Reports by Patients and Dermatologists of Skin Cancer Preventive Services Provided in Dermatology Offices

Objective  To learn how often patients receive skin cancer preventive services in dermatologists' offices.

Design  Survey of dermatology patients and dermatologists.

Setting  Dermatology practices of full- and part-time faculty at a midwestern medical school.

Participants  Patients were randomly selected from clinical sessions of 11 dermatologists. Of 200 patients enrolled, 162 (81%) responded to the survey. Ten (91%) of the dermatologists responded, and 4 additional dermatologists from the faculty were also surveyed.

Main Outcome Measures  Patients' and dermatologists' reports of the provision of skin cancer prevention counseling and screening for skin cancer.

Results  Most patients (93%) had been informed about the risks of sun exposure, but for only 27% was a dermatologist the main source of information. Although 76% of patients had seen a dermatologist at least twice in the last 5 years, only 34% reported that they had ever received a total-body screening examination for skin cancer. Most patients (55%) would like to learn more about skin cancer prevention, and responded that they would learn best from a brochure (43%) or from a dermatologist (42%). All dermatologists believed that some skin cancer preventive services should be provided to each patient, but they varied widely in the proportion of their white adult patients to whom they provide such services. For example, with respect to counseling about sunscreens, the same number of dermatologists (4 [29]) responded that they counsel 25% or less of their patients, and more than 75% of their patients.

Conclusion  There is wide variation in how often skin cancer preventive services are provided in dermatologists' offices.

PATIENT counseling and screening may prevent skin cancers or enable their early detection. There is no consensus, however, about the frequency or extent of skin cancer preventive services that physicians should perform in their practices.^1-6 The American Academy of Dermatology and the Centers for Disease Control and Prevention recommend that physicians should counsel all patients on sun protection, and that "physicians should examine exposed areas of skin for cancer whenever the opportunity arises."¹ On the other hand, the US Preventive Services Task Force concluded that "there is insufficient evidence to recommend for or against routine screening for skin cancer by primary care providers."² Specific recommendations for dermatologists have not been adopted although extensive "prophylaxis and prevention" have been advocated by the American Academy of Dermatology.⁷ Finally, there are impediments to the routine provision of disease prevention services in physicians' practices, such as lack of time or remuneration, and a perception that patients are not receptive to counseling about personal health behaviors.^8,9

The response of dermatologists to these controversies and disincentives is unknown. We surveyed dermatologists and their patients to learn how often patients receive skin cancer preventive services in dermatologists' offices, and their attitudes toward skin health promotion.

We measured the provision of 2 forms of skin cancer preventive services, counseling about ways to prevent and detect skin cancer, and screening for skin cancer.² For patients, we composed a survey instrument to be self-administered after their appointments with dermatologists. The instrument inquired about counseling or screening they had received from any dermatologist, and from the dermatologist they had seen that day. Additional items asked about skin cancer preventive behaviors such as use of sunscreen. This instrument was pretested by 25 individuals; items that they found ambiguous were revised or deleted. For dermatologists, we developed an instrument to be administered in an interview format. The instrument inquired about the proportion of their white adult patients to whom they provide counseling and screening. Additional items asked about factors that affect their decision to provide these services, and on whom they rely to set standards for preventive care for dermatologists.

We surveyed adult patients with appointments in randomly selected clinical sessions from February through April 1997 in the private practices of 11 dermatologists on the faculty of Case Western Reserve University, Cleveland, Ohio. All 216 adult patients with appointments in the selected sessions were offered participation in the study by one of us (A.M.P.) at the time of their appointments. Of 216 patients approached, 12 refused to participate and 4 were judged mentally or physically unable to complete the survey, leaving 200 enrolled patients (93%). Each enrolled patient was asked to complete the survey at home following the appointment and to mail it back during the next 72 hours. Further demographic and clinical information was collected from the medical record. Patients were mailed a reminder postcard the next day, and nonresponders were telephoned and reminded 5 to 7 days later. Of 200 enrolled patients, 162 (81%) returned completed instruments. This study was approved by the Institutional Review Board for Human Investigation.

In April and May 1997 one of us (A.M.P.) surveyed 14 dermatologists on the faculty of Case Western Reserve University. Ten of the dermatologists were those from whose practices patients had been recruited for the study (1 dermatologist from whose practice patients had been recruited declined an interview). The mean number of enrolled patients per dermatologist was 18 (range, 9-36). The remaining 4 dermatologists whose patients had not been surveyed had private suburban practices in the Cleveland area.

Differences between groups were evaluated using χ² or t test analyses. Logistic regression analysis models were used to determine the independent relation between patient characteristics and the receipt of counseling or screening services. For these analyses, we defined counseling as advice given to patients about the risks of sun exposure, ways to avoid sun damage, or how to check their skin for signs of skin cancer, and screening as an examination of the entire skin surface for skin cancer. Qualitative responses were assessed and categorized by one of us (A.M.P.), and categorized responses were ordered by frequency of occurrence.

The mean (±SD) age of the patients was 50 (±19) years, 61% were female, and 76% had seen a dermatologist at least twice in the last 5 years. Most patients (87%) were white, and 62% had skin type I, II, or III (usually burn, tan less than average).¹⁰ A history of skin cancer was reported by 23% of patients. Compared with patients in the study sample, the 38 patients whose survey instruments were not returned did not differ significantly with respect to age or sex (P>.20).

Most of the interviewed dermatologists were men (79%), and their mean (±SD) age was 45 (±7) years. The mean (±SD) number of years since dermatology certification was 11 (±8) years.

Most patients (93%) reported that they had been informed about the risks of sun exposure, but for only 27% was the main source of information a dermatologist. The most frequently cited main source was communications media such as television, magazines, and newspapers (for 54% of patients). Most patients (76%) had had at least 2 visits to dermatologists in the last 5 years. Overall, 61% of patients had ever received counseling (advice about the risks of sun exposure, ways to avoid sun damage, or how to check their skin for signs of skin cancer) from any dermatologist, and only 34% reported that a dermatologist had ever checked their entire skin surface for skin cancer. Particular forms of skin cancer preventive services received in dermatologists' offices are contained in Table 1. When asked about their visit to the dermatologist on that day, 27% of patients reported that the dermatologist had counseled them about the risks of sun exposure, and 25% of patients reported that the dermatologist had screened their entire skin surface for skin cancer.

Patients who reported ever having received preventive services were more likely to have had a history of skin cancer and to have had 2 or more visits to a dermatologist in the last 5 years. In addition, those who had received counseling about skin cancer prevention were more likely to be white, and those who had received a total body screening examination were more likely to be older than 50 years (Table 2). We performed multivariate models of patients' receipt of counseling or screening services, controlling for age older than 50 years, sex, race, history of skin cancer, acute diagnosis of a skin neoplasm, and whether the visit was the patient's first to a dermatologist in the last 5 years. Being white, having a history of skin cancer, and having more than 1 visit to a dermatologist were independently related to receiving counseling (P<.03). Having a history of skin cancer (P=.01) and being older than 50 years (P<.07) were both independently related to receiving a screening examination.

Dermatologists varied widely in how often they reported providing skin cancer preventive services to white adult patients in their offices. For example, 5 dermatologists (36%) reported counseling more than 75% of these patients to avoid the sun at midday, but 3 (21%) stated they gave such advice to 25% or fewer of their patients. Similarly, 4 dermatologists (29%) reported that they screen more than 75% of these patients on their sun-exposed skin, whereas 3 (21%) reported they perform such screening on 25% or fewer of their patients. Most dermatologists (9 of 14) estimated that, overall, they inform 50% or fewer of their white adult patients about their personal risk for skin cancer. Particular forms of counseling and screening reported are contained in Table 3.

Overall, patients reported that they regularly engaged in skin cancer preventive behaviors. For example, most responded that they at least somewhat regularly use sunscreen (60%), limit sun exposure (62%), or wear protective clothing in the sun (55%). Furthermore, most patients (55%) would like to learn more about skin cancer prevention. Of these patients, 43% responded that they would learn best from brochures and 42% from a dermatologist (only 5% responded that they would learn best from a primary care physician). Overall 11 dermatologists (79%) and 63% of patients responded that they were somewhat or extremely satisfied with the counseling provided in dermatologists' offices.

Most dermatologists (64%) believed that routine counseling is recommended, but the same proportion believed that routine screening is controversial. Physicians who believed there to be controversies did not differ from others in age, sex, or years practicing dermatology. When asked on whom they rely to set preventive care standards for dermatologists, most (64%) replied that they rely on their own interpretations of available data; the remainder responded that they rely on the American Academy of Dermatology.

All the dermatologists responded that, ideally, skin cancer preventive recommendations should stipulate that counseling be provided by dermatologists to all patients. Half believed that all patients should receive total-body screening, and 2 believed that all patients should be screened on sun-exposed skin only. Five dermatologists would limit screening to high-risk patients. When asked about the major impediment to the routine provision of skin cancer preventive services in their practices, half of the dermatologists blamed lack of time, 5 responded lack of interest in these services on the part of patients, and 2 believed that they have no impediments to providing these services.

These results are consistent with a lack of consensus about the routine provision of skin cancer preventive services in dermatologists' offices. Although published guidelines do not exist, most of these dermatologists believed in the advisability of universal counseling and routine screening despite the fact that they varied widely in their behaviors, and, in general, did not practice this ideal in their offices.

The results also suggest that when guidelines for preventive services are made they should focus on services not already obtained from nonmedical sources such as television or newspapers. With respect to counseling, for example, most of these patients had been informed about the risk of sun exposure (and practiced skin cancer preventive behaviors regularly), but their main sources of information were not dermatologists. Preventive services from dermatologists should supplement and not reiterate those that patients obtain elsewhere, and should focus specifically on interventions (such as screening examinations) that must be provided by clinicians rather than nonmedical sources.

With respect to screening, there is a marked discrepancy between services dermatologists believe should be provided and those they actually offer. By both dermatologists' and patients' reports, patients do not often receive total-body screening examinations by dermatologists, many of whom nonetheless believed such screening should be routinely performed. The absence of formal recommendations for dermatologists regarding routine screening may contribute to this discrepancy. In practice, dermatologists were much more likely to offer preventive services to higher-risk patients (such as those with a history of skin cancer), but many believed that a more stringent ideal is widely accepted and noncontroversial. They may find such a standard unattainable in their busy practices, a conflict that may make them feel inadequate¹¹ and jeopardize their performance of skin cancer preventive services in general.

The results should be interpreted in light of some potential limitations of this study. We surveyed patients and faculty dermatologists in 1 geographic area only. The patients, however, were similar to those in a typical dermatology practice.¹² Also, of the 14 dermatologists, 5 are members of the part-time faculty who spend most of their time caring for general dermatology patients, and only 2 were primarily dermatologic surgeons. Thus, it is likely that similar results would be found in samples from other areas or from other settings. Also, our findings are based on subject reports rather than direct observation, and patients may not have been aware that they were receiving a screening examination for skin cancer. The variation in dermatologists' reports, however, highlights that a practical consensus may not exist.

In summary, these results highlight the need for guidelines for skin cancer preventive services in dermatologists' offices. These guidelines should be parsimonious, recognizing that much effective counseling about sun-safe behaviors occurs in the nonmedical setting. Further, the guidelines should be dynamic, evolving like other forms of recommended health promotion^9,13 as new data about effectiveness and costs of preventive services become available.¹⁴

Accepted for publication April 28, 1998.

This work was supported by grant K08AR01962 from the National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, US Public Health Service, Bethesda, Md.

We thank the faculty of the Department of Dermatology, Case Western Reserve University and University Hospitals, Cleveland, Ohio, for their participation.

Reprints: Mary-Margaret Chren, MD, Department of Dermatology, University of California, San Francisco, San Francisco VAMC 111-G, 4150 Clement St, San Francisco, CA 94121 (e-mail: mmchren@orca.ucsf.edu).