THEMED ARTICLE y Skin Cancer Review

Melanoma patient
self-detection: a review
of efficacy of the skin
self-examination and
Expert Review of Anticancer Therapy Downloaded from informahealthcare.com by University of Louisville on 01/23/15

patient-directed educational
efforts
Expert Rev. Anticancer Ther. 13(12), 1423–1431 (2013)

Sarah Yagerman1 and Early detection of cutaneous melanoma results in reduced morbidity and mortality. Although
Ashfaq Marghoob*2 screening by physicians has been shown effective, the role of skin self-examination (SSE) in
melanoma secondary prevention is less well studied. Various methods and educational
For personal use only.

1
Memorial Sloan-Kettering Cancer Cen-
ter, New York, NY 10065, USA strategies have been implemented to empower patients to perform efficacious SSEs. Patient
2
Memorial Sloan-Kettering Skin Cancer demographics play an important role in their likelihood to examine their own skin and ability
Center: Hauppauge, 800 Veterans to detect melanoma. Visual aids such as total body photography and dermoscopy, which have
Memorial Highway, 2nd Floor,
Hauppauge, NY 11788, USA
improved physician exams, are becoming elements accessible to patients for augmentation of
*Author for correspondence: self-exam. This review examines the literature of SSE in melanoma detection.
Tel.: +1 212 610 0780
Fax: +1 212 308 0739 KEYWORDS: dermoscopy • early detection • melanoma • skin self-examination • total body photography
marghooa@mskcc.org

The intent of melanoma screening is to detect
this disease while confined to the skin and thus
more amenable to cure. Although acknowledg-
ing the issue of lead-time bias, screening for
melanoma should result in improved absolute
survival rates. The correlation between early dis-
ease and improved survival in cutaneous mela-
noma is well established, with 5-year survival
for localized disease being 98% and dropping to
16% in the presence of distant metastases [101].
A recent population-based screening initiative
of over 300,000 adults showed epidemiological
evidence that strongly suggests that skin cancer
screening by physicians may lead to a reduction
in melanoma-specific mortality [1–5]. Although
numerous studies have shown the effectiveness
of physician-based examinations for the detec-
tion of melanoma, the effectiveness of patient
skin self-examination (SSE) for finding mela-
noma is less well established. In addition, the
impact of educational efforts targeting both
large populations and smaller high-risk patient
populations remains to be elucidated.
The patient education efforts for the detec-
tion of melanoma were significantly aug-
mented with the introduction of the ABCD
acronym in 1985, which intended to high-
light the most salient features of superficial
spreading melanoma, namely asymmetry,
border irregularity, color variegation and
diameter >6 mm [6]. Since its introduction,
numerous variations on the acronym and
combination criteria algorithms have been
proposed, all aiming to further enhance early
detection of melanoma. From analytical lists
of features such as the ABCDs, the idea of
improving patient education has evolved to
incorporate nonanalytical reasoning strategies
such as differential recognition and compara-
tive methods. These more cognitive educa-
tional strategies try to capitalize on our innate
ability to recognize lesions that appear differ-
ent from surrounding nevi and to learn about
the difference in the features of nevi and mel-
anoma by simply looking at exemplary images
of these lesions. Theoretically, both analytical

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2013 Informa UK Ltd ISSN 1473-7140 1423

 Review Yagerman & Marghoob
and nonanalytical reasoning can enhance patient self-detection
of melanoma.
Numerous tools have emerged that augment the diagnostic
accuracy of physicians for detecting subtle melanomas including
those that do not manifest any of the ABCDs. The two most
utilized aids are photography and dermoscopy. Although the
use of total body photography and dermoscopy remains pri-
marily in the hands of physicians, a small but burgeoning pop-
ulation of patients is starting to use these tools to augment
their SSE and to help detect subtly changing lesions, some of
which may prove to be malignant [7]. The combination of pho-
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tography and dermoscopy is an integral aspect of short-term
mole monitoring, which relies on side-by-side comparison of
digital dermoscopic images of a lesion obtained 3–4 months
apart with the intent of identifying subtle changes and other-
wise featureless melanomas.
Entering the modern era of digital fluency has given rise to
numerous technological advancements, including computer
vision. This has resulted in the blossoming of a multitude of
educational and diagnostics applications, or apps, intended to
enhance SSE and melanoma detection. These apps are already
being utilized for patient education and for patient melanoma
self-detection. Their integration with vision-enhancing devices
such as mobile dermatoscopes may shift a portion of melanoma
For personal use only.
detection to an ever-earlier state.
This review seeks to assess the efficacy of the techniques to
assist the public in finding melanoma and includes discussions
on SSE, educational algorithms, the use of total body photogra-
phy (TBP) and digital apps (both educational and diagnostic).
Skin self-examination
SSE empowers patients to take an active role in their health by
being aware of the lesions present on their skin, so that uneven,
different or changing lesions can be identified and brought to
the attention of a physician. Although variable intervals for der-
matologic follow-up are recommended, based on the patient’s
personal and family history of melanoma, it is usually suggested
that SSE be performed monthly, as is the advocated interval
for breast or, in some high-risk populations, testicular self-
exams [8]. Despite advances in imaging techniques, the majority
of breast cancers are still detected by patients, partners or
family members, and thus many argue that breast self-
examination still plays an important role in improving chances
of survival through early detection [9,10]. Similarly, the majority
of melanomas are also found by the patient, partner or family
members [11–13].
Theoretically, monthly SSE allows for the identification of
rapidly growing tumors that may arise between physician visits.
This theory may in part explain why patient-detected melano-
mas are on average thicker than physician-detected melano-
mas [14]; they represent a more biologically aggressive (faster
growing) tumor. Alternatively, physician training and experi-
ence may be responsible for this discrepancy. Melanomas
detected by patients may be separated into those detected by
intentional exam versus incidentally. Those melanomas found
1424
by deliberate SSE have been shown to be thinner than melano-
mas found incidentally [15]. However, it should be noted that
daily SSE should be discouraged, as changes may be too grad-
ual to be detected if a lesion is inspected every day.
Although the American Cancer Society and the American
Academy of Dermatology both advocate for monthly SSE [16],
the US Preventative Services Task Force concluded in
2009 that there is insufficient evidence to recommend for or
against physician advisement for SSE [17]. Although randomized
controlled trials definitively demonstrating survival benefit of
the SSE are lacking, the majority of melanomas or even first
melanoma recurrences are detected by patients [11–13].
Accuracy of the skin self-examination
A limited number of studies have attempted to evaluate the
sensitivity and specificity of the SSE via two primary study
methods. The first uses patient-reported mole counts (total,
atypical or specifically larger pigmented lesion numbers) com-
pared with physician counts [18]. The second assesses a patient
population who are already using baseline photographs for SSE
by digitally altering their baseline photos of specific pigmented
lesions to determine a patient’s ability to detect change of their
lesions [19,20]. Sensitivities are reported anywhere from 25 to
93% and specificities from 83 to 97% [21]. The variable meth-
ods of assessment and the diverse patient populations in these
studies (including those with high nevus counts, positive mela-
noma history and atypical mole syndrome) make it difficult to
pinpoint the true accuracy of the SSE.
One potential challenge in patient identification of suspi-
cious lesions is that patients may hold a false perception of
what morphologic features are worrisome [21]. In an Australian
survey, while patients were able to correctly identify lesional
change and multiple colors as important signs of melanoma,
25% of respondents still put emphasis on the hairiness of a
lesion [22]. Additionally, it is understandable that patients with
many moles have a harder time obtaining an accurate lesion
count and may require additional aids to the SSE such as base-
line photography [18,23].
Morbidity & mortality
Perhaps, the most thorough assessment of the SSE was a case–
control study by Berwick et al. [24] that showed an associated
reduced risk of incidence of melanoma in those performing
SSE and a decrease in lethality of melanomas in patients per-
forming SSE. The study concluded that melanoma mortality
may be reduced by up to 63% by performing SSE. Another
important study that evaluated the combined effect of SSE and
physician screening on melanoma mortality was conducted at
the Lawrence Livermore National Laboratory in Northern Cali-
fornia. This 12-year screening program was initiated secondary
to a discovery by their medical director revealing a three- to
fourfold increase in the incidence of melanoma in this popula-
tion. The primary concern was the link between melanoma
and occupational exposures [25]. Through their intervention,
this study demonstrated a decrease in the crude incidence of
Expert Rev. Anticancer Ther. 13(12), (2013)

thick melanoma (>0.75 mm), and there were no melanoma
deaths in the workforce following the intervention, while the
expected number of deaths predicted by the SEER data, would
have been three [26].
With the aim of increasing the sensitivity for melanoma
detection by patients at the inherent expense of specificity, one
might expect an increase in skin biopsies of benign lesions.
One study evaluated the number of skin biopsies performed in
patients performing SSE in a randomized controlled study [27].
The participants in the intervention arm were instructed on
proper skin examination with the aids of an American Cancer
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Society booklet, ‘Why you should know about melanoma’, and
an educational video, ‘Check It Out: Why and How to do
Skin Self-Exam’. The control group received an intervention
on diet education. The study found that while skin biopsies
increased slightly, 3.6% in those not performing monthly SSE
compared with 8.0% in those performing SSE, in the short
term, there was no difference in biopsy rates after 6 and
12 months [27]. The risks of this short-term increase in skin
biopsies, which possibly is secondary to patient reports of per-
ceived change of a lesion discovered via SSE, may be offset by
the positive mortality benefit expected from finding thinner
melanomas. In fact, it has been proposed that as many as
562 biopsies of benign lesions performed to detect even one
For personal use only.
melanoma before metastasis may be at least cost justified [28].
Another study demonstrating the early detection benefit of
SSE evaluated patients with a history of a previous melanoma.
These patients were taught and encouraged to perform SSE on
a monthly basis. The study showed that any second primary
melanomas found by these patients were thinner as compared
with second melanomas diagnosed in patients who were not
guided to perform SSE [29]. In another study looking at
566 adults with newly diagnosed melanomas, patients who
used a picture aid illustrating a melanoma and performed regu-
lar SSE had thinner melanomas than those who did not [30].
Demographics of patients performing SSE
The SSE can only be a successful means of screening for mela-
noma if patients are willing and able to regularly and thor-
oughly examine their skin. Many studies have evaluated which
patient factors contribute to performing SSE and which are
more likely to result in successful identification of melanomas.
Patients who are more prone to worry and those with a high
risk of developing melanomas are more likely to perform regu-
lar SSE [31]. Even among patients who do report SSE, it is still
very infrequent that they will regularly perform the exam once
a month [32]. However, the belief that the SSE is effective as
an early intervention results in sense of control for patients
and may lead to more adherence with recommended SSE
guidelines [33].
An extremely important factor in successful SSE is the role of
a patient’s family member or partner. Thicker melanomas are
often found on areas of the skin such as the back or posterior
legs/arms that are not readily assessable via self-examination [34].
One behavioral study examined the quality of partner
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Melanoma patient self-detection Review
relationship and involvement in skin examination and found
that good partner relationships and motivation of partners to
participate in the SSE resulted in increased self-efficacy, which
is one’s belief of their capacity to complete a SSE [35]. Addition-
ally, including patient’s partners in the education for SSE practi-
ces made patients more likely to complete SSEs [36]. Of note, it
has been shown that wives detect melanoma approximately
7.5-times as commonly as husbands [12].
Identifying factors that are associated with patients not per-
forming SSE include younger age and those who infrequently
use sun protection strategies [37]. In addition, older individuals
may lack confidence in performing self-examination and may
find it challenging and overwhelming in the presence of many
background lesions such as lentigines and SKs, which com-
monly develop on the skin of these older individuals [38]. Fur-
thermore, poor visual acuity, cataracts, macular degeneration
and poor flexibility may all contribute to their lack of confi-
dence in performing SSE. Interestingly, homebound older
adults have inadequate light levels in their homes [39], which
could contribute to reluctance or inability to perform
adequate SSE.
Physician role for SSE efficacy
Physician encouragement and education on how to perform
an effective and thorough SSE may improve the patient will-
ingness to perform a SSE and accuracy of the SSE. The
‘Check it Out’ trial by Lee et al. [40] reviewed the use and
helpfulness of specific tools for education and SSE assistance.
It found that educational methods such as the American Can-
cer Society brochure on SSE, a shower card highlighting the
salient points of SSE, sample photographs of skin cancers and
a video on how to perform a SSE and what to look for during
this examination were all associated with increased frequency
of SSE. Providing a hand mirror also increased SSE. Another
study randomized patients to receive either a melanoma edu-
cation brochure (control) or and a hands-on tutorial with
computer-assisted education in combination with telecommu-
nication reminders to perform SSE (intervention). The infor-
mation provided to the intervention group was aimed at
improving patient confidence for identifying melanoma. The
study concluded that those in the intervention arm were more
likely to perform SSE at 3 months, odds ratio (OR): 2.36;
p £ 0.05 and more confident in their ability to perform SSE,
OR: 2.72; p £ 0.05 [41]. SSE may be an effective as well as an
empowering endeavor for patients. It is also important to
highlight that the physician-based examination and SSE are
complementary. One study showed that approximately one-
quarter of lesions that patients identify as suspicious on SSE
were deemed benign by physicians and did not require
biopsy [42]. In this study, 30% of the melanomas were patient
identified, providing rationale for SSE. With varying patient
acceptance levels for SSE, physicians and health educators
should consider demographic factors (e.g., age, gender, part-
ner status, educational level and anxiety) when determining
the degree of emphasis on SSE.
1425
 Review Yagerman & Marghoob
Review of patient-focused education strategies
Analytical methods (ABCD & 7-point checklist)
Perhaps, the earliest attempt to alert patients to the clinical fea-
tures of melanoma was the introduction of the ABCD criteria
in 1985 [6]. Subsequently, the same investigators recognized the
importance of temporal change in a lesion and added E for
evolution to their acronym. Thus, ABCDE encompasses both
the morphologic and symptomatic aspects of melanoma [43].
Evaluation of the efficacy of these criteria in differentiating
benign from malignant lesions ranges from a sensitivity of
57–100% and a specificity of 37–100%, when used singularly
Expert Review of Anticancer Therapy Downloaded from informahealthcare.com by University of Louisville on 01/23/15
or in combination [43,44]. However, it may be a self-fulfilling
prophecy that many melanomas possess these features, since
these are the features patients and physicians are taught
to identify.
Limited studies have evaluated the effect of patient knowl-
edge of the ABCD on improving SSE efficacy. One study
examined the efficacy of an ABCDE training session and the
use of a card highlighting the ABCDEs for patients to have at
home. This study found that patients were more likely to use
the card to help check for color variation, indicating that the
other concepts had been sufficiently understood in one didactic
training session and patients did not need to refer back to the
card for examples. As evidence to this effect, while almost half
For personal use only.
of the patients never used the card, the majority of these
patients stated the reason as being that they understood the
concept on first instruction – perhaps indicating that this is an
easy concept to teach and grasp [45]. Counter to this are studies
asking people if they are familiar with the ABCD rule, and if
so, which factors does it highlight. Results indicate that many
lack the knowledge of these criteria [46,47]. Another study
explored melanomas identified by method of detection, self ver-
sus physician, and noted that in patients whose melanomas
were self-detected, there was an associated knowledge of the
ABCD rule and propensity to perform SSE [48]. Novices to the
ABCD checklist may not be able to use it to reliably distin-
guish benign from malignant lesions, with one study demon-
strating significant interobserver variability for the ABCs across
benign and malignant lesions [49].
Another algorithm, developed around the same time as the
ABCD criteria, was the 7-point checklist, which zeroed in on
the importance of change in a lesion. The criteria were initially
proposed based on the positive results of a public health educa-
tion study, which resulted in an increase in referrals of thin
melanomas and a concomitant decrease in proportion of thick
melanomas [50]. The criteria were later modified based on the
evaluation of 100 melanomas, resulting in three major (change
in size, shape and color) and four minor (inflammation, crust-
ing/bleeding, sensory change and diameter ‡7 mm) features [51].
The study was limited by the absence of evaluation of benign
lesions for the seven criteria. A formal assessment of the modi-
fied 7-point checklist included 65 melanomas and found that
all lesions were identified by the criteria, while five were missed
by the ABCDE (E, for elevation) criteria. In terms of specific-
ity, this same study showed that 62% of the melanomas had
1426
one major criteria compared with only 4% of the benign
lesions evaluated [52].
Direct comparison of the efficacy of patient use of the
ABCD criteria to the 7-point checklist has been evaluated in
one study [53]. This study interviewed 67 patients with benign
lesions clinically suspicious for melanoma, and 46 with melano-
mas, before histologic confirmation following biopsy. Patients
were asked to evaluate the lesions based on the ABCD (E for
elevation) and the 7-point check list. It was found that changes
in size (new lesion) and color (two of the major criteria from
the 7-point checklist) were most useful for patients in differen-
tiating benign from malignant. Another comparison study
focused on the accuracy of the two methods in the hands of
physician evaluators [54]. However, when the reason for consul-
tation was evaluated, it became clear that patients tended not
to present to doctors for the irregular border, color variegation
or diameter >6 mm but rather for inflammation, color change,
itch and change in size, all features of the Glasgow 7-point
checklist [54].
Cognitive training & pattern recognition
An alternative method for patient education for identifying
early melanomas is cognitive training. Gachon et al. [55] showed
that dermatologists tend to rely on overall pattern recognition
of a lesion, either as irregular or complex, rather than on spe-
cific criteria for diagnosis. The same investigator went on to
demonstrate in a randomized patient population that cognitive
recognition through a training set of photographs resulted in a
higher specificity compared with the ABCDs, and that in the
setting of anxiety, patients tended to do worse with the ABCDs
whereas a cognitive training group’s performance remained the
same [56]. Furthermore, a community pilot study showed that
64% of people who received and used the brochure of images
were more likely to perform a SSE, with 92% of people agree-
ing that the use of images was the best way to recognize mela-
noma [57]. A systematic review of the use of visual images in
SSE showed a positive effect of the educational process, increas-
ing accuracy, frequency and self-efficacy of the SSE [58]. It is
important to recognize that while both education strategies of
characteristic criteria and cognitive recognition are important in
the learning process for physicians [59], it remains to be proven
whether the same will hold true for patients.
The importance of the outlier lesion
Another significant characteristic for recognizing melanomas is
that they often do not look like the patients’ other moles,
coined the ‘ugly-duckling sign’ [60]. Particularly, in patients
with many nevi, the task of performing an assessment of each
lesion may seem daunting and result in poor compliance in
performing SSE. There is much complexity in making the
diagnosis of melanoma for physicians [61]. Recognizing the dif-
ferent, outlier lesion or the ‘ugly duckling’ has been shown to
be important to experts [55]. This differential recognition proc-
ess is engrained from childhood, when picture books and tele-
vision shows ask children to pick out which shape or object
Expert Rev. Anticancer Ther. 13(12), (2013)

does not go with the rest. A study by Scope et al. [62] showed
that experts, general dermatologists, nurses and nonclinicians
all had good sensitivity for melanoma detection using the ugly-
duckling sign. With many patients reluctant to examine their
own skin, perhaps asking something as simple as looking for
any ugly ducklings on their skin could have enormous impact
on the number of patients participating in SSE.
Total body photography & the SSE
One challenge frequently cited by patients is their trouble
noticing change on their skin, either because of the inability to
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appreciate subtle changes or because their visual senses are over-
whelmed by the sheer number of lesions present. With TBP,
patients are able to use baseline images taken in a series of
standard poses [63], either digitally or in printed copy, to
methodically compare their skin to during SSE. Patients are
more likely to use their photo books if they have a history of
skin cancer or have many moles [64]. Skin exams may be per-
formed by more patients if they are provided with TBP image
sets. Having these image sets in turn may help to quell patient
anxiety regarding their confidence in detecting new or changing
lesions on their skin [64,65]. The proof of this concept was
shown in one study where patients were able to identify change
when digital images of a patient’s lesions had been altered [66].
For personal use only.
Despite the positive effects of the visual aid provided with
TBP, more traditional mole-mapping diagrams may still be
important, helping patients to be active participants in their
baseline exam. The act of marking the location of each mole
helps to solidify the baseline skin in patients’ memory. One
study showed that patients who completed a mole-mapping
diagram were more likely to identify change on overview
images of their backs than those who did not [67]. However,
completing this exercise did not increase the likelihood of a
patient to perform SSE.
The role of apps in the SSE
Digital applications for health and wellness are being created at
exponential rates. One paper noted that a search across various
platforms yielded 46 ‘e-Health tools’ for melanoma [68]. The
range of application types spans from teledermatology consults
with physicians, to automated detection apps, to education
tools, to personalized mole monitoring and tracking apps. This
review will focus on the apps as educational tools and personal-
ized mole monitoring apps as they pertain to enhancement of
the efficacy of the SSE. One should note that with diagnostic
apps, there is no regulatory agency to assess validity. A word of
caution regarding many of these apps is that while there are
ever new and evolving apps available (version 2.0, etc.), there is
no regulation of the quality of material included in the apps
and limited physician involvement in many of the apps
creation [69].
Educational apps may be divided into two categories: those
that attempt to teach a thorough exam thereby improving
patient confidence in the technique, and those that teach
patients how to identify melanoma thereby increasing the
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Melanoma patient self-detection Review
accuracy of the SSE. Furthermore, apps may be either demon-
strative with video or brochure-like material, or interactive,
requiring patient input. One study has evaluated patient
response to at-home use of education involving technology for
patients and showed that it was feasible and even preferred by
patients [70]. However, no formal evaluation has been com-
pleted of specific educational apps for the incorporation in or
the improvement of the SSE.
Apps designed to remind patients to perform SSE and apps
for personalized mole tracking, may be as simple as syncing
the day of the month for one’s SSE with their digital calendar,
or may have the capacity to use device cameras to image indi-
vidual moles, personalizing the app for patients. It has been
shown that telecommunication reminders for patients improve
patient adherence to SSE [41]. Intuitively, the use of paper
planners and calendars are diminishing in favor with the rise
of smart-phone to-do lists and calendars, and thus incorporat-
ing a reminder app would aid patients in recalling to perform
monthly SSEs. However, to date, no formal evaluations of
the efficacy or use profiles of these applications has been
published.
The use of dermoscopy by patients for the SSE
Dermoscopy has been shown to improve diagnostic accuracy
for melanoma in the hands of physicians. Intuitively, the added
optical information gleaned from the ability to view subsurface
structures with the noninvasive technique of dermoscopy
should allow for more specificity in diagnosis. One image-based
study showed that laypersons were able to significantly improve
their sensitivity for diagnosis of melanoma with dermoscopic
images (94% compared with clinical images 91%) [71]. Granted
the subjects in this study were educated with the AC rule
(asymmetry and color), which was designed for dermoscopy [72].
With the widespread, albeit informal, adaptation of telederma-
tology for consultation and the additive information of dermo-
scopic images, it follows that dermoscopy and teledermoscopy
might be important elements in improving the SSE [73]. Proof
of concept was shown in a case report, detailing two patients
who used dermoscopy without prompt from a physician to
identify a suspicious lesion on each patient [74]. In a larger scale
feasibility study, 10 patients, all instructed in the AC rule of
dermoscopy, were given dermatoscopes to use during their reg-
ular SSE [75]. Patients submitted an average of 6.6 photos over
the 7-month study period, with 88% of the dermoscopic
images being of good enough quality for mobile consultation
by a physician. However, patients did image many benign
lesions, perhaps indicating a need for further education on the
differences between benign and malignant dermoscopic
characteristics.
Dermoscopy is also a useful technique for detecting other
melanoma subtypes with subtle clinical presentations such as
thin NM and amelanotic/hypomelanotic melanomas [76,77]. The
utility of patients’ use of dermoscopy for identification of these
lesions remains to be determined, given the subtlety of dermo-
scopic structures in some melanomas and the potential
1427
 Review Yagerman & Marghoob

complexity of teaching all melanoma-specific features and par-
ticularly atypical vascular structures, which may prove challeng-
ing for the general public.
No formal evaluation of patient use of dermoscopic algo-
rithms (mimicking clinical algorithms as described above)
including pattern analysis, 7-point dermoscopy checklist,
3-point dermoscopy checklist and the ABCD rule of dermo-
scopy has been accomplished. It might be surmised that
patient-education efforts in dermoscopy leading to improved
efficacy of SSE will parallel those of clinical algorithms.
Expert Review of Anticancer Therapy Downloaded from informahealthcare.com by University of Louisville on 01/23/15
that are new or changing. Additionally, providing patients with
quick and easy means of having concerning lesions addressed
(i.e., teledermatology) may encourage SSE and improve com-
pliance with performing SSE. Aids to enhance SSE such as
baseline TBP and dermoscopy, in combination with digital
educational apps, may greatly improve the self-detection of
curable skin cancers.
Five-year view
There is significant potential over the next 5 years to improve

education efforts and public awareness campaigns regarding

Expert commentary
the warning signs of melanoma and in highlighting the bene-
There is a rising incidence and prevalence of melanoma with
fits of SSE. Integration of dermoscopy may encourage high-
over 900,000 men and women alive in the USA with a history
risk patients to more thoroughly examine their cutaneous sur-
of melanoma as of 2010 [101] and with 76,690 new cases of
face for skin cancer. In addition, the ability to acquire stand-
invasive melanoma and 61,300 new cases on in situ melanoma
ard dermoscopy images through mobile devices is becoming
anticipated to be diagnosed in the USA in 2013 [78]. Due to a
a reality, and it is becoming easy for some dermatologist to
shortage of primary care physicians and dermatologists in the
rapidly review these images and provide a diagnosis or man-
USA, and across the world, it is difficult for opportunistic
agement plan with a high level of diagnostic accuracy. This
physician-based examinations to significantly impact early
element of ‘virtual’ interaction between the physician and
detection of melanoma or have any substantial impact on
patient may help to allay anxiety of the patient regarding
reducing melanoma-specific mortality. Even those patients
lesion found during the SSE, may result in more patient par-
under periodic surveillance by a dermatologist are at risk for
ticipation and is likely to help in the detection of early
developing rapidly growing skin cancers that are not amenable
For personal use only.

to be discovered at an early stage in their evolution via periodic
screening examinations.
Although educating health care providers about the impor-
tance of incorporating the skin examination into the standard
physical exam may help, this has proven to be a challenge and
may also prove to be an unrealistic expectation. Thus, alterna-
tive methods need to be explored that can help achieve the
same aims. One such method to enhance early detection of
melanoma is to solicit help from people themselves by encour-
aging SSE. Previous attempts at teaching the general public
about the signs and symptoms of melanoma such as with the
ABCDs acronym or via cognitive training have had variable
success. Needless to say, we need better methods of conveying
to the lay public the warning signs of melanoma. Perhaps, the
public health message can be improved upon by supplement-
ing the ABCD acronym with other important signs such as
identifying different or outlier lesions, lesions manifesting
unevenness in distribution of color and textures and lesions
skin cancers.
Although a stretch in the imagination, other tools of auto-
mated diagnosis, such as MelaFind [79], and perhaps even
reflectance confocal microscopy, another tool capable of nonin-
vasive imaging down to the cellular level, might someday find
a role during the SSE [80]. For now, there is a paucity of
randomized controlled trials, and further investigations into
methods to enhance the SSE are warranted.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with
any organization or entity with a financial interest in or financial con-
flict with the subject matter or materials discussed in the manuscript.
This includes employment, consultancies, honoraria, stock ownership or
options, expert testimony, grants or patents received or pending, or
royalties.
No writing assistance was utilized in the production of this
manuscript.

Key issues
• Early detection of melanoma results in significantly lower mortality.
• Physician screening has recently been implicated in decreasing disease-specific mortality from melanoma.
• Skin self-examination (SSE) is a form of secondary prevention that directly involves and empowers the patients in their own care.
• Patient demographics influences the ability and willingness to perform SSE.
• Educational methods such as the ABCD rule combined with cognitive training may improve the accuracy of patient detection of
skin cancer.
• Total body photography may improve efficacy of SSE.
• Digital applications have a role in patient education and SSE reminders.
• Dermoscopy and teledermatology may prove a novel method for enhancing the SSE.

1428 Expert Rev. Anticancer Ther. 13(12), (2013)


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