From the Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center (Dr Whited), and the Divisions of General Internal Medicine (Dr Whited) and Dermatology (Dr Grichnik), Duke University Medical Center, Durham, NC.
The Rational Clinical Examination section editors: David L. Simel,
MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical
Center, Durham, NC; Drummond Rennie, MD, Deputy Editor (West), JAMA .
Lifetime risk for malignant melanoma has increased from 1 in 1500 in
the United States in 1930 to 1 in 75 projected for the year 2000. Because
the tumor's thickness at excision is the primary prognostic determinant, early
detection through the history and physical examination can play an important
role in the patient's clinical course. Two checklists have been developed
as diagnostic aids, the ABCD (A indicates asymmetry; B, border irregularity;
C, irregular color; and D, diameter >6 mm) and the revised 7-point checklists.
These checklists should be interpreted with some discretion, but 2 studies
have found the sensitivity for the ABCD checklist to be 92% (95% confidence
interval [CI], 82%-96%) and 100% (95% CI, 54%-100%); 1 study found the specificity
to be 98% (95% CI, 95%-99%). The revised 7-point checklist has been reported
to have a sensitivity of 79% (95% CI, 70%-85%) to 100% (95% CI, 94%-100%)
and specificity of 30% (95% CI, 21%-39%) to 37% (95% CI, 28%-46%). Physicians'
global assessments for detecting the presence or absence of melanoma are estimated
to have a specificity of 96% to 99%, while sensitivity ranges widely from
50% to 97%. Nondermatologists' examinations appear to be less sensitive than
examinations performed by dermatologists.
Whited JD, Grichnik JM. Does This Patient Have a Mole or a Melanoma?. JAMA. 1998;279(9):696-701. doi:10.1001/jama.279.9.696