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Minimal impact from 1-year dermoscopy training for primary care providers


Among 267 participants, there was a 69% increase in average total number of biopsies per year with a 10% shift from benign to malignant biopsies (p<.0001). The NNB for melanoma decreased from 119 to 53 (p<.001).

Clinical Pearls

  • This was a single-site cohort study of “primary care providers” in internal medicine, internal medicine/pediatrics, pediatrics, or family medicine at one institution to study how a 90-minute dermoscopy and biopsy workshop with monthly telemonitoring review sessions affected the benign-to-malignant (BtM) ratio of biopsies and number needed to biopsy (NNB) to detect melanoma.

  • The authors found that among 267 participants there was a 69% increase in average total number of biopsies per year with a 10% shift from benign to malignant biopsies (p<.0001). The NNB for melanoma decreased from 119 to 53 (p<.001).


Discussion:

Melanoma and non-melanoma skin cancers (NMSCs) comprise the largest proportion of cancers diagnosed annually in the United States, with over 5 million NMSCs and ~200 thousand melanomas. Early detection and management of skin cancers are the key to minimizing morbidity and mortality. However, there continues to be a maldistribution of dermatologists, especially among rural communities with a “dermatologist density” less than the critical threshold of 4 dermatologists/100000 individuals.[1,2]


To that end, the authors of this one-year study investigated the efficacy of a 90 day multi-modal dermoscopy (and biopsy) training course with monthly re-education among 267 primary care (e.g. internal medicine, internal medicine/pediatrics, pediatrics, and family medicine) “providers”. Comparing pathology results of skin biopsies performed for a 5-year period before and 2-year period after the intervention, the authors found a 10% shift in relative number of malignant to benign biopsies with 5% increase in basal cell carcinomas (BCCs), 4% increase in cutaneous squamous cell carcinomas (cSCCs) and 1% increase in melanomas diagnosed over 2 years. The authors also found a decrease in the number-needed to biopsy (NNB) to diagnose 1 melanoma decreased from119 to 53 (p<.001)


The authors note study limitations include limited post-intervention follow-up data, lack of a control group, and small skin cancer incidence among their patient population. Other limitations include failure to specify level of training (i.e., primary care physician vs. non-physician clinicians), prior training, and potential improvement post-intervention all of which may greatly differ among attendings, residents, physician’s assistants and nurse practitioners within and between disciplines. It is also important to note that post-intervention the average annual biopsies performed increased to 1549 vs. 913 pre-intervention. This translates to an average of ~600 additional biopsies annually. Over this time period, a similar number of melanomas were detected (pre-intervention 38 vs post-intervention 48). The authors also do not note the Breslow depth, American Joint Committee on Cancer 8th edition, or any other staging for melanoma or NMSCs nor do they mention patient outcomes.


While the authors suggest that this intervention may decrease health care costs and overdiagnosis, it is unclear what the true clinical significance of these findings are and how patients may truly be affected. Further studies are needed to determine how such an intervention at various levels of medical and nursing training may affect patient outcomes.




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