Opinion: Heresy for dermatologists: An alternative view to mass skin cancer screenings

May 1, 2008

Among the many advantages of being in private practice without ties to any particular establishment is that I can say just about anything without any concern for public ridicule or chastisement (private ridicule continues unabated).

Key Points

Among the many advantages of being in private practice without ties to any particular establishment is that I can say just about anything without any concern for public ridicule or chastisement (private ridicule continues unabated).

Here is my latest heretical notion: Mass skin cancer screenings as promoted by national and local dermatologic societies do little to improve the overall health of communities in which these are conducted.

In the following paragraphs, I will present the theoretical reasons why mass skin cancer screenings could be beneficial and then discuss an alternate point of view.

• Skin cancer screenings elevate dermatologists in the eyes of the community. For the one day per year that dermatologists volunteer for these examinations, our specialty does promote a positive image as the experts in skin cancer care. The patients who are screened are almost always appreciative of the service (except when you tell them you cannot discuss their warts and itch problems with them during these sessions). However, in a somewhat peculiar twist on this theme, the individuals who are sometimes recruited to perform these screening examinations are physician assistants or nurse practitioners who work in the offices of dermatologists. These practitioners are often skilled at these types of examinations; however, what does this communicate to the public about the specific expertise of fully trained skin specialists if physician extenders are capable of performing these examinations?

• Skin cancer screening events produce referrals to dermatologists. Who am I to argue about this rationale for the initiative?

• Screening clinics detect potentially serious skin cancers in individuals who would not ordinarily seek medical attention. Impressive statistics describing large numbers of skin cancers diagnosed in mass screenings may give one the impression that a major dent is being made in this serious public health problem. To the extent that these patients proceed to appropriate care of these newly diagnosed lesions, this is certainly correct. There is little doubt that many lives have been saved by early diagnosis. How could one find fault with this very impressive record? The following story crystallizes why many dermatologists have become less enthusiastic over time with skin cancer screening programs:

There are a limited number of slots available at the screening clinics. Promotional spots on radio and in the newspaper advise prospective patients to call at a certain time to secure an "appointment." Within hours, all of the slots have been filled. On screening day, the majority of the people who arrive for their examinations are those who have been savvy enough to successfully navigate the appointment process, and they have the wherewithal to find the site of the screening clinic and arrive on time. Lo and behold, the volunteer dermatologists see some of their own patients being screened, including an occasional person who has been seen in the office in the very recent past.

Now, we have come to the crux of my problem with the concept of periodic skin cancer screening clinics. They often do not target the individuals who are in need of these examinations. The main public health crisis we face as a nation is the limited access to medical care that millions of our citizens face.

What better contribution can we dermatologists make than to care for these underserved people? A once-a-year skin cancer screening that is specifically aimed at this population is a good start. Perhaps the clinics could be conducted in neighborhoods where low-income families live. The program could be advertised through local community centers or free clinics. Clinics could be held at times that are convenient for working people, in the evenings or on the weekends. Most importantly, the dermatology community could be organized to provide follow-up care so that those in need, with skin cancers, could get the appropriate treatment.

The following is an example of how this can work successfully: In our city, there is a nonprofit healthcare facility that provides medical care to those without financial resources. The local dermatology society has organized its members to volunteer their services as general dermatologists in an efficiently run clinic every two weeks, on a rotating basis throughout the year. What better way is there to improve the health of the community while showing that we, dermatologists, are at the forefront in the effort to provide quality medical services for skin ailments? In almost all ways, this is a superior avenue to the once-yearly skin cancer screening approach to healthcare.