Hindawi Publishing Corporation
Journal of Skin Cancer
Volume 2012, Article ID 187963, 5 pages
ComparingMelanoma Invasiveness inDermatologist- versus
Patient-Detected Lesions:ARetrospective Chart Review
CindyL.Lamerson,1,2KristinaEaton,3Joel L.Sax,2andMohammed Kashani-Sabet4
1University of Nevada School of Medicine, Reno, NV 89557, USA
2Nevada Center for Dermatology, 650 Sierra Rose Drive, Suite A, Reno, NV 89511, USA
3University of California, Irvine, CA 92868, USA
4Center for Melanoma Research and Treatment, California Pacific Medical Center and CPMC Research Institute, San Francisco,
CA 94143, USA
Correspondence should be addressed to Cindy L. Lamerson, firstname.lastname@example.org
Received 10 May 2012; Revised 1 June 2012; Accepted 8 June 2012
Academic Editor: Giuseppe Argenziano
Copyright © 2012 Cindy L. Lamerson et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
This study examined whether patient-identified melanomas were more advanced than dermatologist-identified tumors at routine
clinic visits, and whether a personal or family history of skin cancer was associated with patterns of detection. A retrospective chart
review was performed on melanoma patients (N = 201) in a private dermatology clinic. Variables included age, gender, pattern
of detection (i.e., patient or a board certified dermatologist), personal or family history of skin cancer, skin type, and previous
sun exposure, as well as tumor location and severity. Dermatologist-diagnosed melanomas were less invasive (P < 0.0005), and
more likely present on the chest, back, and legs (P < 0.01). Conversely, patient-identified lesions were more likely to occur on
the face, neck and scalp, be associated with younger patients, and a family history of melanoma, but not other types of skin
cancer (P < 0.01). In a post-hoc analysis examining these factors as predictors of tumor invasiveness, only diagnostic source was
significant. Specifically, dermatologist-identified tumors were significantly less invasive than patient-identified tumors. Although
age, family history, and tumor location played roles in the early detection of melanomas, the most important factor was diagnostic
source. Thus, board-certified dermatologists play a key role in the early detection of malignant melanoma.
Cutaneous malignant melanoma is a serious medical condi-
tion that represents a growing problem both in the United
States and abroad . Indeed, the increase in incidence of
melanoma exceeds that of all other malignancies , and the
cost of treating this disease is significant [3–6]. The increases
in melanoma incidence rates are not simply due to increased
public awareness but a real and growing threat to public
health . Thus, early detection is critical to minimizing
Efforts to better understand and improve early detection
have focused on several areas of research, including skin-self
examination (SSE) and public education [8–10], melanoma
detection patterns [11–22], and risk factors [15, 21, 22].
Currently, in the United States, there is governmental
ambivalence about recommending routine screening for
skin cancer in asymptomatic patients in the primary care
clinical setting using a whole-body skin examination .
However, recent evidence suggests that melanoma detection
by a board-certified dermatologist is more effective than
SSE and public education programs , and comparable
to that of other screening tests, including mammography
. Moreover, in comparison with other physicians (e.g.,
internists, family practice physicians), melanomas detected
by board-certified dermatologists are thinner, in an earlier
stage of development, and have a significantly greater
survival rate [12, 14–16]. This is consistent with evidence
from surveys indicating that many general practitioners lack
confidence in their ability to identify melanomas .
2 Journal of Skin Cancer
Thus, there is clear evidence that dermatologists are
uniquely skilled in their ability to detect melanomas at an
early stage, yet there is little data focusing on dermatologists
as opposed to other physicians. Results of studies in the latter
group indicate that clinicians initially identify between 14–
25% of lesions found [16, 18–23]. These percentages are
useful from an epidemiologic standpoint, but on a more
practical level, this information is not tremendously helpful
to a majority of dermatologists since none of these studies
were performed in a private dermatology practice. Indeed,
there has been only one study examining detection patterns
of lesions were initially identified by the dermatologist .
One finding that is consistent across all studies, however, is
that lesions first identified by a physician are thinner than
melanomas found by patients [12, 16, 19–23].
In contrast to pattern-of-detection studies, one of the
least understood areas of research is the impact of a personal
or family history of skin cancer on early detection. Effective-
ness of skin cancer screening is thought to be increased if
targeted to high-risk persons , however, results of studies
are mixed [15, 21, 22]. It makes intuitive sense that patients
with a family history of melanoma would be more vigilant
in seeking out preventative measures, but given the paucity
of relevant data, it is unclear whether this factor does play a
major role in outcome.
Given these considerations, this study was designed/
performed to address two important limitations of prior
research, (1) a lack of information regarding patterns-of-
detection as they relate specifically to dermatologists in a
private dermatology clinic setting, and (2) the limited data
related to the influence of personal and family history of
skin cancer on those patterns and their influence on early
detection. Thus, we examined whether melanomas self-
identified by patients would be more invasive than those
identified by a board-certified dermatologist at routine office
screening visits, and that individuals with a personal or
family history of skin cancer would be more likely to self
diagnose a melanoma than those with no prior history.
We performed a retrospective chart review of patients (N =
201) diagnosed with melanoma by a board-certified derma-
tologist in a general dermatology clinic in Reno, Nevada,
between 2002 and 2011. Seven subjects had either missing
charts or a severe lack of data that warranted their exclusion
from the study. Patients were initially identified using a
used to obtain data including age, sex, whether subjects had
a family history or personal history of melanoma or other
skin cancer (e.g., basal cell carcinoma, squamous cell carci-
noma), the location of the melanoma (i.e., head/neck, scalp,
chest/trunk, back, arm/hand, leg/foot), Clark’s level, Bres-
tan). Tumor severity was reclassified based on whether the
melanoma was in situ, less than 0.75mm, or greater than
tumor severity or invasiveness. In addition, documentation
was reviewed to determine whether the patient identified
the lesions themselves (or by a family member) or if they
were first identified by the dermatologist during a routine
office visit and screening skin exam. All diagnoses were
confirmed through biopsy and read by an independent
Board Certified Dermatopathologist. Beginning in 2006,
dermoscopy was used as a supporting diagnostic tool by
the clinician. Patients with invasive melanoma that were
candidates for sentinel lymph node biopsy were referred to
a regional melanoma center in San Francisco, CA. Statistical
(SAS Institute Inc, Cary, NC) on a PC computer. We first
examined differences between DI and PI groups for age,
gender, personal history of melanoma and/or other types
of skin cancer, family history of melanoma and/or other
types of skin cancer, lesion location, and tumor severity
using t-tests and chi-square analyses. In order to correct
for increased error rates from these multiple comparisons,
a correction was applied to control for Type I errors (P <
0.01). A post-hoc logistic regression reporting odds ratios
(OR’s) was also performed to determine whether age, family
history, personal history, location, or diagnostic source was
predictive of tumor invasiveness while controlling for their
Institutional Review Board approval for this study was
obtained from the University of Nevada, Reno, Office of
Human Research Protection.
The patients were men (n = 81) and women (n = 120)
ranging in age from 7 to 91 (mean age was 60.3±16.3 versus
54.6 ± 15.6, resp.). Ninety one percent (91%) of patients
had a skin type of II, and 37% had a history of blistering
sunburn. Over a 10-year period, n = 101, melanomas were
initially identified by the dermatologist (DI group), with the
rest initially identified by the patient or family members (PI
group; n = 100) (Table 1). In three cases, patients were
adopted and family history could not be determined, with
the remaining subjects (n = 198) distributed among those
with no family history (n = 121, 61%), a family history
of melanoma (n = 30, 15%), and a family history of other
types of skin cancer (n = 47, 24%). Personal histories were
divided among subjects with no history (n = 89, 44%), and
those with a history of melanoma (n = 18, 9%), atypical
nevi (n = 20, 10%), and other types of skin cancer (n = 74,
37%). Overall, 158 (78.5%) subjects had melanoma in situ,
26 (13%) a Clark’s Level II tumor, 12 (6%) a Clark’s Level
III, 4 (2%) a Level IV, and 1 (0.5%) a Level V tumor. The
average Breslow’s thickness for the 43 subjects in which it
was measured was 0.73mm. Twenty-seven subjects had a
Breslow’s thickness ≥0.75, and 16 subjects <0.75 (Table 2).
The average Breslow thickness in the PI group was 0.79mm
(SD = 0.73mm, n = 33) and 0.53mm in the DI group (SD =
0.26mm, n = 10).
PI (mean age = 54.7yrs, SD = 12.5) and DI groups (mean
age = 60.7yrs, SD = 16.7), (t = 2.9, P < 0.005), (Table 1).
Journal of Skin Cancer3
Table 1: Patient variables.
Age, Mean years (SD)
Patient-identified melanoma (n = 100)a
Dermatologist-identified melanoma (n = 101)a
Skin type (Fitzpatrick scale)
Positive history of blistering sunburns
Family history of melanoma
aData are given as percentages unless otherwise indicated.
bIncludes basal and/or squamous cell carcinoma and atypical nevus.
Table 2: Melanoma characteristics.
Variable Patient-identified melanoma (n = 100)a
Dermatologist-identified melanoma (n = 101)a
aData are given as percentages.
Diagnostic source was also significantly related to a family
history of melanoma, with significantly more melanomas
identified by patients when there was a family history of
melanoma (DI = 7%, PI = 23%) compared to no family
history (DI = 67%, PI = 55%), or a family history of other
skin cancers (DI = 26%, PI = 22%), (χ2= 9.7, P < 0.01).
No such association was found for a personal history of
skin cancer (χ2= 9.5, P < 0.05, n.s.). No between-group
differences were found for gender, skin type, and history of
Differences in tumor types, severity, and location
between DI and PI groups are provided in Table 2. There
was a significant relationship between diagnostic source and
tumor location with DI tumors more likely to be present
on the chest/trunk (DI = 19%, PI = 14%), back (DI =
19%, PI = 14%), and legs (DI = 34%, PI = 21%), while
PI tumors were more frequently identified on the face/
neck (DI = 9%, PI = 29%) and scalp (DI = 1%, PI =
2%), (χ2= 15.4, P < 0.01). No between-group differences
were found for gender, skin type, and history of blistering
Analysis of diagnostic source and tumor severity resulted
in significantly less invasive melanomas in the DI group
compared to the PI group (χ2
Examination of tumor type showed that for DI tumors, 90%
were diagnosed as melanoma in situ, 7% were identified as
Clark’s level II, 2% level III, and 1% level IV. In contrast, PI
tumors were 67% in situ, 19% Clark’s level II, 10% level III,
and 4% level IV.
The post-hoc logistic regression analysis revealed that
only one significant variable predicted tumor invasiveness.
Specifically, of all the predictor variables (age, family history,
personal history, tumor location, and diagnostic source),
only diagnostic source (i.e., PI versus DI) was a significant
predictor of tumor invasiveness (OR = 0.19; 95% CI, 0.08–
0.43; P < 0.0001).
= 15.9, P < 0.0005).
4 Journal of Skin Cancer
This is the first study to systematically examine the effects
of family and personal history on detection patterns of
cutaneous melanomas in a private dermatology clinic.
Results of univariate analyses indicated that individuals with
a family history of melanoma, but not other types of skin
cancer, were significantly more likely to initially identify
a melanoma themselves. No such finding was observed in
individuals with a personal history of skin cancer and no
gender effects were found, but age was related to detection
patterns. Specifically, older patients were significantly more
likely to have a negative family history and a dermatologist-
identified melanoma. Also consistent with previous data,
lesions identified by the dermatologist were more likely to
occur on the chest, back, and legs as opposed to the face,
neck, and scalp.
strating that dermatologist-identified cutaneous melanomas
were significantly less severe than those identified by patients
[12, 15, 16]. They also add to the relative paucity of
data indicating that board-certified dermatologists identify
roughly half of the lesions found during routine private
dermatology clinic visits . These results suggest that
routine screening visits by a board-certified dermatologist
in the private practice setting are crucial to detecting
melanomas at an early stage. If patients wait to report
suspicious lesions, melanomas are more likely to progress
from local to regional or distant disease with a worse
prognosis. All high-risk persons should see a physician for
routine skin cancer screening exams throughout the year.
The relationship observed between a positive family
history of melanoma and an increased likelihood of the
patient self-identifying a melanoma is not surprising. We
expected these high-risk individuals to be more aware and
concerned about new skin growths resulting in greater
vigilance with respect to skin changes. However, given the
inconsistent findings in previous studies [15, 20–22], as
well as the results of the logistic regression presented here,
additional studies are warranted to determine the impact
of this important factor within private dermatology clinic
In contrast to family history, a past personal history of
skin cancer including basal and squamous cell carcinoma, or
melanoma, does not increase a person’s odds of identifying a
cancerous lesion. It makes intuitive sense that patients with a
history of skin cancer are more likely to see a dermatologist
for routine screening visits to ensure early diagnoses, while
patients with no personal history are less likely to see a
dermatologist regularly and only get screened after noticing
a suspicious nevus.
It is worth noting that melanomas on the chest, trunk,
and back were more likely to be found by a dermatologist.
Previous studies of susceptibility suggest different etiologic
pathways of melanoma development depending on the
anatomical location . It is possible that, given the
etiological complexity, dermatologists are uniquely qualified
among clinicians to identify lesions depending on a number
of patient characteristics and the location of the lesion.
Finally, although age was not the primary variable of
interest,resultsindicated thatadvanced agemaybe relatedto
more advanced melanomas. Previous studies have identified
age as an important prognostic factor of melanoma survival,
independent of other factors like tumor thickness and
ulceration . These studies also suggest that age-related
declines in immune-system functioning are the cause of the
increased severity of melanomas found in older patients.
Our finding that older patients with no family history of
skin cancer were more likely to have a lesion identified by
a dermatologist suggests that skin cancer education may be
more effective if targeted to older individuals with no family
history of melanoma.
Despite these findings, results of the logistic regression
age, and other variables on melanoma outcome. Specifically,
when age, family history, personal history, tumor location,
and diagnostic source were included simultaneously in the
analysis, only the diagnostic source proved to be a signifi-
cant predictor of melanoma invasiveness. Few studies have
examined interactions among factors previously associated
with tumor severity, and thus these results demonstrate that
factors interact and eventually impact early detection. Most
importantly, consistent with previous findings [12, 15, 16,
27], they suggest that board-certified dermatologists play a
critical role in the early detection of malignant cutaneous
Despite these findings, this study was limited given that
it relied on a retrospective chart review from a single private
dermatology practice. Thus, it lacked the scientific rigor of a
controlled, prospective study. In order to increase the ability
to generalize these findings across the population, additional
studies in other regions, demographic groups, and clinical
settings are warranted. However, despite these limitations,
these results are consistent with previous studies and add to
a board-certified dermatologist is associated with an earlier
detection as compared to patients who self-identify lesions.
of skin cancer may play a role in early detection.
Dermatology, Ltd. and the Women’s Dermatologic Society
(K. Eaton: Medical Student Research Grant).
The authors wish to thank Dr. Marc D. Chalet, MD, Clinical
Professor of Dermatology at UCLA School of Medicine, and
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