The Role of Gender in Examination and Counseling for Melanoma in Primary Care

Melanoma is increasing in incidence and is often not detected in time for curative excision, despite being clearly visible on the skin surface. More than 80% of the US population sees an outpatient medical provider annually¹; however, primary care providers (PCPs) generally do not examine areas of skin where melanomas arise.² This study measures the role of gender in examination and counseling for melanoma in primary care.

Data for this analysis were collected at baseline for a randomized controlled trial to test the efficacy of a Web-based skin cancer early detection continuing education course (Basic Skin Cancer Triage curriculum) in a sample of primary care physicians.

We assessed PCP performance of skin examination, counseling for skin cancer issues during routine visits, skin cancer triage skills, attitudes and knowledge regarding skin cancer issues through physician surveys and skill tests, patient telephone interviews, and patient medical chart data collected by the research assistants. We recruited physician participants from 4 collaborating centers: Mid-Atlantic (center 1), Ohio (center 2), Kansas (center 3), and Southern California (center 4).

To study the binary-valued primary outcome of interest, we fit a generalized linear mixed-effects model. In this model, the main effects were physician gender and patient gender. The patient gender–physician gender interaction effect was also included in the model. To account for the correlation in the outcome among responses seen by physicians in the same clinic, we included a facility-specific random effect as an intercept in the logit link. Tests of statistical significance were conducted using the likelihood ratio test.

Fifty-three primary care physicians completed the baseline assessment, of which 34 were men and 19 were women. Physician mean age was 48 years for men and 43 years for women.

A total of 1434 patients completed the baseline telephone survey (an average of 27 patients per physician). The patient population was predominantly white and non-Hispanic, with a slight predominance of women and a mean age of 56 years for both men and women. Only 29% of patients reported that their PCPs asked them to totally undress with or without removing undergarments.

Post–clinical examination telephone interviews demonstrated that female physicians performed skin examinations and asked patients if they usually examined their skin more frequently than male PCPs, both for male and female patients (Table). Female PCPs also were more active in discussing skin self-examination with their patients (Table).

Physician surveys revealed that female physicians were significantly more likely than their male colleagues to report performing full-body skin examination (P = .07) and negotiating with patients to set a goal regarding skin self-examination (P = .005). Male PCPs were more likely than women to report confidence in performing full-body skin examination (P = .04) and in diagnosing skin cancer (P = .03), but they were more likely to report that skin cancer prevention counseling was not a priority (P = .02).

Patient medical chart data demonstrated that more female physicians charted performance of any skin examination (P < .001). A greater percentage of female health care providers documented coming to agreement with patients on skin self-examination (P = .01). Male PCPs were more likely to chart the date of their patients' last (P < .001) and next (P = .008) planned full-body skin examination.

Postclinical examination telephone interviews revealed that male patients were more likely to be asked to undress than female patients by female PCPs but not by male PCPs (Table). Male patients were told by male PCPs to examine their skin more frequently than female patients (Table). No other behaviors varied significantly by patient gender.

This study's limitations include the self-reported nature of the data, allowing for recall bias related to the respondent's characteristics. Its strengths include use of 4 geographically diverse centers with a large sample size of patients and physicians.

The significantly greater focus on skin cancer control activities by female physicians has not previously been documented to our knowledge. Female PCPs have been noted to be more likely than male physicians to report performing any gender-specific prevention such as breast examinations, Papanicolaou tests, and mammography orders for female patients; this likelihood was not found to be significant for gender-neutral services such as diet, exercise, and smoking control activities.³

Baseline data from our study elucidate significant gender-related tendencies with respect to skin cancer control activities. Our results indicate a need for increased skin cancer control activities with a focus on skin cancer screening and counseling by male physicians. Male physicians are providing less skin cancer detection and counseling care to their patients. Given these areas of gender-related strengths and weaknesses, gender-tailored education may be a useful adjunct. Improvements in detection and prevention are critical to battle the increasing incidence of melanoma.⁴

Correspondence: Dr Weinstock, Dermatoepidemiology Unit, VA Medical Center, 830 Chalkstone Ave, Unit 111D, Providence, RI 02908 (maw@brown.edu).

Author Contributions:Study concept and design: Weinstock. Acquisition of data: Weinstock, Risica, and Kirtania. Analysis and interpretation of data: Markova, Weinstock, Risica, Kirtania, and Ombao. Drafting of the manuscript: Markova, Weinstock, and Ombao. Critical revision of the manuscript for important intellectual content: Markova, Weinstock, Risica, and Kirtania. Statistical analysis: Markova, Weinstock, Risica, Kirtania, and Ombao. Obtained funding: Weinstock. Administrative, technical, and material support: Markova and Weinstock. Study supervision: Weinstock and Risica.

Financial Disclosure: None reported.

Funding/Support: This study was supported by grant CA106592from the National Cancer Institute.

Previous Presentations: A version of this study was presented as a poster at the Society for Investigative Dermatology Annual Meeting; May 6, 2010; Atlanta, Georgia; and as an oral presentation at the American DermatoEpidemiology Network ancillary meeting; May 8, 2010; Atlanta.

Additional Contributions: The lead investigators at the 4 centers for this study were Christopher Chambers, MD (Mid-Atlantic—Center 1), Douglas Post, PhD (Central Ohio—Center 2), Ken Kallail, PhD (Kansas—Center 3), and Martin Kabongo, MD (Southern California—Center 4).