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Background: Concern about skin cancer is a common reason for people from predominantly fair-skinned populations to present to primary care doctors., Objectives: To examine the frequency and body-site distribution of malignant, pre-malignant and benign pigmented skin lesions excised in primary care., Methods: This prospective study conducted in Queensland, Australia, included 154 primary care doctors. For all excised or biopsied lesions, doctors recorded the patient's age and sex, body site, level of patient pressure to excise, and the clinical diagnosis. Histological confirmation was obtained through pathology laboratories., Results: Of 9650 skin lesions, 57·7% were excised in males and 75·0% excised in patients ≥ 50 years. The most common diagnoses were basal cell carcinoma (BCC) (35·1%) and squamous cell carcinoma (SCC) (19·7%). Compared with the whole body, the highest densities for SCC, BCC and actinic keratoses were observed on chronically sun-exposed areas of the body including the face in males and females, the scalp and ears in males, and the hands in females. The density of BCC was also high on intermittently or rarely exposed body sites. Females, younger patients and patients with melanocytic naevi were significantly more likely to exert moderate/high levels of pressure on the doctor to excise., Conclusions: More than half the excised lesions were skin cancer, which mostly occurred on the more chronically sun-exposed areas of the body. Information on the type and body-site distribution of skin lesions can aid in the diagnosis and planned management of skin cancer and other skin lesions commonly presented in primary care., (© 2011 The Authors. BJD © 2011 British Association of Dermatologists 2011.)

Objective: To assess physician, patient, and skin lesion characteristics that affect the number of benign skin lesions excised by primary care physicians for each skin cancer., Design: Prospective study collecting clinical, patient, and histopathologic details of excisions or biopsies of skin lesions by random samples of primary care physicians., Setting: Southeast Queensland involving traditional family medicine physicians (n = 104; response rate, 53.9%) and family medicine physicians working in 27 primary care skin cancer clinics (n = 50; response rate, 75.0%)., Participants: Of 28 755 skin examinations recorded during the study, 11 403 skin lesions were excised or biopsied; 97.5% of the excised lesions had clinical and histologic diagnoses recorded., Main Outcome Measures: Number of lesions needed to excise or biopsy (NNE) for 1 melanoma (pigmented lesions only) and NNE for 1 nonmelanoma skin cancer (nonpigmented lesions only)., Results: The NNE for nonpigmented lesions (n = 8139) was 1.5 (95% confidence interval, 1.4-1.6) and for pigmented lesions (n = 2977) was 19.6 (16.2-22.9). The NNE estimates were up to 8 times lower if the physician thought the lesion was likely to be malignant and up to 2.5 times higher if there was strong patient pressure to excise. The NNE estimates varied by other physician-, patient-, and lesion-related variables., Conclusions: Clinical impressions of excised skin lesions were strongly associated with NNE estimates. By focusing on pigmented skin lesions and by addressing the physician- and patient-specific factors identified, the effectiveness of future training for primary care physicians in the clinical management of skin cancer could be improved.

Objective: To measure and compare the casemix and diagnostic accuracy of excised or biopsied skin lesions managed by mainstream general practitioners and doctors within primary care skin cancer clinics., Design, Setting and Participants: Prospective comparative study of 104 GPs and 50 skin cancer clinic doctors in south-eastern Queensland, involving 28 755 patient encounters. The study was conducted in 2005., Main Outcome Measures: Prevalence of each type of skin lesion; sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the clinical diagnosis against histology; number needed to excise or biopsy (NNE) for a diagnosis of skin cancer., Results: GPs excised or biopsied 3175 skin lesions (mean 2.5/week) including 743 basal cell carcinomas (BCCs) (23.4%), 704 squamous cell carcinomas (SCCs) (22.2%) and 49 melanomas (1.5%). Skin cancer clinic doctors excised or biopsied 7941 skin lesions (mean 34/week), including 2701 BCCs (34.0%), 1274 SCCs (16.0%) and 103 melanomas (1.3%). Overall, sensitivity for diagnosing any skin cancer was similar for skin cancer clinic doctors (0.94) and GPs (0.91), although higher for skin cancer clinic doctors for BCC (0.89 v 0.79; P < 0.01) and melanoma (0.60 v 0.29; P < 0.01). The overall NNE was similar for skin cancer clinic doctors (1.9; 95% CI, 1.8%-2.1%) and GPs (2.1; 95% CI, 1.9%-2.3%). This did not change after adjusting for years of clinical experience., Conclusions: GPs and skin cancer clinic doctors in Queensland treat large numbers of skin cancers and diagnose these with overall high sensitivity. The two groups diagnosed skin cancer with similar accuracy.

Background: The ability of general practitioners to make important clinical decisions about the diagnosis and management of skin lesions is poorly understood., Methods: A questionnaire on the diagnosis and management of eight photographed skin lesions was sent to 150 GPs in southeast Queensland., Results: The questionnaire was completed by 114 GPs (response rate 77%). General practitioners' provisional diagnoses and management of photographed skin lesions were mostly or always correct, and there was general high consistency between diagnosis and intended management. Pigmented seborrhoeic keratoses were the most difficult lesions for GPs to diagnose correctly. Whether a lesion was different to usual moles appears to have the strongest association with clinical diagnosis., Discussion: The high ability of GPs as measured in this artificial study is encouraging. The strong association between identifying moles that appear different to usual and correct clinical diagnoses suggest that unless GPs can increase the number of skin lesions they see as part of their typical workload, their clinical ability may not increase further.

Community responses (n=925, response rate=71%) of a series of eight photographs of pigmented skin lesions were compared against those of general practitioners (n=114, response rate=77%), considered to be the most relevant gold standard. The eight photographs included three melanomas, two potentially malignant lesions and three benign pigmented lesions. Over the pool of lesions examined, the average probability that community members thought a lesion was likely to be skin cancer (0.68 [99% CI=0.66-0.69]) was higher (p<0.0001) than that of the comparison general practitioners 0.58 [99% CI=0.55-0.62]. This reflects a general (but not consistent) inflated propensity to over-diagnose among community members. The average probability that respondents indicated they would seek medical advice for a lesion was 0.71 [99% CI=0.70-0.73]. As expected, this was strongly associated with their perceptions of the skin lesion. These results suggest that the community can play a valuable role in assessing the need for medical evaluation of pigmented skin lesions.

Objectives: To determine whether an aid to the diagnosis of pigmented skin lesions reduces the ratio of benign lesions to melanomas excised in general practice., Design: Controlled trial randomised by practice., Setting: General practices in Perth, Western Australia., Participants: 468 general practitioners in 223 practices., Interventions: Intervention practices were given an algorithm and instant camera to assist with the diagnosis of pigmented skin lesions. All practices were given national guidelines on managing melanoma., Main Outcome Measures: Ratio of benign pigmented lesions to melanomas excised. Analyses conducted with and without inclusion of seborrhoeic keratoses., Results: At baseline the ratios of benign to malignant lesions were lower in the intervention group than in the control group. During the trial period the ratios were higher in the intervention group (19:1 v 17:1 without seborrhoeic keratoses and 29:1 v 26:1 with seborrhoeic keratoses). After adjustment for patients' age, sex, and socioeconomic status, the ratio was 1.02 times higher (95% confidence interval 0.68 to 1.51, P = 0.94) in the intervention group when seborrhoeic keratoses were not included and 1.03 times higher (0.71 to 1.50, P = 0.88) when seborrhoeic keratoses were included. General practitioners in the intervention group were less likely than those in the control group to excise the most recent pigmented skin lesion they managed (22% v 48%, P < 0.001) and to refer the patient to a specialist (16% v 27%, P = 0.06)., Conclusions: Provision of the algorithm and camera did not decrease the ratio of benign pigmented skin lesions to melanomas excised by general practitioners.

Introduction: Australian national policies do not recommend skin cancer screening. We measured family physicians' beliefs, self-reported practices, and predictors of using clinical skin examination for skin cancer screening., Method: Random self-administered postal survey of 1271 Australian family physicians (FPs) performed during 1996, obtaining 855 completed questionnaires (67% response rate)., Results: Eighty-six percent of FPs surveyed indicated that they thought clinical skin examination was effective in reducing premature death from skin cancer; 72% indicated that they should be performed annually; and 60% indicated that all adults should be screened. Only 3% indicated correctly that screening has not been tested to determine its effectiveness. Although most FPs were unlikely to adopt an opportunistic approach to screening, 64% indicated that they would recommend clinical skin examination during a health check-up. FPs in northern (high incidence) latitudes were 3 to 4 times more likely to adopt opportunistic screening, and twice as likely to discuss clinical skin examination in a dedicated check-up. FPs were more likely to advocate screening in male rather than female patients. Half of respondents were unaware of relevant guidelines., Conclusion: Although Australian policies do not recommend clinical skin examination because of insufficient evidence as yet of effectiveness, FPs show considerable support for screening. Geographic location, patient gender, and physician beliefs predict the self-reported provision of clinical skin examination by family physicians, suggesting that factors other than published guidelines affect clinical practice.

There is debate about the margin of normal tissue that should be included with excisions of melanocytic lesions of the skin, and about which lesions should be referred for specialist care. We describe the determinants of the margins of excised melanocytic skin lesions and of referral patterns from primary care. Copies of the pathology reports of melanocytic skin lesions excised from two cities in tropical Queensland were obtained; questionnaires about each lesion were administered to the excising doctor. Data about 3275 lesions (2914 naevi, 130 lentigos, 151 melanomas, 51 dysplastic naevi, 21 Hutchinson's melanotic freckles and eight other melanocytic lesions) were analysed. Twenty-one per cent of the treatment sessions involved the excision of more than one lesion; 5% involved three lesions or more. Most lesions were managed by one doctor. The overall mean margin of excision was 2.8 mm. It was greater for longer qualified doctors, surgeons and college-affiliated general practitioners, for lesions excised to address malignancy (3.0 mm) rather than cosmetic appearance (2.4 mm), for Hutchinson's melanotic freckles (5.9 mm) and melanomas (5.1 mm) compared with benign lesions (2.7 mm) (P < 0.001) and for older patients (2.6 mm for those < or = 15, 3.5 mm for those > 40 years) (P = 0.001). Wider excisions of skin melanocytic lesions are performed by older and more experienced doctors, on older patients, and for lesions in which malignancy is being addressed.

We report on an observational study of one city in Queensland over a 30-month period to evaluate the effects of two public skin cancer campaigns on the excision rates of melanocytic skin lesions. The numbers of melanomas, the numbers of potentially malignant melanocytic lesions (Hutchinson's melanotic freckles and dysplastic naevi) whose excision might have benefited the patient, and the total number of melanocytic skin lesions submitted to pathology services were recorded. A total of 3221 melanocytic skin lesions were excised. More lesions were excised during summer than non-summer periods (rate ratio 1.22, 95% CI 1.06, 1.40) and, independently, during campaign periods than non-campaign periods (rate ratio 1.24, 95% CI 1.11, 1.37). There were 145 melanomas (4%), of which 116 were < 0.76 mm thick, and an additional 53 (2%) other potentially malignant lesions. During campaigns, proportions of neither type increased significantly, nor was there a significant reduction in excised melanoma thickness. Doctors reported more often that the reason for excision was to exclude malignancy during the campaigns, although they felt themselves to be under less pressure from patients to excise lesions. There may be considerable cost associated with primary prevention campaigns in the form of increased excision of benign skin lesions, which should be addressed in future skin cancer public awareness campaigns.

Objective: Skin cancer is common in Australia. It is managed in large portion within general practice, and early excision usually affords cure, therefore, it may form a much greater workload for general practitioners (GPs) than incidence figures would imply. The aim of this study was to describe the skin cancer workload in Australian general practice., Method: Analysis of data recorded by 495 randomly selected GPs relating to 113,468 consultations (98,796 weighted for State size), which were collected as part of a national descriptive study. Medicare and census data were used to calculate rates at which GPs were consulted for different conditions., Results: Skin tumours accounted for 2,083 (1.5%) of all 145,799 problems managed in 98,796 encounters. Annual rates at which GPs were consulted were: 13/1,000 people for 'malignant' tumours of the skin; 23/1,000 for 'naevus/mole; and 13/1,000 for 'other benign' lesions. The rates of diagnoses of 'malignant skin neoplasms' increased with age to a maximum among women and men aged 65 years or more of > 80/1,000 and > 100/1,000, respectively. For 'naevus/mole' the rates of maximum diagnoses were 40/1,000 for women and 351/1,000 for men aged 15-24 years. There was no sex difference for the maximal rate (15/1,000) among the 45-64 age groups for 'other benign skin lesions'. The main form of management was procedural for malignant skin lesions (90% of consultations) and naevi/moles (50%). Referral to specialist services was most common during consultations for malignant disease (22% of consultations), in comparison to naevi/moles (15%) and other benign skin neoplasms (9%). Procedures (cryotherapy, diathermy and excision) and referrals were more common for malignant lesions and naevi/moles., Conclusions: There were important differences in age distribution for rates of management of benign and malignant skin tumours and naevi. Skin tumours usually were managed in conjunction with other problems. Most were managed procedurally. Only a minority were referred. Skin cancer represents a greater workload for Australian GPs than suggested by previous incidence reports.

The aim of the study was to describe the appropriateness of patient-initiated skin examinations, and assess whether an awareness program leads to a greater proportion of inappropriate patient-initiated skin examinations. General practitioners (n = 27, response rate 71 per cent) from a regional town in Queensland recorded details of consultations involving a skin examination over a five-week period straddling the 1991 National Skin Cancer Awareness Week. The outcome measure was the clinical impression (benign, suspicious or malignant) of the most serious skin lesion presented by each general practice patient (n = 1183). Thirty-six per cent of patient-presented lesions were clinically suspicious or malignant. Lesions were more likely to be clinically suspicious or malignant if they were presented as the primary reason for the consultation (odds ratio OR = 1,219.95 per cent confidence interval (CI) 1.01 to 1.48); if the patient was aged over 35 years (OR = 5.594, CI 1.08 to 7.66); or male (OR = 1.634, CI 1.35 to 2.00). Following a public skin cancer awareness campaign, there was a slight nonsignificant decrease (OR 0.938, CI 0.91 or 1.25) in the proportion of clinically suspicious and malignant lesions detected. An increase in the number of skin examinations following an awareness campaign did not result in an increase in the proportion of inappropriate skin examinations. Patient-initiated skin examinations have an important role to play in the early detection of skin cancer.

We administered a questionnaire to 995 people selected randomly from the electoral roll in one coastal region of subtropical Australia. Three-quarters (739) indicated their skin was checked by a physician, by themselves, or both. Among the 15% who were taught to check their skin, 59% learned to do so from physicians. A family physician would be consulted immediately by 40% who found something suspicious, and by 58% after a period of delay. Several factors associated with other indicators of health-seeking behavior, including being told by a physician that there was a special risk of skin cancer, were related to an increased proportion of respondents who were checked by their physicians as well as themselves. In addition to being the main focus of help should a suspicious lesion be found, physicians may have an important role in introducing the public to the process of early detection of skin cancer as well as providing an important function in its actual conduct.

Objective: To evaluate an intervention designed to reduce the number of benign melanocytic lesions excised from the skin., Design: A randomised controlled field trial based in the medical practices of two cities. Examination of histopathological reports of 5823 melanocytic skin lesions excised over the intervention period and in the preceding six months., Intervention: Medical practitioners were offered an algorithm and use of an instant developing camera., Setting and Subjects: Over 50 medical practitioners, mostly in general practice, in each of two cities in tropical Queensland, Australia., Main Outcome Measures: Percentages of benign (neither malignant nor potentially malignant) melanocytic lesions excised during the two year intervention period., Results: There were no significant differences in the percentages of benign lesions reported in the intervention and control cities before the intervention started (93.6% and 94.0%, respectively), but there was a significant difference afterwards (88.8% and 93.8%, P < 0.001). There was no difference in the percentage of invasive melanomas excised per month in the intervention city (3.4%) compared with control city (3.4%)., Conclusion: Clinical diagnostic accuracy may be enhanced by offering to clinicians managing suspicious melanocytic skin lesions a simple algorithm and a camera with which to record the appearance of lesions objectively.

Objective: To describe the response of general practitioners (GPs) and patients during the 1991 National Skin Cancer Awareness Week media campaign., Design: Skin examinations in general practices in three representative regional towns in Queensland were monitored for five weeks around the time of the campaign and participating GPs were personally interviewed., Outcome Measures: Number and type of consultations in which the skin was examined for cancer before, during and after the campaign, and GPs' attitudes and beliefs about skin checks., Results: The 46 GPs (47%) who participated, representing 60% of the practices, conducted 1805 consultations in which the skin was examined for cancer. The number of consultations in which skin examinations were conducted by each GP increased by 56% during the campaign. Skin checks were nearly always initiated by the patient (90%), and in only half of all cases was the examination given as the primary reason for the consultation. Sixty-two per cent of lesions were considered to be clinically benign., Conclusion: Public education programs may have an impact on the level of skin examinations requested in general practice consultations. Currently, patients are the principal initiators of such examinations during consultations--there is potential to increase the active role played by GPs in support of patient requests for the early detection of skin cancer.

A cross-sectional study of the sun-related attitudes and beliefs of 3,655 children in Grades 7 to 11 attending 55 representative Queensland schools was undertaken using a structured questionnaire administered at school. Factors derived from a series of focus groups were incorporated into the questionnaire. Knowledge about risk factors in the aetiology of skin cancer and the role of protective measures was high. Several potential barriers to the use of sun protection were identified, including the desire to be tanned, the perceived attitudes of the peer group to sun protection, and difficulties with the use of specific sun protection measures. In general, these barriers were significantly more prominent among boys and children from older grades than other students. These data will be used to design school-based sun protection interventions which are sensitive to these age and sex differences.