Melanoma screening efforts in flux

New York - To document the value of melanoma screening, researchers in the United States continue to refine screening strategies, an expert says.

Allan C. Halpern, M.D., says he finds it surprising that in 2014, dermatologists don’t routinely do melanoma screening. He is chief of dermatology, Memorial Sloan-Kettering Cancer Center, New York (MSKCC).

“There’s a lot of public education regarding melanoma,” he says.

There are also guidelines suggesting that people in “high-risk” groups should see a dermatologist, but these groups are poorly defined. A few examples include people with family histories of melanoma or with many atypical moles, Dr. Halpern says.

However, “The United States Preventive Services Task Force (USPSTF) has specifically concluded that there’s not enough data to support population-based screening for melanoma,” he says. “So right now, if you’re a primary care doctor with a patient over age 50, you know you’re supposed to send the patient for a colonoscopy. But you’re not supposed to send your patient for a skin cancer screening.”

Who and how to screen

Accordingly, he says, researchers are focusing on the questions of whether there should be population-based melanoma screening - and if so, who should be screened, and how. Complicating this task is the fact that “the general culture around cancer screening has been in flux for the last few years,” Dr. Halpern says. “On the one hand, there’s been increased recognition that while we’ve been pushing cancer screening as a bit of a panacea for decades, there are actually many potential harms associated with screening.”

Physicians’ use of prostate-specific antigen testing for prostate cancer screening, for example, has fueled a trend toward overtreatment. Therefore, the USPSTF recently recommended that PSA screening should not be done routinely, but at doctors’ discretion.

Simultaneously, he says that although the benefits of preventive cancer screenings are real, stakeholders have realized that “They’re not as dramatic as perhaps they’ve been made out to be.”

The foregoing factors have created a climate in which, he says, “One should be careful not to broadly implement screening without confidence in the trade-off between the benefits and harms.”

Impact of screenings

In this regard, Dr. Halpern says, a large campaign underway in Germany may provide key evidence.

In 2003, the German government began an experiment to gauge the effect of skin cancer screening, performed once every two years for everyone over age 20 in the northernmost German state of Schleswig-Holstein.

“Over the next eight years, researchers saw a significant decrease in mortality from melanoma in that state (Breitbart EW, Waldmann A, Nolte S, et al. J Am Acad Dermatol. 2012;66(2):201-211),” he says.

In 2008, the German government began offering skin cancer screenings for the entire German population over age 35, Dr. Halpern says. “We’re waiting to see what effect that has on melanoma mortality in Germany as a whole. While this is not a formal clinical trial, it’s a very large experiment that may support the fact that screening can save lives.” The study also might help stakeholders determine the actual costs - in terms of both dollars and morbidity - associated with population-based screening, he says.

“Intuitively, skin cancer screening should be a relatively low-cost, low-morbidity procedure that has the potential to save lives. It’s already happening very broadly, on a self-selected basis,” Dr. Halpern says.

Boost in requests

Because dermatologists and groups including the American Academy of Dermatology have provided significant public education, he says, many people are requesting total-body skin examinations from their dermatologists.

“In that setting, it behooves us to begin to develop more efficient and effective ways of screening for skin cancer. That means doing a better job of educating both the public and physicians regarding the warning signs of skin cancer, as well as what benign spots on the skin look like, which will prevent many unnecessary visits,” Dr. Halpern says.

Additionally, reducing unnecessary biopsies will require applying technologies effectively.

“The easiest technologies to bring to bear there include dermatoscopy in clinical practice, and prospective photographically assisted surveillance to monitor for changing lesions in high-risk patients,” he says.

To simplify such surveillance, he says, MSKCC is working with the International Skin Imaging Collaboration to promote the development of standards for skin cancer imaging. Presently, MelaFind (MELA Sciences) is the only device approved by the Food and Drug Administration to help physicians diagnose atypical pigmented skin lesions. Other noninvasive devices under development range from a tape-stripping device that allows analysis of gene expression in individual lesions, to electrical impedance devices that may help diagnose individual lesions, Dr. Halpern says.

For now, some research groups based in the United States are attempting to replicate, on a smaller scale, the German model. Meanwhile, he adds, several groups are working to help dermatologists more efficiently see their own high-risk patients through more effective triage strategies. When patients call with worries about a lesion, Dr. Halpern says says, it can be difficult to fit them into one’s clinic. As such, he says that a small but growing body of research in the United States involves whether some of those visits can be avoided with teledermatology, or at least scheduled more appropriately based on some additional feedback from the patient or another healthcare provider.

Disclosures: Dr. Halpern serves as a scientific adviser to SciBase, DermTech and Canfield Scientific.