Derm Appeal Blog

Cutaneous Oncology in the Primary Care Setting

As one of the most common forms of cancer, skin cancer will affect up to 20% of the United States population over the course of a lifetime. Every day, nearly 10,000 people are diagnosed with skin cancer and more Americans are diagnosed with this condition than with all other cancers combined. Due to time and facility constraints, primary care physicians (PCPs) are frequently the first line of defense in the detection of skin cancer among the population as access to cutaneous specialists continues to become more limited.  

While detecting skin cancer can be challenging as non-malignant skin lesions – such as seborrheic keratoses share features with certain forms of skin cancers – the burden of skin cancer is increasingly falling on the shoulders of PCPs. Today, primary care clinicians play a vital role in detecting and managing patients who present with suspicious skin lesions as timely diagnosis and treatment are essential for patient outcomes and survival rates, especially in cases of life-threatening melanomas.

Recognizing Skin Cancer in Primary Care

In examining suspicious lesions on a patient’s body, primary care clinicians should look out for moles that are very different from other moles on the body as well as any mole that is changing in size, shape, color, or border. Dermatologists employ the so-called “ABCDEs of melanoma” to identify lesions which can prove to be a useful technique to remember the important warning signs of skin cancer. While examining a patient, if the suspicious skin lesions meet any of the below criteria the patient should be referred to a specialist for further evaluation and treatment.

Asymmetry: One half of the mole is unlike the other.

Border: The mole has irregularly shaped or jagged borders.

Color: The mole has multiple colors within it, instead of tan or brown, it is black, red, purple, or has a darker spot in the middle.

Diameter: The lesions is greater than 6mm, or approximately the size of a pencil-eraser.

Evolution: Lesion or mole is changing over time.

Experts advise PCPs to look out for common patient complaints that include areas of skin that are sore or bleeding, seem to heal, and then begin to hurt or bleed again, as these often indicate basal cell carcinoma. Additionally, squamous cell carcinoma often presents as scaly spots, however, many conditions can appear this way and it is recommended PCPs palpate the lesion to determine whether the lesions are on the skin or if it is infiltrating the skin as infiltration typically suggests squamous cell carcinoma.

Referring to a Specialist

When biopsy or removal of suspected skin cancer is needed, primary care physicians should refer their patients to dermatologists – especially in cases of suspected melanoma. In these situations, it is recommended that PCPs help patients set up appointments with dermatologists before patients leave the office to minimize chances of delays in care. Dermatologists are more likely to assist patients directly referred by PCP colleagues as soon as possible. At the same time, if PCPs are unsure or unable to confirm skin cancer diagnosis, referral to dermatologists is still recommended as false alarms may be common yet they are better than risking a melanoma patient going untreated.

Efficacy of Primary Care-Based Skin Cancer Screening

Tackling skin cancer within the primary care setting requires specialist education, training, and resources, all of which are currently lacking. Nonetheless, primary care physicians can effectively and successfully manage cutaneous oncology patients. A 2017 study published in JAMA Dermatology revealed that skin cancer training and screening can be done in primary care and may improve PCP diagnostic accuracy. The research reported that primary care-based skin cancer evaluation was feasible and could be performed without substantial associated harms to populations at risk for advanced melanomas. Additionally, as the industry’s technological capabilities continue to grow, the use of artificial intelligence-assisted resources alongside improved primary care dermatologic education will allow clinicians to navigate the growing burden of skin cancer more effectively.

Skin Cancer Prevention

The primary risk factor for all skin cancer is exposure to ultraviolet-radiation with over 80% of cases considered preventable therefore, PCPS can play a vital role in skin cancer prevention as part of routine medical care. “Part of the role of the PCP is to advise all patients about avoiding peak sun hours between 11 a.m. and 4 p.m., applying high-SPF sunscreen every two hours, using sunglasses and hats, and wearing sun-protective clothing,” Dr. Julia R. Nunley, MD, FACP, professor of dermatology at the Medical College of Virginia Hospitals told ACP Internist.“They should also make sure patients are getting eye exams, perineal exams and dental checkups because melanomas can form in any of those areas as well.”

As the burden of skin cancer continues to weigh on the global population and dermatology specialists become increasingly difficult to access for the wide majority of patients, the future of primary care is likely to include a growing segment of cutaneous oncology. To assist primary care practitioners in developing the necessary skills to perform skin cancer screenings and further prevention efforts in the population LivDerm is offering an in-depth program centered around the most relevant dermatology topics for frontline practitioners, Deep Dive: Dermatology on the Frontlines, taking place on April 24, 2021.

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