May 17, 2011 Among patients referred by non-dermatologists to dermatologists for evaluation of skin lesions suspected of being malignant, only apparently one-fifth were found to be cancerous, although dermatologists identified and biopsied other incidental lesions, approximately half of which were malignant, according to a report in the May issue of Archives of Dermatology, one of the JAMA/Archives journals.
"More than one million skin cancers are diagnosed annually in the United States , with one in five Americans developing skin cancer during their lifetime," the authors write as background information in the article. "Non-dermatologists, particularly primary care physicians, play an important role in skin lesion assessment and initiation of referrals to the dermatologist."
Kate V. Viola, M.D., of the Robert Wood Johnson Clinical Scholars Program and Yale University School of Medicine, New Haven , Conn. , and colleagues sought to evaluate the proportion of suspicious lesions identified by non-dermatologists that are found to be malignant compared to the number of secondary skin lesions identified at the time of dermatology referral.
The authors evaluated medical records of 400 patients who were referred by a non-dermatologist to the dermatology service at the Veterans Affairs (VA) Connecticut Health System for evaluation of suspicious skin lesions between January 1, 2006 and December 31, 2009.
Of the 400 patients included in the study, the average age was 77.7 years, 98 percent were white men and 74 (18.5 percent) had a history of skin cancer. Most lesions (224 of 400 or 56 percent) were considered to be non-malignant by the consulting dermatologist, requiring no biopsy. Of the 176 lesions that needed biopsies, 88 were malignant according to the dermatopathology report, meaning 88 of 400 patients (22 percent) had an index lesion (lesions that prompted the referral) that was positive for cancer.
Dermatologists biopsied an additional 111 incidental lesions (secondary lesions identified, not the reason for referral), of which 61 (55 percent) were malignant. Twelve of 61 patients (19.7 percent) with a malignant incidental lesion had an index lesion that was not biopsied. Nearly half of all skin cancers identified were not the referral lesion, and 9.8 percent of the incidental lesions discovered by the dermatologist were melanomas.
In the present study, "a substantial proportion of malignant lesions was incidentally identified by the consulting dermatologist in addition to the primary lesion of concern," the authors write. The authors also suggest that "non-dermatologists may benefit from focused educational initiatives on skin cancer detection, particularly the significance of the total body skin examination and the expectations for and limitations of teledermatology."
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- K. V. Viola, W. L. Tolpinrud, C. P. Gross, R. S. Kirsner, S. Imaeda, D. G. Federman. Outcomes of Referral to Dermatology for Suspicious Lesions: Implications for Teledermatology. Archives of Dermatology, 2011; 147 (5): 556 DOI: 10.1001/archdermatol.2011.108
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