A low-cost diagnostic technique called dermoscopy can help determine the potential malignancy of skin lesions—especially melanoma, in which early diagnosis is key to survival. However, providers with the specialized knowledge and experience to interpret dermoscopic findings are often limited to large academic dermatology programs and cannot be accessed by patients in underserved areas. To help remedy this disparity, dermatologists at The University of Texas MD Anderson Cancer Center are using telementoring to train dermatology residents in underserved communities to use dermoscopy for skin cancer screening.
“Dermoscopy can substantially improve a physician’s ability to evaluate a skin lesion and make appropriate decisions about whether to biopsy the lesion,” said Kelly Nelson, M.D., an associate professor in the Department of Dermatology. Dr. Nelson uses dermoscopy in her practice at MD Anderson and leads the telementoring program to share her expertise.
“Dermoscopy is a relatively low-tech, low-cost tool that can improve providers’ accuracy in diagnosing melanoma and nonmelanoma skin cancer,” Dr. Nelson said.
In dermoscopy, the clinician evaluates skin lesions using a brightly lit, handheld 10× magnifier called a dermatoscope. The dermatoscope reveals detailed patterns of blood vessels and pigmentation, helping the physician recognize not only signs of malignancy, such as asymmetry and disorganization in shape and color, but also features of normal skin lesions. Polarized light rather than regular visible light may be used to illuminate certain structures in the lesion, called chrysalis structures, which are associated with scarring, fibrosis, and inflammation.
Beyond increased clarity, a dermatoscope lets the physician take high-quality photographs for later reference. “The development of true mastery of skin cancer diagnosis requires the ability to take not only regular clinical photographs but also dermoscopic photographs of what you see in the course of your clinical care,” Dr. Nelson said, “so that when something unexpected is seen, you can go back and learn from it.”
Better skill in evaluating skin lesions translates into more appropriate uses of skin biopsy. In particular, dermoscopic proficiency has been shown to result in fewer biopsies of normal skin growths, thus reducing anxiety, scarring, and financial cost to the patient. For lesions that require biopsy, dermoscopy can be used to select the most appropriate biopsy site and technique.
Dr. Nelson noted that the removal of nonmalignant skin growths that are large and inflamed is still appropriate medical care. “The goal of dermoscopy isn’t to totally eliminate the removal of benign skin growths,” she said. “It’s to try to improve diagnostic accuracy overall so that fewer lesions need to be removed due to physician uncertainty.”
Telementoring in dermoscopy
To be successfully applied in the clinic, dermoscopy must be paired with education. MD Anderson’s Melanoma Moon Shot program has taken the lead in sharing expertise in the use of dermoscopy through a telementoring initiative called Project ECHO, or Extension for Community Healthcare Outcomes. Project ECHO began at the University of New Mexico in 2003 and was adopted at MD Anderson in 2014, partnering specialists at MD Anderson with providers in underserved communities for teleconferences regarding various aspects of cancer care (see Useful Resources: Videoconferences Allow Collaboration in Cancer Prevention, Treatment, Survivorship, OncoLog, January 2018).
Now Project ECHO is bringing education in early melanoma detection to six dermatology residency programs across Texas—and one in Missouri—in the form of monthly educational lectures led by Dr. Nelson and colleagues. Each lesson focuses on a specific topic related to dermoscopy, and the effectiveness of the lessons is tracked by quizzing participants using a series of dermoscopic images at the beginning and end of each session.
“We go through a lot of pictures because we as dermatologists learn through pattern recognition,” said Dr. Nelson. “We’re trying to give people a lot of internal reference points for specific types of lesions.”
More to come
The Project ECHO initiative at MD Anderson is expected to partner with an increasing number of dermatology residency programs over time, Dr. Nelson said. The initiative also seeks to develop educational content that other programs can teach independently.
Also in the works over the next 2–3 years is an online dermoscopy curriculum for primary care physicians. Dr. Nelson envisions a curriculum that is efficient enough to be useful to busy physicians and effective enough to impart the ability to perform full skin evaluations.
“To impact melanoma mortality across the state of Texas and beyond,” Dr. Nelson said, “we will need to have relationships with primary care physicians to support their skill in screening their patients for melanoma.”
For more information, contact Dr. Kelly Nelson at 713-792-6800 or firstname.lastname@example.org.
For those interested in the application of communications technology in dermatology, MD Anderson will host the 7th World Congress of Teledermatology November 17–18, 2018. For more information, call 713-794-1724 or visit https://teledermatology2018.info.
OncoLog, April 2018, Volume 63, Issue 4