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Brief Report
August 2017

Primary Care–Based Skin Cancer Screening in a Veterans Affairs Health Care System

Author Affiliations
  • 1Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 2Department of Dermatology, Pigmented Lesion and Melanoma Program, Stanford University Medical Center and Cancer Institute, Stanford, California
  • 3Center for Dermatoepidemiology, Providence Veterans Affairs Medical Center, Providence, Rhode Island
  • 4Department of Dermatology, Brown University, Providence, Rhode Island
  • 5Center for Innovation to Implementation, Health Services Research and Development, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 6Department of Medicine, Stanford University Medical Center, Stanford, California
JAMA Dermatol. 2017;153(8):797-801. doi:10.1001/jamadermatol.2017.1324
Key Points

Question  Do dermatology referral patterns and skin biopsies differ after skin cancer education and screening by primary care practitioners in a Veterans Affairs Health Care System?

Findings  In this pilot intervention study of 258 patients offered screening, the overall diagnostic accuracy was 34.2% for skin cancer and precancer, 14.8% for skin cancer, and 45.5% for precancer. No significant differences were observed in this measure or the proportion of referrals and skin biopsies before vs after intervention, although the quality of dermatology referrals improved after training.

Meaning  Additional studies are needed to determine whether primary care–based screening can be implemented without a substantial burden on large health care systems.

Abstract

Importance  Skin cancer screening may improve melanoma outcomes and keratinocyte carcinoma morbidity, but little is known about the feasibility of skin cancer training and clinical skin examination (CSE) by primary care practitioners (PCPs) in large health care systems.

Objective  To assess the association of skin cancer training and screening by PCPs with dermatology referral patterns and rates of skin biopsies.

Design, Setting, and Participants  In this pilot interventional study performed at the Veterans Affairs Palo Alto Health Care System, patients 35 years or older scheduled for an annual health habits screen in the PCP general medicine clinics were studied.

Interventions  Six PCPs underwent Internet Curriculum for Melanoma Early Detection (INFORMED) training in May 2015, and 5 screened patients during the following 14 months.

Main Outcomes and Measures  Proportion of dermatology referrals, subsequent skin biopsies, and PCP diagnostic accuracy for skin cancer or precancer compared with dermatologist diagnosis were assessed in screened patients 14 months before the intervention (February 18, 2014, through April 30, 2015) and after the intervention (June 18, 2015, through August 30, 2016).

Results  Among 258 patients offered screening (median age, 70 years; age range, 35-94 years; 255 [98.8%] male), 189 (73.3%) received CSE and 69 (26.7%) declined. A total of 62 of 189 patients (32.8%) were referred to a dermatologist after intervention: 33 (53.2%) for presumptive skin cancers and 15 (24.2%) for precancers. Nine of 50 patients (18.0%) evaluated in dermatology clinic underwent biopsy to exclude skin cancer. Correct diagnoses were made by PCPs in 13 of 38 patients (34.2%; 4 of 27 patients [14.8%] diagnosed with skin cancers and 5 of 11 patients [45.5%] diagnosed with actinic keratoses). Comparison of all outpatient visits for the 5 main participating PCPs before vs after intervention revealed no significant differences in dermatology referrals overall and those for presumptive skin cancer or actinic keratoses, skin biopsies, or PCP diagnostic accuracy with the exception of significantly fewer postintervention dermatology referrals that lacked specific diagnoses (25 [1.0%] vs 10 [0.4%], P = .01).

Conclusions and Relevance  This pilot study suggests that PCP-based skin cancer training and screening are feasible and have the potential to improve PCP diagnostic accuracy without increasing specialty referrals or skin biopsies. Additional studies comparing screening rates, specialty referrals, and patient outcomes in trained vs untrained PCPs are needed before screening is widely implemented in large health care systems in the United States.

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