by David J. Elpern, M.D.
presented in shorter form at the Lown Institute Conference, Washington, D.C.
April 9. 2018

Every peddler praises his needles. Portuguese proverb

In November 2017, the NY Times published an expose about the current state of dermatology.¹ It documented bizarre instances of over-diagnosis and over-treatment that are driven by ignorance and greed. Over the past 40 years, I have witnessed these changes in my specialty and am dismayed by the reluctance of my colleagues to address them. This trend began in the early 1980s when the Academy of Dermatology (AAD) assessed its members over 2 million dollars to hire a prominent New York advertising agency to raise the public’s appreciation of our specialty. The mad men recommended “educating” the public to the fact that dermatologists are skin cancer experts, not just pimple poppers; and so the free National Skin Cancer Screening Day was established.² These screenings serve to inflate the public’s health anxiety about skin cancer and led to the performance of vast amounts of expensive low-value procedures for skin cancer and actinic keratosis (AKs). At the same time, pathologists were expanding their definitions of what a melanoma is, leading to “diagnostic drift” that misleadingly increased the incidence of melanoma while the mortality has remained at 1980 levels. Concomitantly, non-melanoma skin cancers are being over-treated by armies of micrographic surgeons who often treat innocuous skin cancers with unnecessarily aggressive, lucrative surgeries.

This article was written for those members of the public who are interested in avoiding over-diagnosis and over-treatment of skin lesions.

What the patients and their families should know?

Regarding Nonmelanoma Skin Cancers (NMSCs): The majority of NMSCs (basal and squamous cell carcinomas) are slow growing and pose no risk for metastasis. They can be easily treated by scraping or excision in a dermatologist’s office. Some can be handled with creams. Some can be followed. The push for early diagnosis has inflated the incidence of NMSC. Many are in-situ lesions, that are called Stage O. Strictly speaking, in-situ lesions are not really cancers, but they are included in the statistics, thus inflating the incidence figures even more. It should be appreciated that self-serving members of the medical-industrial-academic complex changed the definitions and exaggerated the risks of skin cancer to meet their pecuniary aims. This helped to create the myth of a skin cancer epidemic. NMSC in certain skin sites do require special attention. These are lesions on the face, particularly around the orifices (mouth, nose, eyes, ears). For some of these Mohs micrographic surgery is indicated.^3,4 Because there are so many Mohs surgeons in the U.S., many patients with NMSC are subjected to unnecessary Mohs excisions of lesions on the torso and extremities. This can heighten some patients’ health anxiety. Comparing the numbers of Mohs surgeons in Canada and the U.S. can serve to explain why Mohs surgeons in the U.S. are so hungry, (Table 1).

The mortality rate of NMSC is so low that the National Cancer Institute does not report it.⁵

Regarding Actinic Keratoses (AKs): Some dermatologist treat all actinic keratosis.⁶ Their therapy of choice in liquid nitrogen, aka cryotherapy. Most actinic keratosis do not need to be anointed with the sacrament of liquid nitrogen. Cryotherapy in the United States is a lucrative activity for dermatologists that has little verifiable value. We compared the frequency of liquid nitrogen in six dermatology practices of a county of a New England state and found that it varied by a factor of 130. (Table 2) Patients in the practice where its dermatologist used cryotherapy almost 20,000 in a year frequently remark that they cannot see their dermatologist without having a procedure done.

Some dermatologists call actinic keratosis pre-cancers or even early squamous cell carcinomas. This is not true. The great majority of AKs never become SCCs, indeed many disappear if left alone.⁷ Research documenting the low risk of AKs has not been accepted for publication in major U.S. dermatology journals and the official dogma is that ~ 10% of actinic keratosis become squamous cell carcinoma; while in reality it is less than 1%.⁷ Most dermatologists know this, but they pretend that they don’t. The myth the AKs are dangerous sanctions aggressive treatment of these benign lesions and AKs have become a cottage industry transforming dermatology offices into profit centers.⁶

We have devised a decision aid for AKs what can serve to educate patients when they are seen for these benign skin lesions and give them the option of active surveillance over unnecessary treatment.^8,9

Decision aids can guide providers and patients to choose wisely as they interface with dermatologists and midlevel providers they consult. Decision aids exist for melanoma¹⁰ and could be produced for the treatment of nonmelanoma skin cancer with special attention to when micrographic surgery is indicated.

Regarding the elderly: It should be recognized that the elderly are being targeted for overtreatment of AKs and NMSC by some dermatologists. AKs and low-risk non-melanoma skin cancer can generally be observed in people nearing the end of life. An important article on the management of nonmelanoma skin cancer in patients over age 85 was recently published.¹¹ Yet this research has not been embraced by the American Academy of Dermatology. These treatments do not prolong life and may be painful and disfiguring. The authors concluded: “Most NMSCs are treated surgically, regardless of the patient’s life expectancy. Given the very low tumor recurrence rates and high mortality from causes unrelated to NMSC in patients with LLE [limited life expectancy], clinicians should consider whether these patients would prefer less invasive treatment strategies.”¹¹  We need to find out what the patient or designated care giver wants.

The New York Times article reported on a practice in Michigan that specifically targets nursing home patients for aggressive treatment of AKs and NMSC in patients who often can not give their consent.¹² This dermatology enterprise is clearly a business, not a medical practice. Family care givers for elderly or infirm parents or relatives have to protect their charges from being cash cows for concerns that prey on the elderly. A quarter of sentient patients treated for NMSC describe complications after treatment for these lesions, while only 2.5% of treating physicians recorded these in their patient’s charts¹³. One can only imagine what infirm, cognitively impaired nursing home patients experience.

Regarding Screening for Skin Cancer: Although skin cancer screening is an appealing idea, evidence for its effectiveness is lacking. Indeed, he United States Preventive Services Task Force (USPHTF) has concluded that “There is not enough evidence on the benefits or harms of routine visual skin examinations by a clinician to make a recommendation for or against this type of skin cancer screening for adults who do not have any signs or

symptoms of skin cancer.¹⁴ This does not apply to patients who have a history of skin cancer or have a strong family history. Patient preference here is important as well. Skin cancer screenings are forcefully promoted by the American Academy of Dermatology as this is lucrative for practitioners; yet how much health anxiety does it produce and to what end? There are studies whose results are pro and con regarding screening. Wise consumers need to decide what matters to them based on their risk factors and levels of anxiety. These skin examinations lead to unnecessary biopsies and cryotherapy and are another example of low-value care.

Regarding Melanoma: Melanoma is the most feared skin cancer and the incidence is steadily rising. However, there is controversy regarding why. At least some of the cause is early diagnosis of melanomas that are indolent and unlikely to metastasize or cause death.¹⁵ This can be coupled with a mortality rate that has changed little over the past 30 years.¹⁶ Additionally, pathologists have relaxed their criteria for a melanoma diagnosis (diagnostic drift).¹⁷

Where does this leave the worried public? They should know that there are specific groups at risk for melanoma. These are light completed individuals who burn rather than tan. People with a past history of nonmelanoma skin cancer are also at risk as well as those with a family history of NMSC or melanoma. These people may benefit from being screened periodically.

Once a diagnosis of melanoma is made, treatment recommendations vary widely. Overtreatment of thin melanomas is the rule in many places. Sentinel lymph node biopsy (SLNB) is still the standard in the many academic centers in U.S.; yet its value is hotly contested.¹⁷ Option Grids can help the perplexed patients and their families.^10,18

The topic of melanoma is too large and complex for this paper. To simplify,

1. If a melanoma is less than 1 millimeter thick on biopsy, an excision with one centimeter margins is adequate.
2. SLN biopsy affords no survival benefit, but can tell a patient whether her tumor is likely to metastasize or not.¹⁷
3. Post-0perative follow-up with a dermatologist or oncologist should be done every 4 – 6 months for the first 2 – 3 years.

With regards melanoma there is information overload. The National Library of Medicine’s database of articles from the medical literature (PubMed) has greater than 115,000 hits for melanoma.¹⁹ No physician can master this! A patient or family member needs to find reliable information that does not push overly aggressive management for thin or early melanomas.

What we hope you will have learned from this document:

This article may also guide primary care givers to advise their patients when they are recommended overtreatment for actinic keratosis, melanoma and nonmelanoma skin cancers.

We hope the reader will have acquired an enhanced understanding of the real risks of a diagnosis of melanoma, nonmelanoma skin cancer and actinic keratosis, as well as an appreciation of how the elderly are being exploited. When you or someone you care for are seen by dermatologists you need to appreciate that most actinic keratosis do not need treatment as far less than 1% will progress to squamous cell cancer and most will disappear over a few years. However, it you wish to have a specific lesion treated, you should let your dermatologist know. What matters to you is important, not only what matters to your dermatologist who stands to benefit from doing more.²⁰

There are subsets of nonmelanoma skin cancers that require aggressive therapy, such as Mohs surgery. These are usually located in specific areas: on or around the nose, ears, and eyes. Also tumors with certain histological features, namely, moderately or poorly differentiated, or of an infiltrative or perineural type. Unfortunately, not all pathologists report the subtypes and some biopsies are performed in ways that make typing difficult.

You need to understand how free skin cancer screenings are unnecessary, dangerous and anxiety-provoking. The goal of these activities is recruitment of patients for lucrative low-value treatment by some dermatologists. You will gain an understanding of how dermatologists and the American Academy of Dermatology have promulgated the misleading narrative that everyone needs to be screened for skin cancer.

You will have learned that the geriatric population is being targeted by for-profit dermatology businesses that are sprouting up in many places around the United States. These “practices” are trolling for procedures.

This document is intended as an aid to protect families, patients, communities and individuals from expensive, painful, unnecessary low-value care. At the same time, there are lesions that pose significant risk. How to differentiate them from those that are simply the “bread and butter” of unprincipled or ignorant providers can be difficult. The best way is by finding a dermatologist who you trust, one to whom “the practice of medicine is a calling, not a business.” This physician will not try to scare his patients but will take time to discuss what his findings are, give a rationale for treatment. He will address active surveillance if it is possible, and importantly will find out what matters to you.

 

References:

1. Skin Cancers Rise, Along With Questionable Treatments by Katie Hafner and Griffin Palmerov NY Times, 11.20.2017. Link.

2. Over the years the National Skin Cancer Screening Day has morphed into SpotMe Skin Cancer Screening

3. Chren MM et. al. Variation in care for nonmelanoma skin cancer in a private practice and a veterans affairs clinic. Med Care. 2004;42(10):1019-26.

4. Rosenthal E. Patients’ Costs Skyrocket; Specialists’ Incomes Soar NY Times 1.18.14. Link.

5. National Cancer Institute, Cancer Statistics

6. Kirby JS, et. al. Variation in the Cost of Managing Actinic Keratosis. JAMA Dermatol. 2017 Apr 1;153(4):264-269

7. Marks R et. al. Spontaneous remission of solar keratoses: the case for conservative management. Br J Dermatol. 1986 Dec;115(6):649-55.

8. Roman J, Elpern DJ. Helping Patients Decide on Treatment Options for Actinic Keratosis-Living in Cryo Nation JAMA Dermatol. 2017 Apr 1;153(4):251-253.

9. Actinic Keratosis Decision Aid (click on pdf for better resolution)

10. Option Grid for Melanoma

11. Linos E wt. al. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med. 2013 Jun 10;173(11):1006-12 Full Text.

12. Bedside Dermatology CoTM

13. Linos E, et. al. Patient-reported problems after office procedures. JAMA Intern Med. 2013 Jul 8;173(13):1249-50.

14. USPSTF Skin Cancer: Screening Release Date: February 2009

15. Shaikh WR, et. al. Melanoma Thickness and Survival Trends in the United States, 1989 to 2009. J Natl Cancer Inst. 2015 Nov 12;108(1). pii: djv294.

16. van der Leest RJ et. al. Increasing time trends of thin melanomas in The Netherlands: What are the explanations of recent accelerations? Eur J Cancer. 2015 Dec;51(18):2833-41.

17. Coit D. Sentinel lymph node biopsy for melanoma: a plea to let the data speak. Ann Surg Oncol. 2014 Oct;21(11):3359-61.

18. Option Grid for Melanoms Sentinel Lymph Node Biopsy: http://optiongrid.org/option-grids/grid-landing/32

19. PubMed search for articles on melanoma 12.2.17 (the number was 118,321 on March 9, 2018, and it goes up daily.

20. Kebede S. Ask patients “What matters to you?” rather than “What’s the matter?”. BMJ. 2016 Jul 22;354:i4045. doi: 10.1136/bmj.i4045.

 

Table 1: Distrbution of Mohs Surgeons Canada & U.S.

Canada	Metro area Population	# of Mohs Surgeons	Ratio Pop/Mohs
Calgary	1.4 million	1	1,400,000/1
Toronto	6.4 million	3	2,133,000/1
Vancouver	2.5 million	4	625,000/1
U.S. (Metro area)
Boston	4.6 million	38	120,000/1
Chicago	9.5 million	36	264,000/1
Los Angeles	13 million	33	384,000/1
Memphis	1.3 million	11	118,000/1
New York	20 million	84	238.000/1

 

Table 2: Cryotherapy in a County of a New England State 2012

#1 -6 are the dermatologists

             A             B               C                       D                   E               F

	17000	17003	17000 + 03	$ for 00 + 03	Total $ 2012	D/E
1	3059	17,044	20,004	227,603	940,398	24%
2	866	3147	4013	66,512	323,017	21%
3	351	374	725	19,443	273,006	7%
4	406	549	955	26,842	171,550	16%
5	971	2638	3006	74,088	170,368	43%
6	135	79	214	8694	143,649	6%

CPT Codes

17000 – Cryotherapy for One Lesion Reimbursed at: $59.88
17003 – Cryotherapy for > 1 Lesion   Reimbursed at: $8.05/lesion