When new patients with advanced melanoma arrive in Kelly Nelson’s clinic, she notices that many share the same story: they had insurance and even a primary care doctor, but their melanoma wasn’t caught early because no one examined their skin.
“Opportunities have been lost,” says Nelson, an associate professor of Dermatology. “Melanoma has the highest death rate of all skin cancer types. But when it’s detected in its earliest stages, it’s profoundly curable.”
One of the most effective tools for early detection is the dermoscope – a brightly lit, handheld magnifier that helps doctors visually inspect moles and other pigmented skin lesions. When used correctly, dermoscopes have reduced false positives which occur when normal moles are unnecessarily biopsied, and false negatives which occur when cancerous skin lesions are incorrectly diagnosed as normal. But dermoscopy, as it is called, is not a universal skill, even among dermatologists.
“Dermoscopy is not an easy skill to master by self-study,” says Stephanie Savory, M.D., assistant professor of Dermatology at The University of Texas Southwestern Medical Center in Dallas. “Diagnostic accuracy is highly correlated with the user's amount of training. Unfortunately, an effective dermoscopy education curriculum for medical residents has not been standardized.”
Creating a standardized training program
That’s why in 2017, Savory and Nelson, along with Janice Wilson, M.D., from The University of Texas Medical Branch at Galveston, launched Dermatology Telementoring for Early Melanoma Diagnosis (DERM:EMD). The program is part of MD Anderson’s Melanoma Moon Shot® primary prevention and early diagnosis flagship – a project designed to save lives by preventing melanoma and diagnosing it early. The DERM:EMD program uses the Project ECHO (Extension for Community Healthcare Outcomes) telementoring model to deliver a year-long dermoscopy education course to dermatology residents. The ECHO model connects primary care physicians from rural and underserved areas with specialists from academic medical centers to share best-practice management of complex health conditions.
“What sets our curriculum apart from typical dermoscopy education is we not only provide the foundational knowledge during our introductory training sessions, but we also pair it with challenging case conferences which give the residents an opportunity to practice discussing specific individual cases,” Nelson says. “And that gives them the learning loop of using those skills and practicing them in a small educational setting.”
Before the first-of-its-kind program began, no standard metrics existed to measure dermoscopy knowledge or skills. So the team created and validated their own metrics, which they plan to publish in a dermatology journal next year.
More than 175 dermatology residents received dermoscopy training during DERM:EMD’s first two years. At many schools, faculty also attend lectures and lead case conferences. This year, the program will be offered at all 12 dermatology residency programs in Texas that are accredited by the Accreditation Council for Graduate Medical Education, the body responsible for accrediting most of the graduate medical training programs for physicians in the United States. DERM:EMD also will be offered at several National Cancer Institute-designated cancer center sites nationwide.
“There aren’t enough dermoscopy experts in the U.S.,” Nelson says. “Part of my personal mission is to support the development of other experts with these collaborative relationships.”
The next phase of DERM:EMD is to expand the program to the primary care physicians, including family and general practitioners, and internists.
“For patients who don’t have a dermatologist, primary care physicians are well-positioned to perform dermoscopy and catch melanoma early – if trained to do so,” Nelson says.
Nelson’s team worked with the family medicine residency program at Texas Tech University Health Sciences Center El Paso to develop a new version of the curriculum, which launched in October 2019, specifically designed for primary care providers.
“We serve a particularly vulnerable and underserved population in El Paso, who face barriers to obtaining timely dermatologic care,” says Gerardo Vasquez, M.D., assistant professor and assistant residency program director in Family and Community Medicine at Texas Tech El Paso.
For those who lack insurance in rural areas of Texas, access to a dermatologist can be difficult, if not impossible, to find at home. Catching melanoma at its earliest, most treatable stages is even harder for this population.
“As we thought about the enormity of Texas, we wanted to consider the geographic and racial diversity of the state from the beginning,” Nelson says. “We felt that El Paso would be a good starting point for our collaboration.”
Understanding the melanoma profile of Texas
Caucasian men of low socioeconomic status who live alone are at greatest risk of dying from melanoma in the U.S. However, Texas and California have far more Hispanic melanoma patients than other states.
“We’re partnering with the Texas Cancer Registry to understand the demographics of melanoma for the state of Texas,” Nelson says. “We also want to understand which regions of our state have higher melanoma death rates and higher numbers of advanced cases when first detected.”
This will allow the DERM:EMD team to target future outreach to the areas where it’s needed most. Ultimately, Nelson hopes all Texans will have the opportunity to receive dermoscopy care within their own communities.
“We’re empowering these communities to provide the best care they can,” Nelson says. “When I teach other physicians a clinical skill, I have the opportunity to save more lives than I could caring only for those patients who walk through my clinic door.”