The Guild's Peter Waterman writes in Retail Pharmacy.
The summer season brings with it a greater awareness of the dangers of added exposure to the sun and outdoors – exposure that can lead to skin damage and the possible risk of skin cancer.
Skin cancer is an all-too-common form of cancer in Australia, with the incidence in this country being among the highest in the world, two to three times higher than the rates found in Canada, the US and Britain.
Cancer Australia projects that by year’s end, an estimated 13,283 new cases of melanoma will have been diagnosed in 2016, accounting for 10.2 per cent of all new cancer cases diagnosed this year.
It also projects that the year’s death toll from melanoma will be 1,774 people, with males making up 1,229 of this total.
Early detection through screening is key to improving survival rates, and community pharmacies increasingly are offering such services on a structured basis.
One such system is Spotcheck, a skin spotscreening service that utilises the expertise of doctors practising in skin-cancer medicine. With no appointment necessary, skin spots are photographed and sent to a doctor who is an expert in skin spot analysis. Patients receive the results within 48 hours.
Dr Tony Dicker, one of the doctors behind the Spotcheck system, says about 250 pharmacies are offering the service, including retail pharmacy brand Chemmart.
“We’re doing over 1,000 spots a year and finding about one in six spots is a cancer,” he said.
“Myself and Dr Gary Pellizzari diagnose the images and data sent to us from the pharmacy. We both work in skin-cancer clinics and are trained in dermoscopy diagnosis.
“Despite the ease of access to skin clinics, people are still dying from melanomas, so we thought about how we could get to people who need to have spots checked but, for some reason, don’t go to a doctor or clinic.
“The result is the Spotcheck system for pharmacies. Pharmacies are ideal because they’re very accessible as well as being places that people go to for health advice and information.”
Dr Dicker says the Spotcheck system in community pharmacies has resulted in the diagnosis of more than 50 melanomas.
“When we diagnose a melanoma we immediately contact the patient and tell them they have to see a doctor and have it cut off,” he said. “If they don’t have a doctor, we can help find one for them.
“Through Spotcheck we often are the first point in the diagnosis and are finding problems quickly.”
Spotcheck involves the use of a dermatoscope attached to an iPhone, which in turn has a dedicated app loaded for the process. The unit is able to capture the picture and all the data needed for the diagnosis.
“It’s important to note that with our system the images and information are not stored on the phone, but rather on our servers, which comply with the stringent requirements for storing medical data,” Dr Dicker said.
“The information we gather includes a contact number and email address for the patient, so we can contact them quickly if we find something significant.
“Every person who sends in a spot receives a diagnosis – not a percentage risk, which some other phone apps do. Ours is a diagnosis by a doctor who has special training in analysing dermoscopy images.
“We’re capturing people who haven’t presented to a doctor in the first place, people who would not have had a skin check. We’re capturing people who haven’t had the time to see a doctor. They like the convenience of the walk-past, drop-in service provided by the pharmacy.”
Dr Dicker rejects criticism of the checks being carried out in pharmacy.
“We are doctors doing the diagnosis and the pharmacies are merely gathering the information for us,” he said.
“The nice thing is that the system works and we’re finding things earlier. We have a structure behind us to help refer patients and close the loop so patients get treatment as quickly as possible.
“If we can save lives, we’re ahead of the game.
“We agree that a full skin check is the gold standard, but the people presenting at the pharmacy aren’t even showing the doctors these spots, let alone getting a full skin check. This process can start the journey for them.”
Carolyn Wynen, co-proprietor at Chemmart Casey Central in Victoria, says the pharmacy has been conducting the Spotcheck program for three years.
“It’s been a very worthwhile service and we’ve been able to identify some spots of concern,” she said. “Of course, there are a whole lot more that aren’t [of concern], but the patient gets peace of mind after having the spots checked.
“People often think they’ll leave a spot to be checked until the next time they visit the doctor, but when they go to the doctor, they’re sick, and their focus is on that illness, so the spot is forgotten about.
“With us, we find patients are saying, ‘While I’m here can you check this spot for me?’ They get the spot checked and if there’s nothing to worry about they get peace of mind.
“There are also instances where we do help find spots of concern that need to be acted upon quickly.”
Ms Wynen says accessibility and not having to book ahead are key factors in the service.
“It’s important to stress that we’re not diagnosing and we’re not operating outside our area of expertise,” she said.
“We’re facilitators of the service, working in conjunction with doctors who are experts in skin issues.
“We’re qualified health professionals and we have the professionalism to give advice within our realm of expertise – we’re certainly not saying we’re skin experts. The important thing is that people are having any skin spots they are concerned about checked.”
A spokesperson for Guild Insurance reinforced the need for patients to be advised that pharmacists and pharmacy assistants in the Spotcheck service are simply facilitators.
“It’s important that pharmacists don’t give advice or offer opinions that are outside their expertise,” the spokesperson said.
“There may well be pressure from a patient asking for help on choosing a spot or requesting a diagnosis. It’s important that only the pharmacist provides general advice, such as referring to the ABCDE [‘asymmetrical shape, border, colour, diameter and evolution’] melanoma detection guidelines, and ensures that the patient understands that diagnosis is conducted by the Spotcheck doctor, using the data gathered in the pharmacy. If a patient has concerns, a recommendation to have a full skin check by a qualified health professional should be made.”
“Patients should also have an initial professional skin check by a GP or dermatologist. This will help determine personal risk factors and the frequency of future checks.
“Providing skin checks in pharmacies may well assist people to keep their skin top of mind and help identify anything that may require checking by a GP or dermatologist.”
Collaborative approach reduces incidence
Dermatologist and AMA (NSW) past president Associate Professor Saxon Smith is a strong advocate for skin checks being performed by doctors – but sees an important role for community pharmacies as part of a collaborative approach to reducing the incidence of skin cancers.
He says the ‘slip, slop, slap’ campaign’ is regarded with a degree of apathy and too many Australians fail to give credence to warnings about skin cancer.
“Patients also are not looking at expiry dates on sunscreen, they’re not storing it properly and many don’t actually know how much to put on,” he said.
“These are all important messages that we need to get out and I think community pharmacies are an ideal setting for this sort of education – the get-smart-about-sunprotection education.
“At the moment, Australians seem to be suffering from education fatigue about sun protection and we need to address that.
“Some 30 per cent of young adults in Australia still actively sun tan despite knowing it increases the risk of skin cancer. Plus, 65 per cent of all adults in Australia have been sunburnt at least once in the past 12 months. So education message and prevention are critical.”
However, when it comes to checking for skin cancers, Associate Professor Smith says the first stop should be the family doctor.
“Without question, skin cancer checks should be performed by doctors,” he said.
“One of the problems is that a check in pharmacies only looks at one spot or a few spots and that’s inadequate.
“It’s important that the patients have a full body check, as looking at only one or a few spots raises the dangers of an inaccurate diagnosis or a wrong diagnosis. A top-to-toe examination is needed. We also need to have a full history of the patient, which is not available in pharmacies.”
Associate Professor Smith says another issue with checks in pharmacies is that in these cases the patients are often telling the pharmacist or pharmacy assistant which spot they want checked.
“We know from Australian research that 60 per cent of melanomas picked up by doctors are ones the patient was totally unaware of,” he said.
“In a pharmacy, a patient may ask a pharmacist to check a spot they’re worried about, but be unaware of other spots, which we would pick up in a full body examination.”
Associate Professor Smith also raises concerns about the technology used in some non-medical-practice checks for skin cancer.
‘You’re looking at a 3D lesion in 2D,” he said. “You’re not feeling the lesion and the dermatoscope reduces the capacity to diagnose.
“Also the colour of the lesion is important in diagnosis and this may not be accurately reflected by some dermatoscope examinations. The dematoscope should be regarded as an aid, not a tool in diagnosis.”
Associate Professor Smith says a collaborative and collegial approach among health professionals to reducing skin cancers is important.
“There’s so much we can do together, but we have to know our individual professional limitations,” he said.