Article Review: Total-Body Examination vs. Lesion-Directed Skin Cancer Screening

1. What type of study design was used to compare total-body examination (TBE) versus lesion-directed skin cancer screening (LDS)?
a. Case Report
b. Case-Control
c. Cross Sectional
d. Prospective Cohort

2. The study focused on specifically four outcomes of interest when comparing TBE and LDS. Which of the items below was not included as an outcome measurement?
a. Cost
b. Timeliness
c. Anxiety
d. Detection Rate

3. Which of the following statements describes a null hypothesis of the study?
a. LDS increases the likelihood of detection of skin cancer compared to the TBE.
b. LDS decreases the likelihood of detection of skin cancer compared to the TBE.
c. There is a difference in the likelihood of detection of skin cancer between LDS and TBE.
d. There is no difference in the likelihood of detection of skin cancer between LDS and TBE.

4. Which of the following statements describes the corresponding alternative hypothesis of the study?
a. LDS increases the likelihood of detection of skin cancer compared to the TBE.
b. LDS decreases the likelihood of detection of skin cancer compared to the TBE.
c. There is a difference in the likelihood of detection of skin cancer between LDS and TBE.
d. There is no difference in the likelihood of detection of skin cancer between LDS and TBE.

5. Did this study undergo an approval process prior to the start of the study and if so, who approved it?
a. This study did not go through an approval committee.
b. Yes, the study was approved the Institutional Review Board.
c. Yes, the study was approved by the Flemish government and medical ethics committee of the University Hospital Ghent.
d. Yes, the study was approved by the National Institute for Health in Belgium.

6. True or False: All patients provided only oral consent.

7. Which of the following statistical tests were not utilized in the study?
a. One-sample t-test
b. Fisher exact test
c. Independent-sample Hest
d. Paired t-test

8. From Table 2, which of the following variables were found to be statistically different when comparing TBE and LDS given a = 0.05?

a. Fitzpatrick skin type
b. Nevus count
c. Presence of actinic keratosis
d. None of the above variables were found to be statistically different between TBE and LDS.

9. True or False: The TBE group had a statistically significant higher participation rate compared to the LDS group.

10. Which of the clinical variables had the greatest frequency of clinical diagnosis?
a. Actinic keratosis
b. Basal cell carcinoma
c. Squamous cell carcinoma
d. Bowen disease

11. What was the corresponding frequency of the most frequent clinical diagnosis identified in question 10?
a. 83
b. 17
c. 47
d. 40

12. True or False: Significantly more skin cancers were detected in the TBE compared to the LDS due to TBE being a much more effective method of screening.

13. What is the probability the patient had skin cancer given they had a positive screen for either TBE or LDS?
a. 0.500
b. 0.723
c. 0.566
d. 0.125

14. Paired Hest was used to compare what outcome of interest?
a. Detection Rate
b. Anxiety
c. Cost
d. Participation Rate

15. True or False: TBE was 5.6 times more time consuming than LDS.

16. LDS is an acceptable alternative to TBE in health care systems
a. With limited budgets
b. Long waiting lists
c. Both a & b
d. None of the above

17. Which of the following was not found to be true for the LDS group?
a. Had an overall higher anxiety level compared to the TBE group prior to the screening.
b. Had a participation rate 5 times lower than the TBE group.
c. The mean anxiety level dropped after a negative screening result.
d. Higher educational levels lead to lower participation.

Research - Original Investigation

Total-Body Examination vs Lesion-Directed

Skin Cancer Screening

Isabelle Hoorens, MD; Katrien Vossaert, MD; Lore Pil; Barbara Boone, MD, PhD: Sofie De Schepper, MD, PhD; Katia Ongenae, MD, PhD; Lieven Annemans, MD. PhD; Ines Chevolet, MD; Lieve Brochez, MD, PhD

IMPORTANCE Skin cancer is the most frequent cancer type. It remains unknown if and how screening programs can be organized in a cost-effective manner.

OBJECTIVE To compare the 2 screening strategies of systematic total-body examination (TBE) and lesion-directed screening (LDS), with a focus on the participation rate, detection rate, anxiety, and cost.

DESIGN, SETTING, AND PARTICIPANTS Population-based cross-sectional screenings by a team of 6 dermatologists were organized in 2 sociodemographically similar regions. The TBE was organized in a community of 9325 inhabitants 18 years and older (Wichelen, East Flanders, Belgium) during a 5-day screening (March 14-18, 2014). The LDS was organized in a sociodemographically comparable community (Nevele, East Flanders, Belgium) of 9484 adult inhabitants during a 4-day screening (April 22 and 25-27, 2014). The first population received a personal invitation for a standard TBE. In the second population, individuals were invited for an LDS if they had a lesion meeting 1 or more of the following criteria: ABCD rule (A, asymmetry; B, borders; C, colors; and D, differential structures), ugly duckling sign, new lesion lasting longer than 4 weeks, or red nonhealing lesions.

MAIN OUTCOMES AND MEASURES In total,1982 individuals were screened, and 47 skin cancers (2.4%) were histologically confirmed, including 9 melanomas (0.5%), 37 basal cell carcinomas (1.9%), and 1 squamous cell carcinoma or Bowen disease (0.1%).

RESULTS The positive predictive value for all suspicious lesions was 56.6% (47 of 83). The participation rate was 17.9% (1668 of 9325) in the TBE group vs 3.3% (314 of 9484) in the LDS group (P < .01). The skin cancer detection rate per 100 participants did not differ significantly between the 2 groups, with rates of 2.3% (39 of 1668) in the TBE group vs 3.2% (8 of 248) in the LDS group (P = .40). The operational effectiveness per 100 invitees was 0.4% (39 of 9325) in the TBE group vs 0.1% (8 of 9484) in the LDS group (P < .01). In addition, LDS was 5.6 times less time consuming than TBE. Participants in the LDS group had significantly higher baseline anxiety levels compared with participants in the TBE group (3.7 vs 3.3 points on a visual analog scale, P < .01). In screenees without a suspicious lesion, anxiety levels significantly dropped after screening.

CONCLUSIONS AND RELEVANCE Total-body examination yielded a higher absolute number of skin cancers. Lesion-directed screening had a similar detection rate of 3.2% (8 of 248) but was 5.6 times less time consuming. When performed by dermatologists, LDS is an acceptable alternative screening method in health care systems with limited budgets or long waiting lists.