494 - Skin Cancer Screening, Melanoma Screening, Setting Intention

Follow-up:

John’s Comments: In Take 3 #493 (April 21), we reviewed "electronic cigarettes" for smoking cessation. An alert reader wanted to check whether "vaping" was included in that term. The Cochrane Review contained the following definition statement: "When the text concerns electronic cigarettes we use the abbreviation 'ECs'. EC users are sometimes described as 'vapers', and EC use as 'vaping'."

So, this review did indeed cover "vaping". The CDC uses the term "Electronic Nicotine Delivery Systems (ENDS)", but that hasn't caught on everywhere yet.

From the USPSTF

1)    Screening for Skin Cancer

Skin cancer is the most commonly diagnosed cancer in the US. There are different types of skin cancer varying in disease incidence and severity. Basal and squamous cell carcinomas are the most common types of skin cancer but infrequently lead to death or substantial morbidity. Melanomas represent about 1% of skin cancer and cause the most skin cancer deaths. An estimated 8000 individuals in the US will die of melanoma in 2023.

Exposure to UV radiation from sun exposure, indoor tanning beds, and other UV radiation–emitting devices is the major environmental risk factor for skin cancer. History of frequent sunburns, older age, and male sex are associated with increased risk for skin cancer. Exposure to UV radiation from the use of indoor tanning beds is an important risk factor in adolescents. Incidence of melanoma is higher among White persons compared with persons of other races and ethnicities. This difference likely reflects traits associated with increased melanoma risk, such as fair skin (which is more susceptible to sunburning), light-colored eyes, and red or blond hair being more common among White persons compared with persons of other races and ethnicities.

The USPSTF recently updated their 2016 recommendation regarding screening for skin cancer and concluded that the current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adolescents and adults. (I statement)

This recommendation applies to asymptomatic adolescents and adults who do not have a history of premalignant or malignant skin lesions. It does not apply to symptomatic patients, including those who present with a suspicious skin lesion, or those already under surveillance because of a high risk of skin cancer, such as persons with a familial syndrome (eg, familial atypical mole and melanoma syndrome).

Currently, no professional organizations in the US recommend clinical visual examination for skin cancer screening. Although the American Academy of Dermatology does not have formal guidelines on clinician-performed skin cancer screening, it does encourage and provide resources for its clinician members to hold free skin cancer screening events for the public.

Mark’s Comments:

Remember that an “I” recommendation does not mean don’t do it, only that there is insufficient evidence to support it. For those who wonder, “what’s the harm?”, these could include scarring and infection from the diagnostic work-up, overdiagnosis and overtreatment, false worry, and misdiagnosis. It is also important to remember that the “total-body skin examination” (TBSE), the foundation of dermatologic cancer screening, is not yet standardized in the dermatology world in terms of method and frequency. See Pointer 2 for an attempt at this for screening for cutaneous melanoma.

Reference:

·         US Preventive Services Task Force. Screening for Skin Cancer: USPSTF Recommendation Statement. JAMA. April 18, 2023;329(15):1290-1295. doi:10.1001/jama.2023.4342. Link

From the Literature 

2)    Screening for Cutaneous Melanoma (CM)

While population-based skin cancer screening is unlikely to be cost-effective and may be associated with harms associated with overdiagnosis or misdiagnosis, failure to screen can result in missed detection and poorer long-term outcomes for some patients. Screening higher-risk populations for melanomas may be a more cost-effective approach associated with fewer persons needing to be screened per diagnosis of CM.

This debate becomes more relevant as melanoma management has transformed during the past decade, with therapeutic developments for advanced and adjuvant settings. In clinical practice, various gene expression profile (GEP) assays are commercially available and widely used. However, the GEP assays have not been validated in large multicenter prospective randomized clinical trials, and their use in clinical workflows remains poorly defined.

Regardless, early detection remains a paramount goal given that early-stage melanoma is treated more easily. Unfortunately, the major skin cancer screening guidelines do not provide consistent guidance to support a risk-stratified approach to skin cancer screening. In addition, there is a dearth of evidence to support screening by specific clinician types or for risk-based screening by individuals and/or their partners.

To address this gap, this study brought together a group of melanoma experts to develop a consensus statement on optimal practices for risk-based screening and the diagnostic and prognostic assessment of cutaneous melanoma (CM) using a modified Delphi process.

Using the threshold of 70% agreement to define consensus, the members (n=60) were presented hypothetical scenarios to vote upon via an e-mailed survey (n=42), which was followed by a consensus conference (n = 51) that reviewed the literature and the rationale for survey answers. Panelists participated in a follow-up survey for final recommendations on the scenarios (n = 45). The group supported a risk-stratified approach to various aspects of melanoma screening as well as the use of visual and dermoscopic examination. They did not, based on available evidence, reach consensus on the role for gene expression profile testing in clinical decision-making.

Panelists agreed that those patients at general or lower risk (RR < 2) could be screened by a primary care provider and/or through regular self- or partner examinations whereas those at moderate risk could be screened by their primary care clinician or general dermatologist. They agreed that higher-risk individuals (those with a relative risk [RR] of 5 or greater) could be appropriately screened by a general dermatologist or pigmented lesion evaluation. Higher-risk individuals included those with severe skin damage from the sun, systemic immunosuppression, or a personal history of nonmelanoma or melanoma skin cancer.

Mark’s Comments:

This type of “expert consensus” study would not be a usual selection for Take 3. The conflict-of-interest disclosures alone were extensive and eye-brow-raising.

What was notable, however, was both the lack of evidence for skin cancer screening in general (see Pointer 1) and the lack of even consensus guidance among national dermatology organizations. What also caught my attention was an apparent shift among the “experts” toward endorsing primary care physicians to screen the general population using a “total-body skin examination” (TBSE). Note that there is not even agreement within the dermatology community as to exactly what constitutes a TBSE. However, this is certainly something we as primary care clinicians should be able to capably perform on our patients. I for one would welcome the opportunity to relegate the patient request to visit the dermatologist for “my yearly skin exam” with low to moderate risk into the history books. Repeat after me: “I’m glad to do that screen for you, and we can likely do any necessary treatment right here in our clinic as well!”

Reference:

·         Kashani-Sabet, M. Early Detection and Prognostic Assessment of Cutaneous Melanoma: Consensus on Optimal Practice and the Role of Gene Expression Profile Testing. JAMA Dermatol. Published online March 15, 2023. doi:10.1001/jamadermatol.2023.0127. Link

From PeerRxMed ( www.PeerRxMed.org )

3)    The Life-Changing Practice of Setting Intention

“We either live with intention or exist by default.” – Kristin Armstrong, professional cyclist and 3-time Olympic gold medal winner (and no relation to Lance …)

It has been many years ago now, but the memory is as fresh as if it happened yesterday. There I was, nervously sitting on a mat at the start of my first-ever yoga class, when the instructor asked the following: “What is your intention for your practice today?”

“What!?” I thought, already prepared for this experience to be outside my comfort zone.

He went on to explain that setting an intention would help us get our mind and body aligned and allow them to both be present in the space – to “be here now.” He further encouraged us to consider making it an “I am” statement to allow it to indicate both a present intention and future aspiration. “You don’t even have to believe that it is true!”

“I am … calm,” I thought to myself. That was certainly both a present desire and future aspiration. And after repeating it to myself and going through the class, I actually did feel calmer, and returned the next week, and the next, and soon I was hooked not only on the practice of yoga, but also on the act of deliberate and conscious intention-setting. In the process, the application of those intentions expanded from “pre-class” to the entirety of my life.

Later I learned the Sanskrit name for this “whole life” intention-setting process is sankalpa. A sankalpa is an intention formed by the heart and mind – it is a is a vow and commitment made to support one’s highest truth and best self, and is something lived into in the present, not some time off in the future. Doing so is what makes it more powerful than a goal. Think of it as “a promise to your Soul.” It is a word or phrase that can be used regularly to serve as a reminder:  “This is my intention for the practice of my life in this moment.” Research has found that such regular intention setting can actually “rewire” our brain, alter our psyche, and even change our physiology.

All this resonated with me, and as I began to practice this daily, it became a very powerful tool to help me proactively calibrate my “life lens” and in the process, more effectively navigate the many challenges, frustrations, and “surprises” of life. Upon waking, I would pause and ask, then answer, the question “who will and how will I show up to this day?” with my family, friends, colleagues, patients, work team, neighbors, strangers – to those who are kind to me, and those who are not. My personal daily sankalpa became “Today I will live in Love as Light.”

And it still is …

How about you – “What is your intention for your practice today?” What “Soul promise” are you embracing each day to help provide focus as you connect with others in your world?     Consider creating the habit of making it by design, rather than by default, and notice what happens. You can thank me later …

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org