Lack of harms from community‐based melanoma screening by primary care providers

The work by Weinstock et al represents an important contribution to what to our knowledge is the sparse literature assessing the ramifications of routine melanoma skin cancer screening practices. The need to improve the early detection of cutaneous melanoma (CM) is clearly highlighted by the increasing rate of melanoma mortality, with >10,000 melanoma deaths estimated to occur the United States in 2016. Although unprecedented progress has been made in the field of therapy for metastatic melanoma, advances in early diagnosis have been hampered by inconclusive evidence regarding the value of skin cancer screening, particularly by primary care providers (PCPs). There is little question that the detection of thinner tumors with minimal to no metastatic potential could save hundreds of thousands of lives, as opposed to focusing on the small number of patients with advanced disease. An additional consideration is the financial cost associated with the current treatment of metastatic melanoma and its associated side effects, which is projected to range from $10,879 to $35,472 per patient per month on active treatment. Given the rationale for the early detection of CM, the question arises as to why screening has not been effectively implemented to reduce mortality rates. Among the multiple explanations are the lack of a comprehensive risk-stratified approach to melanoma screening; the high cost associated with randomized screening clinical trials; the current absence of data demonstrating a mortality reduction; and the need for appropriate assessment of the potential harms of screening, including cost and burden for both PCPs and patients. Despite these challenges, published and ongoing studies have attempted to address the impact on CM screening with mixed results given the complexity of the target populations studied, baseline skin cancer awareness status, and level of training associated with the practitioners performing the screening interventions. As proposed in the study by Weinstock et al, PCPs are the key individuals to target for effective skin cancer early diagnosis training programs. However, one of the assumed barriers for PCP-based skin screening is the concern that the expansion of current screening efforts will lead to an increased number of unnecessary procedures and specialty referrals, leading to increased patient morbidity and health-related costs. To the best of our knowledge, the potential harms of screening have not been adequately addressed or studied to date, which is a major limitation raised by the US Preventive Service Task Force Draft Recommendation issued in November 2015 (available at: http://www.uspreventiveservicestaskforce.org). To our knowledge, the quality initiative conducted at the University of Pittsburgh Medical Center (UPMC) by Weinstock et al represents the first large-scale study in the United States to attempt to address this important criticism. The overall objective of the study was to determine whether training of PCPs via the Web-based INFORMED (INternet course FOR Melanoma Early Detection) skin cancer and triage program could reduce the risk of screening-induced harms by correctly reassuring patients of benign skin lesions, while maintaining appropriate referral to specialists for those with a potential diagnosis of skin cancer. When comparing the UPMC skin cancer screening effort with other screening initiatives worldwide, there are several noteworthy differences (Table 1). It is important to note that variability in the a priori education of the population to enhance awareness, and the type of training delivered to the health care providers participating in these studies, might play a significant role in the observed outcomes