heavily procedurally oriented, small specialty – less then 1% of all physicians – which has experienced dramatic growth in procedure volume over the past couple decades. As such, it is a high-priority target for congressional cost-cutting efforts. In the first 4 months of next year, Dr. Coldiron said he expects reimbursement for codes pertaining to actinic keratosis treatment to be cut by 25%-50%, along with a roughly 20% reduction in payment for Mohs surgery. And that’s just the beginning.

Dermatology and other small specialties will bear the brunt of any cost-savings attempts by Congress. Dermatology has powerful enemies in Congress, the Centers for Medicare and Medicaid Services, and the American Medical Association, who view dermatologists as overpaid, wasteful abusers of the system, explained Dr. Coldiron, who is president of the American College of Mohs Surgery and a 2013 member of the American Academy of Dermatology’s board of directors.

Among his predictions for the next 5 years:

• Hospitals and pharmacies, if squeezed too hard, will simply close. Insurers will move into other lines of business coverage. Pharmaceutical companies will reduce their research and development budgets. Thus, reducing physician income will be one of the few politically acceptable health care cost-cutting avenues available.

• There will be more bundling of minor procedures into evaluation and management fees.

• The government will attempt to force all physicians to accept Medicaid. "They’ll probably try to tie it to your acceptance of Medicare. Or maybe they’ll say, ‘We paid for 4 years of postgraduate education; now you owe us 4 years of taking Medicaid,’ " he said.

• The use of physician assistants and nurse practitioners will grow in dermatology. This will result in increased utilization and more intense billing audits along with reimbursement cuts aimed at cancelling out the economic impact of greater utilization.

• Cosmetic procedures and reconstructive surgery will remain safe havens. "They may try to pass a cosmetic procedure tax, but I think the fact that you have another source of income is very important," noted Dr. Coldiron, a dermatologist at the University of Cincinnati.

He recommended that dermatologists temper their income projections for the coming half-decade: "Don’t promise big salaries to new associates, only a percentage of income collected."

Also, read the fine print before jumping on board one of the accountable care organizations that are springing up. "This is government-driven managed care with capitation. What they’re going to do is extract from the specialists and give back to primary care. It’s kind of a loser’s game," he said.

Beyond the next 5 years, however, the outlook for dermatology is bright, Dr. Coldiron stressed.

"Be strong. We are not greedy specialists; we are a frontline specialty fighting an epidemic of skin cancer. We are needed by our patients and by the health care system. The pendulum will eventually swing back our way," he concluded.

Dr. Coldiron reported having no relevant financial conflicts. SDEF and this news organization are owned by Elsevier.