Skin Cancer Early Detection and Prevention for the Primary Care Physician: Assessing and Changing Physicians' Knowledge, Attitudes, and Behaviors

Context: Skin Cancer is of growing public health concern. The incidence and mortality of skin cancer continues to rise. The morbidity and mortality from skin cancer is directly proportional to the depth of invasion of the tumor. Primary care physicians are in an optimum position to diagnose skin cancer due to their frequent exposure to patients. However, it is not clear if primary care physicians have adequate knowledge or diagnostic ability to detect skin cancer. Additionally it is not clear if primary care physicians are screening or counseling high-risk patients. Objectives: To assess primary care physicians' knowledge, attitudes, and behavior concerning early detection and prevention of skin cancer, and to assess changes in primary care physicians' knowledge, attitudes, and behavior following implementation of a brief educational intervention developed by the authors. Design: Prospective Randomized Controlled Trial Setting and Participants: Family medicine and internal medicine residency programs (9 total) in academic and community based settings were randomized to control or intervention groups. Participants from both groups (174 total) completed an initial survey to assess baseline knowledge, attitudes, and behavior with regards to early detection and prevention of skin cancer. The control groups attended their normal conference while the intervention groups attended a skin cancer education module. The same survey was completed again at 2-4 weeks follow up by 88 of the original 174 participants. Of the 88 participants who completed both surveys, 43 were in the intervention group and 45 were in the control group. Baseline and follow up surveys were analyzed. Intervention: 1-hour educational presentation covering skin cancer epidemiology, diagnosis, decision-making, screening, and counseling. A copy of the presentation and additional educational materials provided to participants can be found in appendix 1. Main Outcome Measures: Participant survey responses at baseline and follow-up. The survey found in appendix 2 tested skin cancer knowledge, diagnostic ability, attitudes, and behavior. Results: The baseline survey revealed primary care physicians' deficiencies in general skin cancer knowledge and diagnostic ability. 28% knew the lifetime risk of melanoma for someone in the year 2000 and 18% correctly identified 3 out of 3 melanomas. 43% knew all four of the ABCD's of melanoma, and 18% listed at least 5 risk factors for skin cancer. Following the educational intervention, participants in the intervention group gained significant knowledge and diagnostic ability. Participants in the intervention group scored significantly better on: 3 of 6 general skin cancer knowledge questions, listing the ABCDs of melanoma, and listing risk factors of melanoma. Participants in the intervention group correctly diagnosed 2 of the 3 melanomas more frequently than those in the control group. Primary care physicians in the intervention group reported performing skin cancer preventive or early detection measures with new or high-risk patients more often than those in the control group. Conclusions: Primary care physicians possess inadequate knowledge, diagnostic skills, and preventive behaviors with regards to skin cancer prevention and early detection that can be improved using a brief educational intervention.Master of Public Healt

A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.

ImportanceExcisional skin cancer surgery is a common procedure, with no formal consensus for mitigating the risk of wrong-site cutaneous surgery.ObjectiveTo systematically consider the usefulness and feasibility of proposed methods for correct biopsy site identification in dermatology.Evidence reviewSurvey study with a formal consensus process. Item development was via a literature review and expert interviews, followed by 2 stages of a Delphi process to develop consensus recommendations.FindingsIn total, 2323 articles were reviewed in the literature search, with data extraction from 14. Twenty-five experts underwent 30-minute structured interviews, which were transcribed and coded. The resulting survey was composed of 42 proposed interventions by multiple stakeholders (biopsying physicians, operating physicians, nurses, ancillary staff, patients, caregivers, and family members) at 3 time points (day of biopsy, delay and consultation period, and day of definitive surgery). Two rounds of a Delphi process with 59 experts (25 academic and 34 private practice) scored the survey. Strong consensus was obtained on 14 behaviors, and moderate consensus was obtained on 21 other behaviors. In addition, a 2-state simultaneous algorithm was developed to model surgeon behavior on the day of definitive surgery based on surgeon and patient perceptions.Conclusions and relevanceWhen definitive surgery is performed after the initial biopsy and by a different surgeon, procedures can be implemented at several time points to increase the likelihood of correct site identification. The specific circumstances of a case suggest which methods may be most appropriate and feasible, and some may be implemented. The risk of wrong-site cutaneous surgery can be reduced but not eliminated

Evidence-Based Clinical Practice Guidelines for Microcystic Adnexal Carcinoma: Informed by a Systematic Review

Importance: Microcystic adnexal carcinoma (MAC) occurs primarily in older adults of white race/ethnicity on sun-exposed skin of the head and neck. There are no formal guiding principles based on expert review of the evidence to assist clinicians in providing the highest-quality care for patients. Objective: To develop recommendations for the care of adults with MAC. Evidence Review: A systematic review of the literature (1990 to June 2018) was performed using MEDLINE, Embase, Web of Science, and the Cochrane Library. The keywords searched were microcystic adnexal carcinoma, sclerosing sweat gland carcinoma, sclerosing sweat duct carcinoma, syringomatous carcinoma, malignant syringoma, sweat gland carcinoma with syringomatous features, locally aggressive adnexal carcinoma, and combined adnexal tumor. A multidisciplinary expert committee critically evaluated the literature to create recommendations for clinical practice. Statistical analysis was used to estimate optimal surgical margins. Findings: In total, 55 studies met our inclusion criteria. The mean age of 1968 patients across the studies was 61.8 years; 54.1% were women. Recommendations were generated for diagnosis, treatment, and follow-up of MAC. There are 5 key findings of the expert committee based on the available evidence: (1) A suspect skin lesion requires a deep biopsy that includes subcutis. (2) MAC confined to the skin is best treated by surgery that examines the surrounding and deep edges of the tissue removed (Mohs micrographic surgery or complete circumferential peripheral and deep margin assessment). (3) Radiotherapy can be considered as an adjuvant for MAC at high risk for recurrence, surgically unresectable tumors, or patients who cannot have surgery for medical reasons. (4) Patients should be seen by a physician familiar with MAC every 6 to 12 months for the first 5 years after treatment. Patient education on photoprotection, periodic skin self-examination, postoperative healing, and the possible normal changes in local sensation (eg, initial hyperalgesia) should be considered. (5) There is limited evidence to guide the treatment of metastasis in MAC due to its rarity. Limitations of our findings are that the medical literature on MAC comprises only retrospective reviews and descriptions of individual patients and there are no controlled studies to guide management. Conclusions and Relevance: The presented clinical practice guidelines provide an outline for the diagnosis and management of MAC. Future efforts using multi-institutional registries may improve our understanding of the natural history of the disease in patients with lymph node or nerve involvement, the role of radiotherapy, and the treatment of metastatic MAC with drug therapy

Evidence-Based Clinical Practice Guidelines for Microcystic Adnexal Carcinoma: Informed by a Systematic Review

Microcystic adnexal carcinoma (MAC) occurs primarily in older adults of white race/ethnicity on sun-exposed skin of the head and neck. There are no formal guiding principles based on expert review of the evidence to assist clinicians in providing the highest-quality care for patients. To develop recommendations for the care of adults with MAC. A systematic review of the literature (1990 to June 2018) was performed using MEDLINE, Embase, Web of Science, and the Cochrane Library. The keywords searched were microcystic adnexal carcinoma, sclerosing sweat gland carcinoma, sclerosing sweat duct carcinoma, syringomatous carcinoma, malignant syringoma, sweat gland carcinoma with syringomatous features, locally aggressive adnexal carcinoma, and combined adnexal tumor. A multidisciplinary expert committee critically evaluated the literature to create recommendations for clinical practice. Statistical analysis was used to estimate optimal surgical margins. In total, 55 studies met our inclusion criteria. The mean age of 1968 patients across the studies was 61.8 years; 54.1% were women. Recommendations were generated for diagnosis, treatment, and follow-up of MAC. There are 5 key findings of the expert committee based on the available evidence: (1) A suspect skin lesion requires a deep biopsy that includes subcutis. (2) MAC confined to the skin is best treated by surgery that examines the surrounding and deep edges of the tissue removed (Mohs micrographic surgery or complete circumferential peripheral and deep margin assessment). (3) Radiotherapy can be considered as an adjuvant for MAC at high risk for recurrence, surgically unresectable tumors, or patients who cannot have surgery for medical reasons. (4) Patients should be seen by a physician familiar with MAC every 6 to 12 months for the first 5 years after treatment. Patient education on photoprotection, periodic skin self-examination, postoperative healing, and the possible normal changes in local sensation (eg, initial hyperalgesia) should be considered. (5) There is limited evidence to guide the treatment of metastasis in MAC due to its rarity. Limitations of our findings are that the medical literature on MAC comprises only retrospective reviews and descriptions of individual patients and there are no controlled studies to guide management. The presented clinical practice guidelines provide an outline for the diagnosis and management of MAC. Future efforts using multi-institutional registries may improve our understanding of the natural history of the disease in patients with lymph node or nerve involvement, the role of radiotherapy, and the treatment of metastatic MAC with drug therapy

Sebaceous carcinoma: evidence-based clinical practice guidelines

Sebaceous carcinoma usually occurs in adults older than 60 years, on the eyelid, head and neck, and trunk. In this Review, we present clinical care recommendations for sebaceous carcinoma, which were developed as a result of an expert panel evaluation of the findings of a systematic review. Key conclusions were drawn and recommendations made for diagnosis, first-line treatment, radiotherapy, and post-treatment care. For diagnosis, we concluded that deep biopsy is often required; furthermore, differential diagnoses that mimic the condition can be excluded with special histological stains. For treatment, the recommended first-line therapy is surgical removal, followed by margin assessment of the peripheral and deep tissue edges; conjunctival mapping biopsies can facilitate surgical planning. Radiotherapy can be considered for cases with nerve or lymph node involvement, and as the primary treatment in patients who are ineligible for surgery. Post-treatment clinical examination should occur every 6 months for at least 3 years. No specific systemic therapies for advanced disease can be recommended, but targeted therapies and immunotherapies are being developed