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Figure.
Dermoscopy Use in VA Melanoma Cases Between 2000 and 2015
Dermoscopy Use in VA Melanoma Cases Between 2000 and 2015

The increasing rates of dermoscopy use demonstrate a significant trend over time (P < .001).

1.
Tromme  I, Legrand  C, Devleesschauwer  B,  et al.  Cost-effectiveness analysis in melanoma detection: A transition model applied to dermoscopy.  Eur J Cancer. 2016;67:38-45.PubMedGoogle ScholarCrossref
2.
Nehal  KS, Oliveria  SA, Marghoob  AA,  et al.  Use of and beliefs about dermoscopy in the management of patients with pigmented lesions: a survey of dermatology residency programmes in the United States.  Melanoma Res. 2002;12(6):601-605.PubMedGoogle ScholarCrossref
3.
Terushkin  V, Oliveria  SA, Marghoob  AA, Halpern  AC.  Use of and beliefs about total body photography and dermatoscopy among US dermatology training programs: an update.  J Am Acad Dermatol. 2010;62(5):794-803.PubMedGoogle ScholarCrossref
4.
Engasser  HC, Warshaw  EM.  Dermatoscopy use by US dermatologists: a cross-sectional survey.  J Am Acad Dermatol. 2010;63(3):412-419, 419.e1-419.e2.PubMedGoogle ScholarCrossref
5.
Weinstock  MA, Lott  JP, Wang  Q,  et al.  Skin biopsy utilization and melanoma incidence among medicare beneficiaries  [published online September 17, 2016].  Br J Dermatol. 2016. doi:10.1111/bjd.15077PubMedGoogle Scholar
6.
Carli  P, De Giorgi  V, Crocetti  E,  et al.  Improvement of malignant/benign ratio in excised melanocytic lesions in the ‘dermoscopy era’: a retrospective study 1997-2001.  Br J Dermatol. 2004;150(4):687-692.PubMedGoogle ScholarCrossref
Research Letter
June 2017

Rates of Dermoscopy Use for Melanoma Diagnosis in the Miami VA Medical Center

Author Affiliations
  • 1Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
  • 2Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Dermatol. 2017;153(6):602-603. doi:10.1001/jamadermatol.2016.6025

In the past 25 years, dermoscopy has had a major impact on the diagnosis of cutaneous lesions. Adequate dermoscopy training can be cost-effective and reduce melanoma-associated morbidity and mortality.1 Since 2006, dermatoscopes have been provided to incoming dermatology residents at the University of Miami as a part of the training curriculum in addition to didactic dermoscopy training by a pigmented lesion expert.

Methods

We sought to determine the rates of dermoscopy use in melanoma detection at the Miami Veterans Affairs (VA) Medical Center whereby dermatology residents are the frontline clinicians. With approval from the Miami Veterans Affairs institutional review board, we searched by International Classification of Diseases, Ninth Revision diagnosis codes (172.0-172.9) for cutaneous melanoma cases with histopathological confirmation between January 2000 and December 2015 (n = 519). Medical record review captured patient demographics, Breslow depth, and dermoscopy use. Cases were considered to have dermoscopy use if dermoscopic features (eg, general patterns or features of a pigmented lesion) were documented and used to prompt biopsy of the lesion found to be a melanoma. Patient informed consent was not required due to the nature of the study.

Results

We found that dermoscopy usage increased from 8 of 127 cases [6%] between 2000 and 2005 to 63 of 168 cases [37%] between 2006 and 2010 to 157 of 224 cases [70%] between 2011 and 2015. The data demonstrates a significant trend over time (Figure). There was an inverse correlation between dermoscopy use and Breslow depth with significantly thinner melanomas associated with dermoscopy-use cases compared to nondermoscopy use cases (median Breslow depth 0 mm vs 0.26 mm; Wilcoxon rank-sum test, P < .001).

Discussion

Similar to the trend seen at our training institution, the rates of dermoscopy use have increased over the past 2 decades. In a 2002 survey,2 only 38% of US dermatology residents reported dermoscopy training during their residency, and more than one-third had never used a dermatoscope. The same group updated their survey in 2010 and noted a 40% increase in the proportion of residency programs that used dermoscopy and 52% increase in those residents receiving training.3 This same temporal trend has been reported in the United Kingdom: 54% of respondents reported regular dermoscopy use in 2003, compared with 98.5% in 2012. In the United States, dermoscopy users are more likely to be younger, recently graduated, and involved with teaching residents.4 The reported reasons for dermoscopy nonuse are consistently due to lack of dedicated training.

Our study examines the use of dermoscopy (whereby clinical documentation is a marker for use) for melanoma diagnosis at the Miami VA Medical Center and suggests that dermoscopy learners have a positive impact on the secondary prevention of melanoma, by way of identifying thinner lesions at diagnosis. Our findings also illustrate the actual rates of dermoscopy use among physicians-in-training in a longitudinal fashion. Physicians-in-training under the supervision of an attending physician are the key health care providers performing skin cancer screenings of patients in the VA system. The present strengths of our study include consistent record keeping by electronic medical record, reliable pathologic thresholds, and relative uniformity of thresholds for biopsy.

This study has some limitations that have to be acknowledged. Average Breslow depth has been skewed toward thinner tumors over time due to multifactorial factors including increased biopsy rates, improved early detection, and changes in histopathologic measures for borderline lesions.5 Second, we only included those cases with verified documentation of dermoscopy use, so the actual rates of use may be higher. Finally, the homogenous demographics of the VA study population who have equalized access to care may limit the generalizability of this study.

It is known that dermoscopy use improves the malignant-to-benign ratio for melanocytic lesions in dermoscopy users compared with nonusers.6 We advocate for providing devices to residents along with structured dermoscopy education to encourage postresidency use.

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Article Information

Corresponding Author: Lucy L. Chen, MD, Department of Dermatology and Cutaneous Surgery, University of Miami, 1600 NW 10th Ave, Rm 2023, Miami, FL 33136 (lucy.chen@jhsmiami.org).

Accepted for Publication: December 15, 2016.

Published Online: March 8, 2017. doi:10.1001/jamadermatol.2016.6025

Author Contributions: Drs Chen and Wei had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Chen, Wei, Hu.

Acquisition, analysis, or interpretation of data: Wei, Ma, Keri, Hu.

Drafting of the manuscript: Chen.

Critical revision of the manuscript for important intellectual content: Wei, Ma, Keri, Hu.

Statistical analysis: Chen, Wei, Ma.

Administrative, technical, or material support: Wei, Keri.

Study supervision: Hu.

Conflict of Interest Disclosures: None reported.

References
1.
Tromme  I, Legrand  C, Devleesschauwer  B,  et al.  Cost-effectiveness analysis in melanoma detection: A transition model applied to dermoscopy.  Eur J Cancer. 2016;67:38-45.PubMedGoogle ScholarCrossref
2.
Nehal  KS, Oliveria  SA, Marghoob  AA,  et al.  Use of and beliefs about dermoscopy in the management of patients with pigmented lesions: a survey of dermatology residency programmes in the United States.  Melanoma Res. 2002;12(6):601-605.PubMedGoogle ScholarCrossref
3.
Terushkin  V, Oliveria  SA, Marghoob  AA, Halpern  AC.  Use of and beliefs about total body photography and dermatoscopy among US dermatology training programs: an update.  J Am Acad Dermatol. 2010;62(5):794-803.PubMedGoogle ScholarCrossref
4.
Engasser  HC, Warshaw  EM.  Dermatoscopy use by US dermatologists: a cross-sectional survey.  J Am Acad Dermatol. 2010;63(3):412-419, 419.e1-419.e2.PubMedGoogle ScholarCrossref
5.
Weinstock  MA, Lott  JP, Wang  Q,  et al.  Skin biopsy utilization and melanoma incidence among medicare beneficiaries  [published online September 17, 2016].  Br J Dermatol. 2016. doi:10.1111/bjd.15077PubMedGoogle Scholar
6.
Carli  P, De Giorgi  V, Crocetti  E,  et al.  Improvement of malignant/benign ratio in excised melanocytic lesions in the ‘dermoscopy era’: a retrospective study 1997-2001.  Br J Dermatol. 2004;150(4):687-692.PubMedGoogle ScholarCrossref
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