United States Preventive Services Task Force Overstates Cosmetic Harms of Skin Cancer Screening

Abstract

The United States Preventive Services Task Force (USPSTF) 2016 recommendation for skin cancer screening in asymptomatic healthy adults concluded that current evidence is “insufficient to assess the balance and harms of visual skin examination.” One contributing factor leading to the insufficient grade was a concern for cosmetic harms resulting from unnecessary biopsies or excisions. This commentary briefly highlights the pertinent studies and currently accepted methods for pigmented lesion biopsy. Reviewing these data will permit clinicians to more thoroughly analyze the USPSTF statement and might assist in routine assessment and management of suspicious pigmented lesions in adult patients.

In 2016, the United States Preventive Services Task Force (USPSTF) updated its 2009 recommendation for skin cancer screening in asymptomatic healthy adults.1 The task force again concluded that “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 adults.” Recently published editorials present rational counterarguments to the USPSTF’s conclusions.2–5 One contributing factor leading to the “insufficient grade” was a concern for cosmetic harms resulting from unnecessary biopsies or excisions (removal of clinically suspicious pigmented lesions subsequently determined to be benign by pathologic exam). In this commentary, we seek to clarify data regarding the potential cosmetic harms of skin cancer screening since this has not been specifically addressed in prior commentaries.

The USPSTF cites two “fair-quality” studies that attempt to extrapolate measures of harm from screening via patient satisfaction and biopsy yield.6,7 The first study investigated cosmetic results of deep shave excision of clinically benign nevi, and revealed that seven percent (4/56) of patients and 16 percent (9/56) of physicians expressed poor satisfaction.7 The USPSTF acknowledges that these findings “do not directly assess cosmetic results from excisional biopsies needed for melanoma diagnosis.” The second cited article notes that 22 to 41 “excisions” might be necessary to detect one melanoma.6 Two critical flaws in the USPSTF’s analysis of these studies should be addressed.

First, the USPSTF underscores the untoward cosmetic events identified by Gambichler et al7 despite the investigators’ emphasis of favorable patient-reported cosmetic results of shave removal of skin lesions (89% of 56 patients graded their scar as excellent or good six months after biopsy, regardless of anatomic location). The USPSTF position is further weakened because nevi were removed for cosmetic purposes, not for suspicion of malignancy. Cosmetic patients might be more discriminating about postoperative results,8 and satisfaction scores might be higher in a cohort of patients with clinically suspicious nevi. In a comparable study not reported by the USPSTF, Ferrandiz and colleagues9 evaluated the cosmetic results of mid-dermal shave biopsies of 204 benign nevi. Similarly, 92 percent of patients graded their scars as excellent or acceptable. Perhaps most telling, 98 percent of patients stated they preferred their new scar compared to the pre-existing mole and that they would be willing to repeat the biopsy. Based on these studies, it seems erroneous to conclude that shave removal (e.g., scoop shave, saucerization, tangential excision) of pigmented lesions produces an aesthetic harm when used to sample pigmented lesions.

The second flaw in the USPSTF statement regarding cosmetic harms is the inference that fusiform excisional biopsies are the major approach to sampling suspicious lesions and must be performed for proper melanoma diagnosis. Direct comparisons of excisional versus shave biopsies have not been performed, but it is true that deeper and longer skin incisions are more likely to produce worse cosmetic results.10 However, the zeitgeist of sampling suspected melanomas has shifted away from full-thickness excisions that require suturing. Numerous studies reveal that the most common methods of biopsying lesions suspicious for melanoma are non-excisional (e.g., shave or scoop-shave).11–13 Indeed, consensus guidelines from the American Academy of Dermatology (AAD) support biopsy of suspicious pigmented lesions with shave removal if performed to a plane beneath the anticipated depth of the lesion.14 Sentinel lymph node results, tumor recurrence, and disease-specific survival—long touted as the primary reasons for full-thickness excisional biopsy—are not impaired with shave biopsy.11,12,15,16

It should be noted that patients concerned with self-identified atypical nevi on their body experience psychological distress until they are provided a skin exam by a clinician who concludes that the lesions in question do not require biopsy.17,18 Patients undergoing biopsy for a suspicious pigmented lesion experience elevated anxiety until they receive a final pathologic diagnosis. Interestingly, patient anxiety decreases after being told of the diagnosis regardless of whether the lesion is malignant or benign.18 These data suggest that the “unknown” induces psychological distress, and patients with suspicious nevi benefit from biopsy for pathologic confirmation. Since the current standard of care necessitates removal of clinically suspicious nevi, it would be ethically dubious to investigate how patients feel if suspicious nevi are not biopsied.

In summary, the USPSTF’s evaluation of the aesthetic harms of skin biopsy does not accurately reflect the existing body of evidence and current state of practice. Stating that “excision-related harms are important because initial management with biopsy alone is not sufficient for removing the entire lesion”1 is deceiving to those that screen patients for melanoma. Biopsy of pigmented lesions with methods other than fusiform excision can be performed with high satisfaction to reliably diagnose melanoma without compromising oncologic and aesthetic outcomes. The USPSTF might be well served to reevaluate their analysis of potential harms from screening so that future patients are not inadvertently harmed from delayed detection of melanoma.