Federman DG, Kravetz JD, Haskell SG, Ma F, Kirsner RS. Full-Body Skin Examinations and the Female VeteranPrevalence and Perspective. Arch Dermatol. 2006;142(3):312-316. doi:10.1001/archderm.142.3.312
Copyright 2006 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2006
To determine the frequency of full-body skin examinations (FBSEs) among female veterans and to determine whether patient risk factors for skin cancer alter the frequency of screening. Subjects were also queried as to attitudes about FBSE.
Questionnaires pertaining to whether patients underwent regular FBSE, their opinions and attitudes about this screening test, and their risks for developing skin cancer.
A primary health care clinic for female veterans at a Veterans Affairs medical center.
A convenience sample of 245 patients awaiting clinic appointments. Of those asked to participate, 201 agreed, for a participation rate of 82%.
Main Outcome Measures
Patient report of undergoing FBSE, attitudes regarding FBSE, and risk factors for cutaneous malignancy.
Eighteen percent of all respondents reported undergoing regular FBSE by their primary care provider, whereas 9 (45%) of the 20 with a history of skin cancer reported undergoing FBSE. Fifteen percent of subjects reported embarrassment with FBSE. Seventy-nine percent reported that their primary care provider would be considered thorough by performing FBSE, and 69% would like their primary care provider to perform FBSE regularly. We found that 16% of subjects would refuse the examination if the primary care provider were of the opposite sex, whereas 38% would not refuse but be less willing to be examined.
Female veterans report a low incidence of FBSE, although those with a personal history of skin cancer are more likely to undergo screening. Despite embarrassment expressed about a sex difference between the patient and examiner, female veterans have a strong preference to undergo FBSE.
Skin cancer is the most common malignancy in the United States and accounts for nearly half of all malignancies.1 Melanoma, the deadliest of the 3 major types of skin cancer, is increasing rapidly in incidence2,3 and is estimated to account for approximately 59 580 cases and 7770 deaths in 2005.1 Nonmelanoma skin cancer, the most common malignancy, accounts for more than 1 million cases annually.1
Skin cancer may be the ideal cancer for screening, because many risk factors are well known and there are opportunities for early detection. Approximately 85% of the population sees a physician every 2 years, and routine examinations are among the 10 most common reasons for patient visits.4 Although the US Preventive Services Task Force concluded in 2001 that insufficient evidence existed to recommend for or against routine skin cancer screening,5 the American Cancer Society recommends skin cancer screening as part of a cancer-related checkup every 3 years for people aged 20 to 40 years and annually for those older than 40 years.6
Many inherent features of skin cancer render it suitable for screening, including the following: (1) it is highly prevalent; (2) it exacts a considerable cost (such as morbidity, mortality, and economic cost); (3) the natural history of the disease is well known; and (4) early treatment may reduce these associated costs. Furthermore, screening examinations are easily performed, inexpensive, noninvasive, well tolerated, and safe.7 A recent study conducted within a population of predominantly elderly white male veterans found that 54% of patients presenting for skin cancer screening had results suggestive of skin cancer,8 with the conclusion that skin cancer screening among a population of veterans might be beneficial.
For a number of reasons, however, the full effect of screening for melanoma and nonmelanoma skin cancer among the general population has not been achieved. Previous studies using medical chart reviews and surveys have demonstrated a low incidence of skin cancer screening by primary care providers (PCPs) and dermatologists.9- 11 Estimating the true incidence of skin cancer screening is difficult because practitioner self-reported frequency may overestimate screening rates and medical chart review may underestimate rates. Practitioners may also selectively apply screening only to patients perceived to be at an increased risk for skin cancer relative to the general population.10,11
A recent study from our group found a low incidence of screening with full-body skin examination (FBSE), despite patients associating FBSE screening with provider thoroughness and reporting a low rate of embarrassment.12 However, in that study, 97% of respondents were male. It is not known whether similar findings can be generalized to female patients.
In addition, it is important to assess patients' perceptions and satisfaction with respect to skin cancer screening, because in today's era of increased managed health care, patients are considered health care consumers and ultimately the purchasers of health care resources. To assess the frequency of skin cancer screening in female patients, whether patient risk factors for cutaneous malignancy alter this rate, and patient preferences regarding screening, we surveyed patients in the Women's Center clinics at the West Haven Veterans Affairs Medical Center, West Haven, Conn.
The West Haven Veterans Affairs Medical Center provides care for more than 29 000 veterans who are older (average age, 61 years) and predominantly male (91%). Ninety-eight percent of female veterans enrolled in primary care at the West Haven campus of VA Connecticut Health Care System receive their primary care in the Women's Center clinics. The Women's Center clinics are staffed by 4 female internists who are attending physicians, a male gynecologist, a female breast surgeon, a female nurse practitioner, and 40 internal medicine residents, of whom 27 are male and 13 are female. All residents work under the supervision of attending physicians. Medical students did not see patients in the Women's Center. The attending physicians and residents working in the Women's Center are affiliated with the Yale University School of Medicine, New Haven, Conn.
Eligible patients included female veterans older than 40 years awaiting scheduled appointments in the waiting room of the Women's Center clinics. Subjects were recruited on 36 clinic days during a 5-month period from February 1 through June 30, 2004. A trained research assistant administered the study questionnaires to a convenience sample of patients before their clinic appointment. The study protocol was approved by the local investigational review board at the West Haven Veterans Affairs Hospital.
All participants were asked whether their PCP regularly performed an FBSE; a regular FBSE was defined for each subject as an examination where a patient's entire skin is examined after the patient is completely unclothed, yearly or every other year. Participants were also asked whether they would feel embarrassed by an FBSE, whether it would be appropriate for a PCP to perform regular FBSEs, and whether they thought the PCP was being thorough if he or she performed the examination.
Participants were asked if they had risk factors for cutaneous malignancy, such as childhood blistering sunburn, employment that required work outdoors, leisure-time activities that include outdoor exposure, moles on their skin, and family and personal history of skin cancer. Those who admitted having a history of skin cancer were asked what type of skin cancer they had had. All participants were also asked their eye color, whether they examine themselves for skin cancer, and whether they always burn, sometimes burn and sometimes tan, or always tan when exposed to sunlight.
Study subjects were asked questions regarding their desire to undergo an FBSE by their PCP and a dermatologist. They were also asked whether they would prefer undergoing an FBSE as part of their routine care by their PCP or having it performed at a different time by a dermatologist. In addition, they were also asked how they would feel about undergoing an FBSE if the examiner were of the opposite sex.
Possible responses to questions regarding their desire to undergo FBSE by their PCP and a dermatologist were “strongly agree,” “agree,” neither agree nor disagree,” “disagree,” and “strongly disagree.” For analysis, the responses “strongly agree” and “agree” were combined, whereas the 3 remaining categories were also combined into an “all others” category.
Demographic information, including each participant's age, level of education, and self-reported health status, was obtained at the interview.
To assess for potential differences between the groups, we used the 2-tailed t test (unpaired) for continuous variables such as age and education, and we used the χ2 test for categorical variables such as self-reported skin cancer history and outdoor sun exposure. In any case when the expected number in a table was less than 5, we used the Fisher exact test. The significance level was set at .05 for all tests. The analyses were performed using SAS statistical software for Windows, version 8 (SAS Institute Inc, Cary, NC).
We asked a total of 245 subjects to participate. Of these, 201 agreed to complete the questionnaire, for an overall participation rate of 82.0%. The mean age of the subjects was 59.5 years (range, 40-87 years), and 77.7% described themselves as white, 11.7% as black, 5.1% as Hispanic, 0.5% as Asian, and 5.1% as other. More than half of the participants (51.6%) reported completing an education beyond the 12th grade. On questions about the subjects’ self-reported health, 67% of respondents stated that their health was good or excellent, 30% as fair, and 3% as poor. Of 195 subjects responding to the question regarding personal history of skin cancer, 20 (10.3%) reported a personal history of skin cancer, whereas another 11 (5.6%) were unsure whether they had ever had skin cancer. Of these 20 subjects with a history of skin cancer, 12 (60%) were not able to identify whether they had a history of basal cell carcinoma, squamous cell carcinoma, melanoma, or other skin cancer.
Only 17.9% of all respondents reported undergoing regular FBSEs by their PCP, whereas 68.7% stated they did not and 12.4% were unsure. Subjects older than 60 years were more likely to report undergoing regular FBSE than younger subjects (27.2% vs 12.0%; P = .01), as were those with a personal history of skin cancer compared with those without a personal history of skin cancer (45.0% vs 15.9%; P = .01). Respondents who performed self-examination for skin cancer were also more likely to report undergoing regular FBSE than those who did not (24.2% vs 12.9%; P = .002) (Table 1). Those who reported occupational sun exposure reported undergoing FBSE more often than those who did not have such occupational exposure (P = .05). Subjects with a family history of skin cancer (P = .32), blistering sunburns as children (P = .24), and sun exposure in their leisure-time activities (P = .09) were not significantly more likely to report undergoing FBSE than those who did not. Respondent eye color (P = .12) and self-reported cutaneous reaction to sun exposure (P = .30) did not influence the rate of FBSEs.
Thirty subjects (15.0%) reported that they would feel embarrassed by undergoing an FBSE, whereas 155 (78.7%) and 152 (77.2%) reported that their health care provider would be considered thorough and appropriate, respectively, by performing regular FBSE screening.
Subjects were asked whether sex differences between the examiner and patient would influence their decision to undergo FBSE. Of the 190 subjects who responded to this question, 31 (16.3%) stated that they would refuse the examination; 73 (38.4%) stated that they would be less willing to be examined, but would not refuse the examination; 76 (40.0%) stated that it would not influence their decision; and 10 (5.3%) stated that they would be more willing to be examined.
The questionnaire asked subjects about their desire to undergo screening for skin cancer by their PCP and/or a dermatologist. Of 193 subjects who responded to the question, 134 (69.4%) agreed with the statement, “I would like my primary care practitioner to perform a full-body skin examination regularly to detect skin cancer,” whereas only 16 (8.3%) disagreed. Similarly, of these 193 subjects, 137 (71.0%) agreed with the statement, “I would like to have a dermatologist (specialist in skin diseases) perform a full-body skin examination on me regularly to detect skin cancer,” whereas 19 (9.8%) disagreed.
Subjects were also asked whether they would prefer undergoing skin cancer screening as part of routine physical examinations performed by their PCP or having an examination performed at a different time by a dermatologist. Overall, of the 189 subjects who answered this question, 50 (26.5%) preferred having a screening examination for skin cancer performed by their PCP, 84 (44.4%) preferred a separate appointment with a dermatologist, and 55 (29.1%) reported no preference (P = .01).
Of the 194 subjects who responded to the question about self-examination, 93 (47.9%) stated that they examine themselves for skin cancer, whereas 101 (52.1%) do not. Subjects who reported having a first-degree relative with skin cancer (P = .03) and blistering sunburns as children (P = .02) were more likely to report performing self-examination for skin cancer detection than those without such risk factors (Table 2).
We found that female veterans do not report a high frequency of undergoing FBSE to screen for skin cancer by their PCPs. Our rate of 17.9% is somewhat lower than those of previous studies that used various methods in cohorts of male veterans. Our group has previously found screening rates of 28% using a medical chart review of predominantly male veteran patients seen in primary care10 and 32% when this same questionnaire was administered to a cohort of patients that was 97% male.12 Using a nationally representative survey, Saraiya et al13 reported that 14.5% of the population reported ever having a skin cancer screening examination by a physician and only 8% reported a recent skin examination. Other studies looking at the self-reported skin cancer screening practices of PCPs in the community found rates of 31%10 and 42%.14
These low rates are evident, despite our findings that patients desire to undergo FBSE and have positive feelings about the health care providers performing skin cancer screening. Although most patients do not undergo regular skin cancer screening, we found that female veterans have a considerable desire to undergo screening by their PCP or by a dermatologist. When given the choice of undergoing FBSE within the context of their regular primary care visits or making an additional visit to a dermatologist, patient convenience was not a major influential factor, as more patients preferred the dermatologist, although almost one third had no preference.
Although our study is underpowered to detect differences in frequency of FBSE for those with several of the less common risk factors for skin cancer, we found that those who were older and had a personal history of cutaneous malignancy were more likely to report undergoing FBSE than those without such risk factors. This finding is reassuring, given the importance of these risk factors for the development of skin cancer.
Although subjects expressed a desire to undergo FBSE, only a minority performed skin self-examination. Patients with a first-degree relative with skin cancer and blistering sunburns as children were more likely to report performing self-examination than those without such risk factors. Providers should increase educational efforts aimed at the early self-detection of malignancy to patients at risk for skin cancer.
Our finding that most female veterans would refuse or be less willing to undergo FBSE if the examining practitioner were of the opposite sex is not surprising. Previous studies have shown that sex concordance between the patient and physician has increased in recent years, particularly in primary care,15 and female patients prefer female practitioners to perform pelvic examinations.16 Female health care providers have been shown to perform more preventive health services for their female patients than male health care providers.15,17 In our study, we did not question subjects about the sex of their PCP. Future studies should not only examine differences in skin cancer screening between male and female patients but also examine the influence of provider sex on skin cancer screening rates in female patients.
Our study has several limitations. Because we studied female veterans, we do not know whether our findings are generalizable to all female patients. Female veterans might differ from female patients who did not serve in the military, particularly as there appears to be a high rate of sexual abuse in the military.18 In addition, physicians in training were overrepresented in our study. We do not know whether physicians in training are more or less likely to perform skin cancer screening than more experienced clinicians. The age disparity between the patients and residents in training might make the patients more reluctant to undergo screening, although, to our knowledge, no study supports this hypothesis. Last, our study was conducted at a single site, and we do not know that this site is representative of a larger population of female veterans.
In conclusion, our study confirms low rates of skin cancer screening among female veterans, despite a high level of patient acceptance and desire to undergo the examination. Educational efforts to increase the low rate of skin cancer screening should be aimed at both PCPs and patients.
Correspondence: Daniel G. Federman, MD, Veterans Affairs Connecticut Health Care System (11ACSL), 950 Campbell Ave, West Haven, CT 06516 (firstname.lastname@example.org).
Financial Disclosure: None.
Accepted for Publication: September 2, 2005.
Author Contributions:Study concept and design: Federman, Kravetz, and Kirsner. Acquisition of data: Federman, Kravetz, and Haskell. Analysis and interpretation of data: Federman, Ma, and Kirsner. Drafting of the manuscript: Federman. Critical revision of the manuscript for important intellectual content: Federman, Kravetz, Haskell, Ma, and Kirsner. Statistical analysis: Ma. Obtained funding: Federman. Administrative, technical, and material support: Federman and Haskell. Study supervision: Federman, Haskell, and Kirsner. Dr Federman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Funding/Support: This study was supported in part by the Clinical Epidemiology Resource Center, West Haven Veterans Affairs Medical Center, West Haven, Conn (Dr Federman).
Role of the Sponsor: The funding organization played no role in the design, collection, management, or interpretation of the study, but did support the statistical analysis. The funding organization did not prepare, review, or seek approval of the submitted manuscript.