Tuesday, February 12, 2013

USPTF, CCE, Melanoma, and Survival


Screening for melanoma should be a simple task, especially with the recent use of dermoscopy, but somehow it is not. The USPTF is one of the many bodies under the ACA which will create limitations on patient care, namely a means to reduce costs. Melanoma is an all too tragic disease, one which should and can be militated against. Unfortunately the death rate from melanoma has not decreased and with the current recommendations it may very well increase.

Let us begin by reviewing the current Government ruling on skin examination. One should remember that this is the basis for Comparative Clinical Effectiveness, CCE. We discussed this issue just a few postings back. We have also been concerned since the beginning of the ACA debacle about its negative impact on Health Care. The USPTF has presented a set of at best non-recommendations[1].

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for skin cancer by primary care clinicians or by patient skin self-examination. (I statement)

Namely the recommendation is that primary care physicians are not trained to make a correct diagnosis. However it does not admit that Dermatologists do so as well. One may envision a great opportunity for Teledermoscopy allowing the capture of in office dermoscope images and then referral to a Dermatologist. Reading the dermoscopic images takes less than a minute by a trained Dermatologist and the specificity of such a reading can be quite high.

The USPTF Report continues:

Primary care physicians are moderately accurate in diagnosing melanoma, with a sensitivity of 42% to 100% and a specificity of 70% to 98%. A large systematic review analyzed the evidence on diagnostic accuracy of primary care physicians and dermatologists; most of the studies used images of lesions that had been histologically confirmed. The systematic review included 11 studies with primary care physicians and found a sensitivity of 42% to 100% and a specificity of 98% in the diagnosis of melanoma. The authors concluded that the evidence was insufficient to determine whether dermatologists and primary care physicians differed in accuracy . However, most studies on the accuracy of diagnosis of melanoma by primary care physicians evaluated the ability to identify melanoma from images of lesions of a known diagnosis; the applicability of this evidence to a whole-body skin examination in the setting of screening for skin cancer is not clear.

In a recent Editorial in Investigative Dermatology the authors state regarding recent and currently standing USPTF recommendations the following[2]:

….. incorporating new policy initiatives is paramount. The USPSTF recently gave a B-level recommendation for behavioral counseling to prevent skin cancer in patients 10 to 24 years old, an upgrade from the previous I rating (insufficient evidence). Such ratings indicate at least fair evidence that the service improves important health outcomes and concludes that benefits outweigh harms. Results from the well-executed German screening and educational program (albeit not a randomized study) should now be proactively shared with the USPSTF, which has previously argued that there is insufficient evidence to support the recommendation of population- based skin cancer screening. In its most recent report on screening, the USPSTF noted that “no studies of the benefits of screening have compared a screened population with an unscreened population with respect to appropriate health outcomes”

This is recommendation is vague and to some degree flies in the face of the obvious. Screening, especially with a dermoscope, works in most cases. The specificity is high, and even if in doubt the removal of a questionable lesion is hardly traumatic.

A study of potential harms of screening is key—although the USPSTF has expressed concern that false-positive results may lead to biopsies and unnecessary treatment, they have acknowledged that the evidence to back up this theory is limited. Screening should be lodged within closed health-care systems that have experience in large screening trials and the demonstrated ability to follow up on all participants.

They would also need to be capable of capturing melanoma thickness, mortality, and other relevant data. In addition, there may be the potential to seek funding for a Medicare demonstration project, possibly in a state with high melanoma mortality rates and physician networks lodged in underserved areas. Lessons can be learned on obtaining cost estimates for broad-scale public health efforts from the Assessing Cost-Effectiveness– Obesity group and its important contribution to obesity prevention programs.

The authors of the Editorial conclude:

In summary, in the United States, melanoma remains the only preventable cancer for which mortality rates are not dropping. Nevertheless, population- wide screening rates remain low. As melanoma rates continue to rise and patient demand for screening accelerates, the current deficit in the dermatology workforce will become even more apparent. However, a confluence of new developments holds much promise. Web-based technology affords the potential to teach standardized skin cancer examinations to physicians, physician extenders, and high risk patients in multiple settings. Digital dermoscopy offers clinicians new options for distinguishing between benign, atypical, and aggressive lesions.

The Affordable Care Act has the promise of providing screenings to the majority of the US high-risk population that has yet to be screened. Finally, the results of the German screening program provide new and important evidence for the value and benefits of visual examination for melanoma.

Thus we believe that although such screening is possible, and highly productive in reducing morbidity and mortality, the way the USPTF phrases its results will have a negative impact on patient survival.

References

USPTF, Screening for Skin Cancer: U.S. Preventive Services Task Force Recommendation Statement, Ann Intern Med. 3 February 2009; 150(3):188-193

Geller, A., A. Halpern, The Ever-Evolving Landscape for Detection of Early Melanoma: Challenges and Promises, Journal of Investigative Dermatology (2013) 133, 583–585.