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Houston NAM, Secrest AM, Harris RJ, et al. Patient Preferences During Skin Cancer Screening Examination. JAMA Dermatol. 2016;152(9):1052–1054. doi:10.1001/jamadermatol.2016.1005
Although skin cancer screening through total-body skin examination (TBSE) may reduce morbidity or mortality from skin cancer, one potential harm of screening is that the nature of this examination may cause patient embarrassment. Among female patients undergoing colonoscopy and pelvic examinations there is a strong preference for a female physician.1,2 To our knowledge, the influence of physician sex on patient attitudes toward skin cancer screening has not been studied in a nonveteran population.3,4
Using an anonymous, cross-sectional survey (determined to be exempt from full board review by the institutional review boards of the University of Pittsburgh, University of Utah, and East Carolina University), adults (≥18 years) undergoing a TBSE at these 3 institutions were surveyed to determine their preferences of screening clinician’s sex and degree of disrobement during TBSE. Univariate significance was tested using the t test or the χ2 test.
Of 483 invited participants, 443 completed some or all of the survey and 82 refused (response rate, 85.5%). Population demographics and preferences for examining clinician’s sex are shown (Table 1). Eighty-five women (33.7%) and 32 men (16.8%) had a preference for physician sex (P < .001), among whom 84 women (98.8%) and 12 men (37.5%) preferred a female physician (P < .001). Clinician sex preference correlated inversely with patient age (50% of women were <30 years; 24.2% of women were ≥70 years) but not with educational attainment or body mass index.
For the TBSE, women were more likely than men to prefer to leave undergarments in place (46.2% vs 39.7%; P = .05) and to not have their genitals examined (31.3% vs 12.5%; P < .001) (Table 2). However, women were more likely to be asked to remove their undergarments prior to examination (46.3% vs 25.3%; P = .004). In visits with physician-patient sex concordance (n = 218), patients were more likely to be asked to remove their underwear (36.9% vs 25.5%; P = .01), and women were more likely to have their breasts examined (81.2% vs 71.7%; P = .03) than in visits with physician-patient sex nonconcordance. While women were more likely than men to report feeling embarrassed prior to TBSE (using a Likert scale of 1-5, with 5 indicating the most embarrassment), with mean (SD) scores of 1.8 (1.1) for women and 1.4 (0.7) for men (P < .001), the clinical significance of this difference is unclear.
A study of military veterans showed that physician-patient sex nonconcordance resulted in the refusal of the TBSE among 16% of women but only 2% of men.3 We found a similar preference for female clinicians as well as specific preferences during examination of sensitive areas during the TBSE in a nonveteran population. This offers an opportunity to provide patient-centered care and reduce patient discomfort during TBSE. Considering that genital melanomas comprise only 0.2% to 0.8% of all melanomas,5,6 it is important to balance the low risk of missing such a melanoma with the relatively higher risk of potentially causing patient discomfort by performing this examination. Limitations of this study include use of a population who already had a scheduled TBSE, most of whom were highly educated and had undergone TBSE in the past. This design did not allow us to survey those who avoided skin cancer screenings altogether. The choice of sex of all individuals, including residents and medical students, present during the TBSE may have been limited at the academic sites where the study was conducted.
Allowing patients to choose their degree of disrobing, body areas examined and the sex of clinician for TBSE may reduce patient discomfort or embarrassment as a potential barrier to regular skin cancer screening.
Corresponding Author: Laura K. Ferris, MD, PhD, UPMC, Department of Dermatology, Falk Medical Center, 3601 Fifth Ave, Fifth Floor, Pittsburgh, PA 15213 (firstname.lastname@example.org).
Accepted for Publication: March 17, 2016.
Published Online: May 11, 2016. doi:10.1001/jamadermatol.2016.1005.
Author Contributions: Drs Secrest and Ferris had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Houston, Secrest, Eliason, Ferris.
Acquisition, analysis, or interpretation of data: Houston, Secrest, Harris, Mori, Phillips, Ferris.
Drafting of the manuscript: Houston, Mori, Phillips, Ferris.
Critical revision of the manuscript for important intellectual content: Houston, Secrest, Harris, Eliason, Ferris.
Statistical analysis: Secrest.
Obtained funding: Ferris.
Administrative, technical, or material support: All authors.
Study supervision: Houston, Secrest, Phillips, Ferris.
Conflict of Interest Disclosures: Dr Ferris has been an investigator and consultant for Castle Biosciences and DermTech International. No other disclosures are reported.
Funding/Support: This study was supported in part by the Clinical and Translational Science Institute at the University of Pittsburgh (National Institutes of Health, grant Nos. UL1-TR-000005 and P50CA121973).
Role of the Funder/Sponsor: The Clinical and Translational Science Institute at the University of Pittsburgh a role in the design and conduct of the study but not in the collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank the Clinical and Translational Science Institute at the University of Pittsburgh and Daniel Winger, MS, Clinical and Translational Sciences Institute, for assistance with survey design and Timothy Patton, DO, Department of Dermatology, both at the University of Pittsburgh, for assistance with data collection. They were not compensated for their assistance.