Clinicians cite time, patient embarrassment as barriers to performing skin cancer exams

Time constraints, other illnesses and patient embarrassment may prevent dermatologists, internists and family practitioners from conducting full-body skin examinations, according to a report in the January issue of Archives of Dermatology, one of the JAMA/Archives journals. However, dermatologists are significantly more likely than internists and family practitioners to conduct such screenings.

Skin cancer is the most frequently diagnosed cancer in the United States, according to background information in the article. 'It is critical for patients to adhere to primary prevention behaviours and for clinicians to adopt secondary prevention strategies aimed at early detection of skin cancer to reduce its associated morbidity and mortality,' the authors write. 'Previous studies have suggested that many individuals, particularly those with established risk factors for melanoma, would benefit from active skin cancer screening and surveillance, and screening by dermatologists in particular may also be cost-effective.'

Susan A. Oliveria, Sc.D., M.P.H., of Memorial Sloan-Kettering Cancer Centre, New York, and colleagues surveyed 2,999 physicians randomly selected from the American Medical Association's Medical Marketing Services database in 2005. Of those, 1,669 (59.2 percent) returned surveys, including 559 family practitioners, 431 internists and 679 dermatologists.

More dermatologists (81.3 percent) than family practitioners (59.6 percent) or internists (56.4 percent) report regularly performing full-body skin examinations on their patients.

Among all the responding physicians, the top three barriers to performing these examinations were time constraints, competing illnesses and patient embarrassment or reluctance. More family practitioners (54.4 percent) and internists (54.5 percent) reported time constraints as a moderate or major barrier than did dermatologists (30.6 percent),

Dermatologists were more likely to cite patient embarrassment or reluctance as a moderate or major barrier (44.2 percent, vs. 31.3 percent of family practitioners and 32.7 percent of internists). This may be because patients visit the dermatologist with more stigmatising skin conditions, because they don't have an established relationship with a specialist or because they do not expect to undress, the authors note. 'Patients may see a dermatologist for an isolated skin condition, such as a wart, and the dermatologist may feel awkward asking this person to undress for a full-body skin examination,' they write. Conversely, internists and primary care providers routinely ask patients to undress for physical examinations (such as pelvic and rectal examinations); thus, undressing for the examination is understood and expected by the patient.'

Recognising such barriers could help to overcome them in both primary and secondary care settings, the authors conclude. 'Skin cancer is an ideal cancer for encouraging screening because many risk factors are well known, including family history, the presence of atypical nevi, skin type and history and pattern of sun exposure; because the disease is highly prevalent; and because there are opportunities for early detection,' they write. 'Understanding the determinants of patient skin cancer screening could help promote interventions based on physician characteristics that are amenable to change, potentially improve physicians' prevention practices and help promote early detection.'