FP Report -- December 1999
Melanoma: Are you missing it in your practice?
LA JOLLA, Calif. -- For Tom Zuber, M.D., of Saginaw, Mich., melanoma is a mission.
"I firmly believe that melanoma is present in patients in all family physician practices," Zuber told an audience of more than 200 physicians. "If you aren't seeing it, you're missing it."
Thomas Triehy, D.O., left, of Great Falls, Mont., and Rimas Janusonis, M.D., of Clinton, Utah, practice electrotherapy techniques during the AAFP's CME course "Common Problems and Diseases of the Skin" Nov. 4-7 in La Jolla, Calif. The new course, scheduled in response to numerous member requests, offered seven procedural workshops, 27 lectures and four case discussion workshops.Zuber, director of the family medicine residency at Saginaw Cooperative Hospitals, was program chair of the AAFP's CME course "Common Problems and Diseases of the Skin," held for the first time Nov. 4-7 in La Jolla. The AAFP created the program because members requested a chance to learn more about the skin problems and conditions they were seeing in their practices. According to a study published in 1996, the estimated lifetime risk for melanoma in 1981 was 1 in 250. In 1996, the risk increased to 1 in 87. Currently, Zuber said, it is estimated that melanoma cases are increasing 6 percent each year.
"Melanoma is the fastest- growing cancer in the United States and worldwide," he said, "and the incidence rate is going through the ceiling in the U.S. Family physicians once again are on the front lines of this disease, and we have to be aware of it."
Zuber urged FPs to do the melanoma ABCD exam, with some modifications, during every comprehensive physical examination.
"Choose a mole that the patient can easily see, like on their arm," he said. "Then demonstrate what you're looking for to the patient."
But Zuber said FPs need to go beyond the ABCD exam by including an E for elevation or enlargement -- and an F for family history.
"Family history is vital to this exam," he said. "Ask the patient whether melanoma or any form of skin cancer has ever been present in their family. Ask what their jobs were as teenagers, whether they spent a lot of time in the sun as kids. 80 percent of lifetime sun exposure occurs before age 18. All of this information is helpful."
ABCDs -- plus E and F -- of Melanoma Recognition
The goal is to recognize melanoma at the earliest stage. Melanomas tend to have the following characteristics:
Asymmetry
Border irregularity
Color variegation
Diameter greater than six millimetersZuber suggests adding:
Enlargement or elevation
Family historyZuber also recommended taking photographs of some moles for the patient's file. Then the FP can keep an eye on changes and show them to the patient.
The most important step FPs can take is to convince patients they need to be protected, either by avoiding the sun or using a strong sunscreen.
"How do you convince someone to stay out of the tanning booth, that having a tan isn't healthy?" asked Barry Hainer, M.D., of Charleston, S.C., another presenter at the course. He is professor of family medicine at the Medical University of South Carolina. "I work in the Sun Belt, so I see patients with years and years of sun damage. I think FPs should make sun avoidance more of a priority than reliance on skin protectants."
FPs whose patients use tanning beds also should suggest over- the-counter tanning products.
"You could tell them to quit going, but they won't." Hainer said. "It's an issue of appearance and image, so any future concerns about skin damage aren't important to the patient."
And it's not likely to change anytime soon, Hainer said. "We're going to have to face this as long as we have an image in our society that being tanned is healthy and attractive."
The AAFP will offer the CME course "Common Problems and Diseases of the Skin" again Nov. 2-5 in Tampa, Fla.
By Leigh Anne Bathke, Associate Editor
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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