To better understand the underlying factors for not performing TBSE in connection to TDS consultations in primary care, we conducted a retrospective cohort study. Not surprising, the reason that brought the patient to seek medical care impacted risk of omitted TBSE most. Unfortunately, the risk of omitted TBSE was not only high when the primary purpose of the visit was non-skin related but also when patients sought consultation concerning a specific skin lesion. Furthermore, high age and female gender, both of the patient and the physician, had a negative effect on the probability of receiving a TBSE.
The importance of performing TBSE is emphasized in several previous studies. Aldrige et al. 14 found through analysis of two prospective cohorts of patients, referred from primary care to dermatology clinics, that more than 30% of detected melanomas were found upon TBSE. Similarly, a prospective, population-based cohort study in Australia found that 12% of all melanomas were incidentally detected and 35% were detected through routine skin checks15. In two studies from dermatology hospital clinics in Spain and the UK, as much as 26.6% and 21.7% of all detected skin cancers were detected incidentally13. However, these results might not be entirely applicable to the primary care setting, in which the populations are not selected on skin cancer risk. In a study from Belgium, the skin cancer detection rate per 100 screened participants did not differ between TBSE (2.3%), and LDS (3.2%) and LDS were found to be 5.6 times less time consuming5. Studies have also been performed on patients referred by TDS and found that 3.6–15.6% were found to have incidental skin cancers upon a face-to-face follow-up. Risk factors for having incidental skin cancers include older age (> 50), male gender, light skin phototype, having many nevi, living alone, lesion on the trunk, family history of skin cancer, personal history of skin cancer12,13,16,17.
With increasing age, this study found that the risk of omitting TBSE increased. This effect appeared in people over 59 years old, and in people over 80 years this risk was increased by 4.5 times compared to persons younger than 30 years. In several previous skin cancer risk models, older age has been shown to be a significant factor 18,19. Therefore, it is particularly unfortunate that this patient group is at a higher risk of not receiving TBSE in primary care, especially in the setting of TDS which results in fewer TBSEs performed by dermatologists. To avoid missed skin cancers, this unfavorable situation must be addressed to stress the importance of TBSE already at the primary care level when managing older persons with TDS.
A performed TBSE includes examination of private body parts and the different gender combinations can influence if a TBSE is performed and whether examination of sensitive body parts is included in the TBSE. Kuraitis et al. found in a survey study of dermatology residents in America that male residents had lower exposure during training to female genital examinations which might impact their future practice20. This is in contrast with our study that found that male physicians more often performed TBSE. There was neither a great impact on physician-patient gender discordance, even though the chance of having a TBSE was highest for male persons that was examined by male physicians. The underlying explanation for these gender differences are difficult to discern and needs further study.
Not surprisingly, the primary reason for the visit to primary care had great impact on the probability of getting a TBSE. The prevalence of multimorbidity among patients visiting primary care is high. In a prior study nine out of ten persons had more than one chronic condition and the prevalence of multimorbidity increased with age21. The primary health care system in Sweden was reformed in 2009, introducing free choice of provider for the population in combination with freedom of establishment for private primary care providers22. Gradually all regions in Sweden now have a reimbursement system that promotes that all health issues of a patient are dealt with during as few visits as possible. Hence, Swedish primary care physicians tend to deal with skin lesions brought to their attention by the patient during other visits, which presumably results in too little time to perform TBSEs. In addition, to save time and if patients seek advice in primary care for one specific skin lesion, traditionally the standard care has been to only examine this particular lesion. In an era of increasing management of patients through e-health, the standard methods of examining patients must be re-evaluated and evidence-based. Failure to perform TBSE in primary care, especially in the setting of TDS, carries an obvious risk of missing skin cancer. This risk is particularly unfavourable for patients at high risk of skin cancer, for example persons with fair skin types, older age, male gender, living alone, prior skin cancer (including a malignant index skin lesion), severely sun damaged skin, many nevi, and heredity for skin cancer. We argue that consideration of risk factors for incidental skin cancer should be taken into account when managing patients with TDS. For high-risk patients that asks for assessment of a skin lesion during a visit for another primary reason (such as hypertension or diabetes mellitus), primary care physicians might serve the patient better by setting up a new visit that allows for TBSE in conjunction with TDS.
Strengths And Limitations
The main strength of our study is the extensive data set during twelve consecutive years, including both genders and all ages. Our main limitations include the large proportion of missing information on performed TBSE and the lack of information on other risk factors for skin cancer. Also, there was no information about the reason for not performing TBSE. Hence, we do not know if the patient declined a TBSE or if time was the limiting factor. Furthermore, there is no internationally accepted practice on how to perform a TBSE. Currently, each physician develop their personal way of performing a TBSE. Therefore, we could expect variations in how comprehensive a registered TBSE is, not only in this study.8