Checking moles can save your life. But who can you trust for accurate diagnosis and fair fees?
By the time he left the medical centre after his 20-minute “mole map”, 67-year-old retiree Brian* wondered briefly if the GP who examined him might also be moonlighting as a used car salesman. The $99 “special” for the skin check had brought Brian in the door. Thirty minutes later, he was almost running out of it as the doctor printed bank account forms to transfer $920 to immediately remove two lesions he’d found and said were at risk of developing into melanomas.
Brian was about to go overseas and wanted to delay the surgery. “We’re talking about your health, and you should not wait any longer than you have to,” the doctor chided him.
The hard-sell tactics might have alarmed some patients. Indeed, one testimonial on the practice’s website – and such personal stories used in advertising are themselves frowned on by medical authorities – is from a patient expressing gratitude that the GP had removed 10 “cancerous moles” one evening after finding them that same day.
Brian, a former journalist, was less impressed. “He was just too clipped for my liking, acting like a banker.” He got a second opinion, this time from a GP with extra training in skin cancer diagnosis and management. His verdict? There was nothing to worry about – come back in six months to check on one mole that might be problematic but probably wasn’t. Although he’s going with the second doctor’s opinion, Brian admits he has little way of knowing whether the second doctor is any better qualified than the first one.
“How do I know who to believe?” he says. “Does a GP really require no special training before he or she can set up shop to treat one of our most deadly diseases? Is there no registration process? Should we be going to dermatologists instead?”
They’re questions the profession has already been asking itself.
“The area is a minefield,” one melanoma surgeon, who declined to be named, told the Listener. “It’s a political nightmare and it’s worth highlighting.” He says Brian’s case is “a classic”.
“He doesn’t know where to go and gets different opinions from different people. Skin is dealt with by so many different specialties. You have GPs with no specific training, GPs with an interest in skin, who do only skin. Then you’ve got dermatologists, plastic surgeons and head and neck surgeons – all doing some skin because it crosses lots of different boundaries and everyone has a go at it. You have a multidisciplinary, multi-skilled group and there is no standard anyone has to achieve, no certificate, diploma or degree that says you’re better than anyone else. There’s no standard in the field at all.”
* Brian’s name has been changed.
The perfect crime?
New Zealand leads the world in the incidence of melanoma: more than 2300 cases are diagnosed every year, so the field is a very big one. Southern Cross, the country’s largest private health-care insurer, last year paid out on 3.1 million claims for skin-lesion removal and funded more than 21,000 operations at a cost of $28 million. Removal of skin lesions – whether cancerous or benign – is the most commonly claimed procedure.
Many of the medical professionals the Listener spoke to were aware of the tensions in the field, but wouldn’t be named. The melanoma surgeon said: “The dermatologists don’t think the GPs should be doing any of this. The surgeons think dermatologists should be doing only psoriasis and acne and they’re not trained surgeons, but now they’re doing all skin and excisional stuff because it’s where the money is. But the GPs say the dermatologists are doing what they could be doing much cheaper. And then you’ve got the plastic surgeons who say they should be doing it all. You have all these different factions and everyone thinks they’re the best at it. It’s a highly political area.”
He doesn’t think, though, that the system is being “rorted”. “No one’s saying they’re out there cutting things off willy-nilly to make money. I’d like to think no one’s out there doing that.”
Another said: “It’s the perfect crime because no one’s complaining.” However, the Listener has since learnt that another Auckland GP, who believed Brian’s first doctor was taking out benign lesions unnecessarily, complained informally to the Medical Council this year.
A patient came to him to have stitches removed from his wrist after the other doctor had excised a lesion, for a fee of about $460, and said the doctor had identified two other lesions on his back and one on his leg that looked suspicious and advised removal. “My comment to the patient was that they appeared benign and that removal seemed intended for the financial benefit of the doctor and not his health.”
The doctor sent photographs of the other lesions to the Medical Council but was told the council would act only if the advice was patently wrong or if the patient was coerced into unnecessary treatment. The doctor takes issue with the council’s response.
“In my opinion it’s irrelevant what conversation took place between the doctor and the patient. That the patient was left with the impression that he required three clinically benign lesions to be removed indicates that the doctor has failed on communication, failed on diagnosis or deliberately intended to profit.”
The Listener contacted one of the patients who’d left a testimonial on the first doctor’s website, saying his skin cancers were removed with “excellent skill and care”. “The fact I’d had someone else look at the same things and tell me they were all right was the reason I gave him the reference,” he told us. He says the report came back from the lab saying three of the four lesions removed were cancerous, but he doesn’t know what type of cancers they were. “They weren’t melanoma, but they could have turned into melanoma.”
Who to trust
For most of us, the family GP will be the first person we see if we’re worried about a suspicious-looking mole. It was for Brian. “I always get my GP to run her eyes over my flabby body in search of skin nasties, but I never get much confidence in such a cursory look.”
Experts say checks using only the naked eye shouldn’t be relied on, and the skin should be examined with a dermatoscope, which combines a magnifier and a light source that reduces skin reflection.
But short of asking for the doctor to set out his diplomas or certificates, what other evidence can patients assess when deciding whose opinion to trust? A good start is to find out whether the person operating on you is a Southern Cross “affiliated provider” to remove lesions. Although the scheme has been contentious, the society says it’s necessary to reduce rising costs. It made skin-lesion removal an affiliated-provider-only procedure in 2014.
GPs can’t qualify as affiliated providers unless they’re trained in dermoscopy, have cut out a minimum of 100 lesions in the past six months and audit their outcomes. They must not remove more than six benign lesions to every malignancy.
Only the second of the GPs Brian saw is an affiliated provider. He is also a fellow of, and accredited by, the Skin Cancer College of Australasia, a relatively new training organisation that aims to bring consistency and transparency to skin-cancer qualifications. The college offers diplomas in dermoscopy and surgery, which require six months of study.
Southern Cross head of provider networks Geoff Searle says the insurer will always fund a second specialist opinion if the member has a policy covering specialist consultations, but he’s seen little evidence that lesions are being removed unnecessarily.
However, a paper published last year by Waitemata and Waikato District Health Board skin-cancer specialists referenced Australian figures showing about 17 benign lesions are taken out for every malignancy in primary care, compared with only four to six in services led by dermatologists.
“Diagnostic uncertainty results in large numbers of referrals being made to specialists for evaluation,” says the paper. “Many benign skin lesions are unnecessarily excised, due to a low threshold for suspecting melanoma. Wait times in the public health system are often prolonged.”
Co-author Dr Amanda Oakley, a Waikato dermatologist and honorary associate professor at the University of Auckland, has been behind moves at both DHBs to establish “virtual lesion clinics” that allow GPs to send photographs of suspicious-looking moles for assessment by specialist dermatologists. In about 75% of cases, she says, the lesions are benign. A diagnosis can be made on photographs alone 95% of the time.
The paper concluded that virtual lesion clinics could save money and reduce waiting times, making it a “viable and sustainable triage service”.
Oakley says she runs many teaching sessions for GPs, and at a recent course in Canterbury, was “very concerned” at the “variable” knowledge of the participants. “They certainly tend to over-call suspicious lesions and we know that numerous unnecessary surgeries are undertaken for completely harmless lesions. Diagnosis of melanoma is one of the most difficult in clinical medicine – you have to look at about 500 benign lesions to find a melanoma – and GPs are very scared of missing it. They tend to remove things rather than leaving them and wishing they hadn’t. You can understand how some doctors are inclined to say, ‘If in doubt, cut it out.’”
She believes medical students need more tuition in dermatology. In the entire six-year course, the sum of the education is two hours’ training, a two-hour tutorial, and attendance at two dermatology clinics. Though the teaching is better structured than it used to be, “students have really taken on the need to self-learn and skills year by year are improving impressively. We do concentrate on melanoma, but that’s perhaps a total of half an hour of training in the whole of medical school.”
Internationally, she says, New Zealand doctors are “up there among the best [at identifying cancers] – and I am including our general practitioners”. Australian figures suggest some GPs there are removing 20-100 benign lesions for every melanoma. A nationwide review hasn’t been done here, but Canterbury GPs results are audited and those with “outlier” ratios are “gently advised they need upskilling”, says Oakley.
She says patients can ask GPs if they audit their excisions and for their ratio of benign to malignant lesion removals. If a GP wants to remove or leave a lesion, a patient can ask why the doctor is worried or not worried about it.
In 2013, a national melanoma tumour standards working group produced a provisional set of diagnostic and treatment guidelines for doctors (see sidebar page 22) to ensure patients receive a consistent standard of care, regardless of where they live, but they still haven’t been introduced.
Around 30,000 patients a year – up from 18,000 just four years ago – are getting their skin checked and photographed by the skin cancer detection programme MoleMap, but chief executive Adrian Bowling says doctors who offer a completely different service are “piggybacking” on the name because it couldn’t be trademarked when the company launched in 1997.
“We used to get quite angsty about it,” he says, adding that several doctors offering “mole mapping” are “barely ethical as to how they present it”.
“For us, mole mapping means you have a complete record of the skin, record all the significant lesions no matter where they are, and map them on the body so from year to year we can image again. If it hasn’t changed, it’s probably benign, and if it has, it’s an area of concern. We cover 98% of the body, so if a new mole appears, we can go back to the photo of that part and say it wasn’t there last time.”
A GP offering the service Brian experienced, for example, would examine the skin and mark the lesions on a drawing of a mannequin on paper and wouldn’t necessarily keep images that could be compared.
Bowling says about 90% of MoleMap clients are the “worried well” and not at elevated risk. Their average age is 42.
“Ninety-nine per cent of the lesions we photograph are benign. We might find 200 melanomas a year.” But he says the average depth of the melanomas detected is 0.6mm, compared with the 1.3mm average of national cancer registry figures.
He says MoleMap misses only about 5% of melanomas. It was investigated by the health and disability commissioner in 2013 after a dermatologist reading photos for the service failed to diagnose a melanoma on a man’s forearm in six checks between 2003 and 2009. The man died in 2010.
MoleMap wasn’t found in breach for the failures, but the dermatologist was. An audit of his reports showed there was no pattern of misdiagnosis – he had reported on nearly 37,000 cases, reviewing more than 675,000 lesions with a false negative rate of just 1.2%. The company has now changed its protocols to ensure photographs are no longer read by the same dermatologist year after year.
Insurers don’t cover melanoma screening. “You go and see a dermatologist and get a skin check done – it’s reimbursed, because you’re worried about a mole. But everyone who comes to us is worried about a mole.”
With the full mole map costing $379, Bowling says from a public health perspective the biggest problem for patients is that skin cancer diagnosis and treatment isn’t accessible enough. “It would cost $200-250 to go to a good skin cancer doctor, and that excludes a big part of the population.”
The company has the infrastructure to supply cameras to GPs and provide a secure telemedicine platform to which they could upload photos of suspicious lesions for dermatologists to diagnose, but “the district health boards and the PHOs [primary health organisations] can’t decide who’ll pay for it”.
A shortage of dermatologists
A dermatology workforce report in 2014 found New Zealand has just one public dermatologist to 274,000 patients – internationally recommended figures are 1:50,000. With only about 60 registered dermatologists in practice, Bowling says, skin checks are “a low-margin business for them. They’d much rather cut things out than do skin checks.”
But Auckland dermatologist Steve Helander, for whom skin cancer work represents 60% of his practice, says melanoma is such a big problem in New Zealand that “it doesn’t help for one group to say we’re the only people who can manage this, or operate on skin.
“It’s very easy to get into a patch war and one wants to protect their profession, but we’re the melanoma capital of the world. Dermatology has changed enormously over the past 30 years. It used to be a medical specialty and now most dermatologists, myself included, would spend far more time treating sun-damaged skin than anything else.”
Public hospitals won’t screen even high-risk patients, so the task is left to the private sector. “Someone has to have the expertise to find these lesions and there’s a huge shortage of dermatologists.”
Like Oakley, Helander is a big believer in using GPs with extra training in skin cancer. “There’s an enormous need for upskilling. We do see examples of people who’ve gone to some of these GP-based skin-cancer-check clinics, sometimes for a relatively inexpensive visit, and then they’re told they might need to have 10 lesions removed. Then the 10 come back as being benign.
“When a patient comes to you and asks you to check their skin, you’re in an enormous position of power. You say, ‘These 10 things need to be removed’ – is someone going to argue with you? Some people may even think, ‘Well, that was very thorough.’ Cynically, there is an enormous amount of money to be made by cutting out huge numbers of lesions. And that’s what worries me. But I’d hope that’s not the motivation and they are doing it just to be thorough.”
Auckland GP and skin cancer expert Chris Boberg is the Royal New Zealand College of General Practitioners’ representative on the Melanoma Network of New Zealand (Melnet) and its delegate on the Ministry of Health’s melanoma standards committee. He says it’s difficult for patients to know who’s experienced, skilled and qualified to detect melanomas. He says dermatoscopes improve skin cancer detection – especially melanoma – by 25%, but their use is not yet taught at medical schools. It is, however, beginning to be introduced for GPs during their registrar training programme and is offered in postgraduate general practice education. Skin-cancer refresher courses are held up to six times a year by Melnet and some doctors have taken advanced courses in Australia and Austria.
“Knowing when to refer is a fundamental skill a GP needs and this is especially true for skin-cancer care,” he says.
Weigh it up
Without GPs doing a big proportion of skin-cancer work, the system would be swamped and unable to cope, says John de Waal, immediate past president of the New Zealand Association of Plastic Surgeons, but their expertise varies. “Everyone has an area they’re a bit better in, and medicine relies on knowing what they know and what they don’t know and where their limits lie.”
The Listener has been told that at a recent meeting of plastic surgeons in Auckland, one surgeon expressed concern about having to fix the work of a GP specialising in skin cancer. De Waal says he wasn’t at the meeting, but those sorts of views are common in many different specialties. When they are expressed publicly, “it just looks like we’re having a turf war.
“When you go to a professional, you’ve got to trust them, whether it’s a builder or lawyer or doctor. That’s why we have colleges, authenticating authorities and legislation.
“Most of the time you can trust most professionals, but every now and again there’s someone who makes a bad judgment call or isn’t quite as qualified as they seem to be. But I don’t think you can make it as simple as saying specialists are qualified to do this and GPs aren’t. No one gets it right 100% of the time.”
The melanoma surgeon the Listener spoke to advises patients to weigh up the relative experience and skill of the doctor and the outcome. “Obviously a plastic surgeon will probably do a better cosmetic job than a GP, especially on the face. But a plastic surgeon might charge $2000 and a GP $200. If it’s an 80-year-old with a back lesion, why not get a GP to take it off because it doesn’t matter what the scar looks like.”
But a GP who regularly does skin cancer removals says GPs with extra training and experience can achieve excellent results at a fraction of the cost of a plastic surgeon. He says he’s seen a patient charged $4800 by a plastic surgeon for a cosmetic procedure when $2300 would have been a fair price. “He charged $1700 for consumables. I can work for a month doing skin cancer excisions using that amount of consumables, so how he could charge that and look at himself in the mirror and say it was worth it? I don’t know.”
He says he’d charge a patient $500 for an operation that would cost $4000 if done by a plastic surgeon. “It’s always if you follow the money, that’s where the issue comes.”
Brian, who brought the story of his conflicting diagnoses to us, has since decided to have the potentially problematic lesion on his back removed by the second GP later this month. The GP told him the mole had a “12-15% chance” of turning cancerous – an estimate several other experts told us was “nonsense”.
“You simply cannot give a percentage that something is a melanoma,” said the surgeon. “That to me is suggesting he doesn’t think it’s melanoma but he’s encouraging the patient to have it taken off because you and I wouldn’t accept a risk of 12-15%.”
And so it has proved for Brian. “He suggested keeping an eye on it, but I said if it has that potential, I’d feel calmer getting it out. My case is quite piddly – I don’t believe there’s any great danger to me. The issue is we all used to lie in the sun caking ourselves with coconut oil and now we’ve got this big baby boomer blip. But the question is who do you trust?”
By the numbers
New Zealand has the highest rate of melanoma in the world and rates have doubled over the past 30 years from about 26 cases per 100,000 people in 1982 to about 50 cases per 100,000 in 2011.
It is the fourth most common cancer in New Zealand: more than 2300 cases are diagnosed annually and more than 300 people die of it.
Non-melanoma skin cancers aren’t registered, but it’s estimated 67,000 New Zealanders are diagnosed with them each year, costing $123 million.
Removing skin lesions is Southern Cross Health Society’s most commonly claimed-for elective procedure. In 2015, it funded 21,400 operations. More than 7700 were done by plastic surgeons, 5700 by dermatologists, 2300 by general surgeons, 4700 by GPs and 760 by other surgeons.
What to expect in a thorough skin examination:
• A full review of your medical history, assessing your risk of melanoma.
• A systematic review of your skin from head to toe. Some doctors prefer you to strip down to your underwear; others will ask for skin to be revealed a bit at a time.
• A check that includes the scalp; behind the ears; the sides of the nose and neck; the trunk, back, legs and toes and soles of the feet; and between the fingers.
• Breasts and genitals aren’t normally examined unless you have concerns about them.
• Doctors should use a magnifying and lighting device known as a dermatoscope.
The National Melanoma Tumour Standards Working Group has recommended provisional service guidelines. They suggest that:
• Patients should be offered evidence-based information on risk factors, prevention and early detection. Risk factors are age, prior melanoma or skin cancer, sun damage and many and/or large moles. However, two-thirds of melanomas occur in “average-risk” patients.
• Patients should be taught skin-examination techniques and recommended to have an annual full skin check if they are at risk. If they have many moles, digital dermatoscopy (taking images) is recommended.
• All primary doctors should be trained to recognise skin lesions that could be melanoma.
• Doctors should estimate a patient’s risk, stay alert to incidental lesions and carry out a full skin check to determine what’s normal for the patient.
• People at increased melanoma risk should be identified and properly managed, and their skin examined for mole numbers and pattern, focusing on large moles, small dark moles and “odd-looking” moles.
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