Abstract
The incidence of skin cancer is increasing and evaluation of the utility of total body skin examination (TBSE) in detecting incidental skin cancers is warranted. To evaluate the proportion and rate of incidental skin cancer detection in urgent skin cancer clinics and investigate the rate of incidental skin cancer detection in 2 groups based on the degree of clinical suspicion of the index lesion for malignancy. A multicenter retrospective cohort study with a case note review of consecutive secondary care consultations was conducted using data from 2 urgent suspected skin cancer screening clinics in UK National Health Service trusts. The study was performed from January 1, 2015, to March 31, 2016, and data analysis was performed from October 14, 2018, to February 1, 2019. Patients included those presenting with a skin lesion suspicious of malignancy who were referred to the urgent suspected skin cancer clinic (N = 5944) over 15 months. Patients who accepted and received a TBSE were subsequently included in the analysis. The proportion and rate of incidental skin cancer detection through TBSE and whether a clinically suspicious (malignant) index lesion was associated with a higher chance of having a malignant incidental lesion. Of the 5944 patients referred to the clinic, 4726 individuals (79.5%) were evaluated. In the cohort included in the analyses, the median age was 57 years (interquartile range, 39-73 years); 2567 patients (54.3%) were women. A total of 1117 skin cancers were identified; of these, 242 lesions (21.7%) were detected incidentally through TBSE, including 197 of 570 (34.6%) basal cell carcinomas, 16 of 250 (6.4%) squamous cell carcinomas, and 25 of 215 (11.6%) melanomas. The detection rate of incidental malignant lesions was 5.1 lesions per 100 patients examined (5.1%; 95% CI, 4.5%-5.8%). There was a higher detection rate of histologically confirmed incidental malignant lesions in individuals with clinically suspicious index lesions requiring biopsy (10.9%; 95% CI, 9.5%-12.5%) compared with those presenting with clinically benign index lesions (2.0%; 95% CI, 1.6%-2.5%) (P < .001). The findings of this study support the use of TBSE for urgent skin cancer referrals, highlighting the potential harms of solitary lesion assessment in a subgroup. Individuals presenting with a clinically suspicious index lesion requiring biopsy are most likely to benefit from TBSE and should be counseled regarding the benefit.
Highlights
There was a higher detection rate of histologically confirmed incidental malignant lesions in individuals with clinically suspicious index lesions requiring biopsy (10.9%; 95% CI, 9.5%-12.5%) compared with those presenting with clinically benign index lesions (2.0%; 95% CI, 1.6%-2.5%) (P < .001)
Individuals presenting with a clinically suspicious index lesion requiring biopsy are most likely to benefit from Total body skin examination (TBSE) and should be counseled regarding the benefit
Of 5944 patients referred to an urgent skin cancer screening clinic, TBSE was accepted by 4726 individuals (79.5%), partially completed for 324 patients (5.5%), and declined by 329 patients (5.5%); 555 patients (9.3%) did not have documentation of whether TBSE was performed
Summary
The incidence of skin cancers is rapidly increasing in the UK, with corresponding increases in mortality, morbidity, and health care costs.[1,2,3,4,5,6,7] This increase appears to be primarily influenced by an aging population, increased recreational sun exposure, and tanning bed use leading to higher lifetime UV exposure in conjunction with possible earlier detection.[8,9]In the UK National Health Service, patients with suspected malignant melanoma (MM) or squamous cell carcinoma (SCC) are referred from general practitioners (primary care) to secondary care dermatology services using an urgent suspected skin cancer referral pathway within 2 weeks.[10]. Total body skin examination (TBSE) is the systematic examination of a patient’s entire skin surface, nails, hair, and relevant mucosal surfaces aiming to identify incidental skin cancers that the patient may not be able to see, leading to earlier cancer detection.[11,12,13] Screening of the general population using TBSE remains controversial,[14] with ambiguity about which sites should be included in TBSE15 and concerns about cost-effectiveness.[16] In 1 UK study, as many as a third of melanomas were incidental lesions detected by TBSE,[11] with higher proportions reported in other countries where UV exposure may be greater.[12,13,17] Based on these data, Oxford University Hospitals and Whittington Hospital Health National Health Service Foundation trusts offer TBSE to all new patients referred to our urgent skin cancer screening clinics to maximize yield in detecting incidental lesions
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