Diagnostic Accuracy of Patients in Performing Skin Self-examination and the Impact of Photography Diagnostic Accuracy of Patients in Performing Skin Self-examination and the Impact of Photography Susan A. Oliveria, ScD; Dorothy Chau, MD; Paul J. Christos, MPH; Carlos A. Charles, MD; Alvin I. Mushlin, MD; Allan C. Halpern, MD Objective: To determine the sensitivity and specificity of skin self-examination (SSE) to detect new and chang- ing moles with and without the aid of baseline digital pho- tographs in patients with dysplastic nevi. Design and Intervention: Patients had baseline digi- tal photography and mole counts of their back, chest, and abdomen and were instructed to perform a baseline SSE. Print copies of the images were provided to the patient. Following the baseline examination, the appearance of existing moles was altered and new moles were created using cosmetic eyeliner. The number of moles altered and/or created totaled approximately 10% of each pa- tients’ absolute mole count. Setting and Patients: Fifty patients with 5 or more dysplastic nevi from the outpatient clinic at Memorial Sloan-Kettering Cancer Center, New York, NY. Main Outcome Measure: Skin self-examinations with and without access to the baseline photographs to iden- tify the number of new and altered moles. Results: The sensitivity and specificity of SSE for de- tection of both altered and new moles without photog- raphy were 60.2% and 96.2%, respectively. Skin self- examination with photography yielded a sensitivity and specificity of 72.4% and 98.4%, respectively. The find- ings were similar when stratified by site (back vs chest or abdomen). The sensitivity and specificity for new moles were higher compared with altered moles. Conclusions: Access to baseline photography improved the diagnostic accuracy of SSE on the back and chest or abdomen and improved detection of changing and new moles. Our results suggest that baseline digital photogra- phy in tandem with SSE may be effective in improving the diagnostic accuracy of patients performing SSE. Arch Dermatol. 2004;140:57-62 L ESION THICKNESS (BRESLOW depth) has been identified as the most important prognos- tic factor for primary cuta- neous melanoma, with sur- vival inversely related to lesion thickness.1-4 There is a direct relationship between sur- vival of patients with melanoma and early detection. The 5-year survival rate for pa- tients with melanoma smaller than 1 mm thick is 94% compared with 50% for mela- nomas larger than 3 mm thick.5 This find- ing suggests that the identification and ex- cision of thin lesions may be important in reducing mortality from melanoma. The American Academy of Derma- tology has recommended that individu- als practice skin self-examination (SSE) to detect new and/or changing lesions.6 Self- screening is important because self- detection by patients, spouses, and fami- lies is the most common way skin cancer is currently detected, even though SSE may not be performed routinely or thor- oughly.7-9 Results suggest that SSE is as- sociated with a reduced risk of mela- noma, and it is a moderately effective tool for detecting changes in mole size.10-12 During the past decades, atypical nevi (dysplastic nevi) have been identified as the strongest indicators of melanoma risk.13-18 The presence of large numbers of clinically atypical nevi hinders self- examination and professional evalua- tion. Because the wholesale excision of these lesions is impractical, the present standard of care for individuals with dys- plastic nevi is close observation and exci- sion of changing lesions.19-21 In individu- als with large numbers of moles and/or dysplastic nevi, attempts to recognize new or changing lesions are aided by compari- son of the clinical examination to pic- tures of the individual’s skin at an earlier point in time.19,22-24 Providing patients with photographs offers a baseline measure and may encourage the patient to carefully watch lesions.25 It has been suggested that STUDY From the Dermatology Service, Memorial Sloan-Kettering Cancer Center (Drs Oliveria, Chau, Charles, and Halpern and Mr Christos), and Department of Public Health, Weill Medical College of Cornell University (Dr Mushlin and Mr Christos), New York, NY; and Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, Fla (Dr Charles). The authors have no relevant financial interest in this article. (REPRINTED) ARCH DERMATOL / VOL 140, JAN 2004 WWW.ARCHDERMATOL.COM 57 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 patients may be able to better detect changes in their le- sions if they have an opportunity to repeatedly view the original lesion with photographs.26 In addition, through the application of computerized image analysis, digital imaging may offer an opportunity to identify new le- sions or changes in lesions earlier and more accurately than standard photographically assisted follow-up. The purpose of this study was to determine the sen- sitivity and specificity of SSE to detect new and changing moles in patients with dysplastic nevi. New and chang- ing moles were artificially created with the use of cos- metic makeup. We also assessed the impact of making per- sonal baseline digital photographs available to these patients at the time of SSE on diagnostic accuracy (ie, sensitivity and specificity). METHODS STUDY PARTICIPANTS The study was conducted in the outpatient setting of the Pig- mented Lesion Clinic of the Dermatology Service at Memorial Sloan-Kettering Cancer Center (New York, NY). Fifty patients 18 years or older with 5 or more clinical dysplastic nevi who were willing to have digital whole-body photography were re- cruited and informed consent obtained. Patients who were vi- sually or physically impaired were not eligible for the study. CONDUCT OF THE STUDY AND DATA COLLECTION Baseline Examination Information was obtained from each participant at baseline us- ing an in-person interview conducted and recorded by a re- search fellow (D.C.). Specifically, information was collected on age, sex, race/ethnicity, hair color at the age of 18 years, eye color, skin tone, tendency to burn, ability to tan, self-reported mole count, personal and family history of skin cancer, and SSE practices. As part of the baseline data collection, patients were asked to perform SSE with the aid of a full-length (35 � 127 cm) and hand-held mirror (16 � 19 cm). Patients who wore cor- rective glasses were instructed to wear them while performing their SSE. Digital photography and mole counts of the chest, abdomen, and back were performed on each patient by a re- search fellow (Figure 1).22 Print copies of the images were pro- vided to the patient. Procedures to Create and Alter Moles This was an intervention study design whereby patients received the intervention (alteration or creation of moles) and served as their own comparison group. Following the baseline examination, the appearance of existing moles was altered and new moles were created using cosmetic eyeliner that was water soluble and nontoxic. Four different color shades of eyeliner were available, and the shade closest in color to the patient’s typical nevi was used to minimize any color discrimi- nation by the patient. Each patient had approximately 10% of their moles altered and/or created on their back and chest or abdomen. To alter the size and shape of moles, a template was used to convert existing 5-mm moles to slightly more irregu- larly shaped 7-mm moles. To assess the ability of patients to identify focal changes in the color of moles, a 2-mm, dark brown mark was made in the confines of existing 5-mm moles. A template was used to create new 4-mm moles (Figures 2, 3, 4, and 5). Blindfolding of patients and sham drawing on multiple sites were used to ensure that the patients were unaware of the location of cosmetically altered Figure 2. Unaltered mole. BA Figure 1. Body areas for digital photography and mole counts. (REPRINTED) ARCH DERMATOL / VOL 140, JAN 2004 WWW.ARCHDERMATOL.COM 58 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 moles and to preclude tactile recall of the sites of the altered and created moles. Patient Assessment of New and Altered Moles Patients had the blindfolds removed and were then asked to perform SSE (with full-length and hand-held mirror) first with- out the aid of baseline digital photographs and subsequently with access to their personal photographs. The research fel- low recorded the number and types (new vs altered mole) of changes correctly and incorrectly identified by the patient. Statistical Analysis Descriptive statistics were used to characterize the study popu- lation. Sensitivity, specificity, � statistic, 95% confidence in- tervals, and P values derived from the � statistic are presented. Using the mole as the unit of analysis, the sensitivity and speci- ficity of SSE to detect new and changing moles were calcu- lated for SSE with and without the aid of baseline digital pho- tographs. The reference standard was the lesion count and recorded number of moles changed and/or created. The � statistic was used to evaluate the diagnostic accu- racy (sensitivity and specificity) of each SSE modality (eg, with and without baseline photography). In this context, � is a weighted statistic that expresses the desirable properties of the test (eg, low probability of false results). The comparison of the � statistic between each SSE modality and the resultant P value are based on an approach for the comparison of 2 di- agnostic tests, each evaluated against the same gold standard (eg, actual number of moles physically altered and/or created) in the same study sample.27 The positive predictive values (PPVs) and negative predictive value (NPVs) of SSE, with and with- out the aid of baseline digital photography, were also calcu- lated using the Bayes theorem.28 The diagnostic accuracy of SSE can be affected by numer- ous factors. Stratified analyses were performed by age, sex, his- tory of melanoma, melanoma risk factors, and SSE practices. We explored the potential effects on SSE accuracy of mole lo- cation (back vs chest or abdomen), type of mole detected (newly created moles vs altered existing moles), and total number of moles altered and/or created on the patient (dichotomized at median; �5 moles altered or created vs �5 moles altered or created) by conducting stratified analyses. RESULTS The participation rate for this study was 93% (50/54). Characteristics of the 50 patients who were recruited and completed the study are presented in Table 1. There was a total of 3167 moles (median, 50; mean, 63) that con- tributed to the analyses; 108 moles were altered and 211 new moles were created. The number of altered or cre- ated moles per patient ranged from 2 to 27 based on the criteria of altering 10% of each patients’ moles. Fifty- two percent of the patients had 5 or fewer moles altered or created, and 48% of the patients had more than 5 moles altered or created. The sensitivity and specificity of SSE for detection of both new and altered moles without pho- tography were 60.2% and 96.2%, respectively, whereas SSE with photography yielded a sensitivity and specific- ity of 72.4% and 98.4%, respectively (Table 2). Sex differences were apparent, with men perform- ing better than women without the aid of photographs (Table 3). However, women had a higher sensitivity and specificity of SSE with the use of photographs com- pared with men. Results showed that patients with more than 5 moles altered or created had significant improve- ments in diagnostic accuracy with the aid of baseline pho- tographs, although patients with 5 or fewer moles al- tered or created still gained some benefit from access to photography (Table 4). The stratified analyses sug- gested that patients with fairer complexions (eg, light skin, eye, and hair color, tendency to burn, and ability to tan) had higher sensitivities both with (76.6%, 82.8%, 79.8%, 76.0%, and 78.7%, respectively) and without (59.9%, 70.5%, 67.5%, 60.5%, and 61.9%, respectively) the aid of photographs compared with patients who did not have these risk factors (with photography: 62.9%, 66.0%, 68.3%, 54.7%, and 66.5%, respectively; without photog- Figure 3. New 4-mm mole. Figure 4. A 2-mm, dark brown mark within the existing 5-mm mole. Figure 5. A 5-mm mole changed to an irregularly shaped, 7-mm mole. (REPRINTED) ARCH DERMATOL / VOL 140, JAN 2004 WWW.ARCHDERMATOL.COM 59 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 raphy: 60.8%, 53.8%, 56.1%, 58.4%, and 58.5%, respectively). There were no similar trends in the analy- ses stratified by family history of skin cancer or SSE prac- tices. However, patients with a personal history of mela- noma had higher sensitivities both with (80.0%) and without (65.8%) the aid of photography compared with patients with no such personal history (with photogra- phy: 67.8%; without photography: 56.8%). We calculated the PPV and NPV for SSE with and without the aid of baseline photography. The stratified estimates for PPV and NPV for SSE with photography ranged from 70% to 90% and 97% to 99%, respectively. For SSE without the aid of baseline photography, the strati- fied estimates for PPV and NPV for SSE ranged from 54% to 67% and 96% to 98%, respectively. However, these es- timates are highly dependent on the prior selected preva- lence of altered or created moles and should therefore be interpreted with caution. The PPV and NPV results could differ in a population with a different prevalence of new and changing moles; in our study, we fixed the prevalence at 10%, since we created the new and chang- ing moles. COMMENT This pilot study determined the sensitivity and specific- ity of SSE to detect new and changing moles in patients with dysplastic nevi and also assessed the impact of mak- ing personal baseline digital photographs available to these patients at the time of initial self-examination. The sen- sitivity of SSE to detect both new and altered moles was 60.2% without photography and increased substantially to 72.4% with the aid of digital photographs. The re- sults suggest that patients had high specificity (few false- positive results) both with and without access to photo- graphs. The specificity was 96.2% without photographs and increased slightly to 98.4% with the aid of photo- graphs. Berwick et al10 reported that SSE is associated with a reduced risk of melanoma, with the potential for a 63% reduction in mortality. A prospective study of the effec- tiveness of SSE is needed; however, the logistic con- straints in conducting such a study are obvious. In a pre- liminary study by Muhn et al,11 the efficacy of SSE to detect changes in mole size has been investigated in high-risk patients.11 The specificity of SSE was 62% and the sen- sitivities of detecting 2-mm and 4-mm changes were 58% and 75%, respectively. In a recent study by Dawid et al,12 the ability of patients to identify real changes in mela- nocytic nevi was evaluated in 251 patients with 1431 me- lanocytic nevi. The sensitivity to detect enlarging nevi was low (10.9%), whereas the specificity was 99.2%. In a study by Edmondson et al,25 the effect of instant pho- tography as a method for screening melanoma during rou- tine health examinations was assessed. Copies of the prints were given to patients for observation of any changes in the lesions of interest. Although the objective was not to study the effect of providing photographs to patients, the results showed that the possession of a photograph by the patient led to a diagnosis of melanoma in 2 in- stances. Although the ultimate end point of interest in a screening study of this type would be melanoma, we de- fined new lesions and lesion change as intermediate out- comes because we believe these are the most important and relevant for self-directed prescreening and early de- tection. Limitations of the study are that SSE was not for- mally taught to the patients and the study was not re- stricted to patients who could adequately perform SSE. Patients who are taught SSE may receive more benefit. We only assessed the diagnostic accuracy of SSE per- formed on the back and chest or abdomen, and the re- sults may not be generalizable to different sites on the body. Also, there can be other subtle changes related to margins, thickness, and texture that are not captured with this simplistic approach of creating new moles and al- tering existing moles using cosmetic eyeliner. The design of the intervention for this study differs from the intervention design that would be observed in routine follow-up examination because the study popu- Table 1. Patient Characteristics Characteristic Patients, No. (%) (N = 50)* Sex Male 20 (40) Female 30 (60) Age, y �30 13 (26) 31-40 18 (36) 41-50 12 (24) �51 3 (6) White race 50 (100) Tendency to burn Easily or some 43 (86) Rarely or never 7 (14) Tendency to tan Deep or moderate 25 (50) Mild or none 25 (50) Eye color Blue or green 20 (40) Hazel or brown 30 (60) Hair color at age 18 y Blond or red 20 (40) Brunette or black 30 (60) Skin tone Very fair or fair 35 (70) Medium or dark 15 (30) Personal history of melanoma Yes 22 (44) No 28 (56) Family history of melanoma Yes 14 (28) No 25 (50) Family history of basal cell carcinoma Yes 18 (36) No 21 (42) Family history of squamous cell carcinoma Yes 4 (8) No 29 (58) No. of skin self-examinations in last 4 mo 0 17 (34) 1-4 33 (66) No. of moles altered and/or created for study protocol �5 (range, 2-5; mean, 4; median, 4) 26 (52) �5 (range, 6-27; mean, 9; median, 7) 24 (48) *Some percentages do not total 100% because of missing responses. (REPRINTED) ARCH DERMATOL / VOL 140, JAN 2004 WWW.ARCHDERMATOL.COM 60 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 lation was a select, highly motivated group composed of patients at high risk for melanoma based on the pres- ence of 5 or more dysplastic nevi. These patients ex- pected an artificial alteration in a lesion, and the alter- ation and SSE to detect change were performed at the same appointment. Because the assessment of diagnostic ac- curacy of SSE occurred shortly after the baseline SSE, pa- tients were relying on immediate rather than long-term Table 2. Sensitivity and Specificity of Skin Self-examination for Identification of Altered (A) and New (N) Moles Mole Category* Without Photography, % (95% CI) With Photography, % (95% CI) P Value†Sensitivity Specificity Sensitivity Specificity All A/N moles 60.2 (54.6-65.6) 96.2 (95.4-96.8) 72.4 (67.1-77.2) 98.4 (97.9-98.8) �.001 Back A/N moles 57.5 (50.3-64.4) 97.0 (96.1-97.7) 68.5 (61.5-74.8) 98.3 (97.6-98.8) �.001 Chest or abdomen A/N moles 64.7 (55.4-73.1) 94.8 (93.3-96.0) 79.0 (70.4-85.7) 98.5 (97.6-99.1) �.001 All new moles 63.0 (56.1-69.5) 97.8 (97.3-98.3) 75.8 (69.4-81.3) 99.4 (99.1-99.6) �.001 All altered moles 54.6 (44.8-64.1) 98.3 (97.8-98.7) 65.7 (55.9-74.4) 99.0 (98.6-99.3) �.001 Moles altered in size‡ 56.0 (41.4-69.7) . . . 74.0 (59.4-84.9) . . . .01 Moles altered in color‡ 53.4 (40.0-66.5) . . . 58.6 (45.0-71.1) . . . .58 Abbreviation: CI, confidence interval. *N = 50 patients. All A/N moles, n = 319; back A/N moles, n = 200; chest or abdomen A/N moles, n = 119; new moles, n = 211; all altered moles, n = 108; moles altered in size, n = 50; moles altered in color, n = 58; all unaltered moles, n = 3059; back unaltered moles, n = 1922; and chest or abdomen unaltered moles, n = 1137. †P value for paired comparison of skin self-examination diagnostic accuracy with and without the aid of baseline photography. ‡Patients were not asked if an identified altered mole was specifically altered with respect to size or color. As a result, the specificity of moles altered in size or color could not be calculated. Table 3. Sensitivity of Skin Self-examination for Identification of Altered (A) and New (N) Moles According to Sex Mole Category* Men (n = 20) Women (n = 30) Sensitivity, % (95% CI) P Value† Sensitivity, % (95% CI) P Value†Without Photography With Photography Without Photography With Photography All A/N moles 63.8 (55.4-71.4) 67.8 (59.6-75.1) .01 57.1 (49.3-64.5) 76.5 (69.2-82.5) �.001 Back A/N moles 61.3 (50.6-71.1) 65.6 (54.9-74.9) .32 54.2 (44.3-63.8) 71.0 (61.3-79.2) �.001 Chest or abdomen A/N moles 67.9 (53.9-79.4) 71.4 (57.6-82.3) .001 61.9 (48.8-73.6) 85.7 (74.1-92.9) �.001 All new moles 67.8 (57.0-77.0) 68.9 (58.1-78.0) .09 59.5 (50.2-68.2) 81.0 (72.6-87.3) �.001 All altered moles 57.6 (44.1-70.2) 66.1 (52.5-77.6) .04 51.0 (36.5-65.4) 65.3 (50.3-77.9) .002 Moles altered in size 64.3 (44.1-80.7) 82.1 (62.4-93.2) .13 45.5 (25.1-67.3) 63.6 (40.8-82.0) .13 Moles altered in color 51.6 (33.4-69.4) 51.6 (33.4-69.4) �.99 55.6 (35.6-74.0) 66.7 (46.0-82.8) .38 Abbreviation: CI, confidence interval. *Men: all A/N moles, n = 149; back A/N moles, n = 93; chest or abdomen A/N moles, n = 56; all new moles, n = 90; all altered moles, n = 59; moles altered in size, n = 28; and moles altered in color, n = 31. Women: all A/N moles, n = 170; back A/N moles, n = 107; chest or abdomen A/N moles, n = 63; all new moles, n = 121; all altered moles, n = 49; moles altered in size, n = 22; and moles altered in color, n = 27. †P value for paired comparison of skin self-examination diagnostic accuracy with and without the aid of baseline photography. Table 4. Sensitivity of Skin Self-examination for Identification of Altered (A) and New (N) Moles According to Number of Moles Mole Category* �5 A/N Moles (n = 26) �5 A/N Moles (n = 24) Sensitivity, % (95% CI) P Value† Sensitivity, % (95% CI) P Value†Without Photography With Photography Without Photography With Photography All A/N moles 66.0 (56.0-74.9) 70.9 (61.0-79.2) �.001 57.4 (50.5-64.0) 73.1 (66.6-78.8) �.001 Back A/N moles 61.7 (48.2-73.7) 65.0 (51.5-76.6) .05 55.7 (47.1-64.0) 70.0 (61.6-77.3) �.001 Chest or abdomen A/N moles 72.1 (56.1-84.2) 79.1 (63.5-89.4) �.001 60.5 (48.6-71.4) 78.9 (67.8-87.1) �.001 All new moles 60.0 (48.0-70.9) 70.7 (58.9-80.3) �.001 64.7 (56.0-72.6) 78.7 (70.7-85.0) �.001 All altered moles 82.1 (62.4-93.2) 71.4 (51.1-86.1) .58 45.0 (34.0-56.5) 63.8 (52.2-74.0) �.001 Moles altered in size 80.0 (51.4-94.7) 80.0 (51.4-94.7) �.99 45.7 (29.2-63.1) 71.4 (53.5-84.8) .01 Moles altered in color 84.6 (53.7-97.3) 61.5 (32.3-84.9) .25 44.4 (30.0-59.9) 57.8 (42.2-72.0) .11 Abbreviation: CI, confidence interval. *Five or fewer A/N moles: all A/N moles, n = 103; back A/N moles, n = 60; chest or abdomen A/N moles, n = 43; all new moles, n = 75; all altered moles, n = 28; moles altered in size, n = 15; moles altered in color, n = 13. More than 5 A/N moles: all A/N moles, n = 216; back A/N moles, n = 140; chest or abdomen A/N moles, n = 76; all new moles, n = 136; all altered moles, n = 80; moles altered in size, n = 35; and moles altered in color, n = 45. †P value for paired comparison of skin self-examination diagnostic accuracy with and without the aid of baseline photography. (REPRINTED) ARCH DERMATOL / VOL 140, JAN 2004 WWW.ARCHDERMATOL.COM 61 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 recall of the location and characteristics of their moles, and there is the potential for an overestimate of the di- agnostic accuracy. The research fellow who interviewed the patients and altered the patients’ moles was also re- sponsible for recording the patients’ ascertainment of al- tered moles. Hence, there may be the potential for bias related to accuracy ascertainment. However, the re- search fellow was instructed to simply record the pa- tients’ responses with respect to ascertainment. Due to logistical constraints, it was not feasible to use a sepa- rate research fellow for accuracy ascertainment. This study was conducted in an experimental, highly controlled situation and may not represent what would occur in a population-based setting. Sham- altered nevi may not represent what would occur in a real-world setting; however, this was designed as a pilot study. A prospective study is being planned, and the results will allow us to draw firm conclusions about the impact of digital photography on accuracy of SSE in high-risk patients. The patient population was also highly motivated, with a high prevalence of dysplastic nevi (100%), his- tory of malignant melanoma (65.8%), and previous per- formance of SSE (66.0%). These preliminary results likely represent the best case scenario, since our study popu- lation was highly motivated and had the advantage of an immediately antecedent baseline SSE. The availability of baseline digital photographs im- proved the sensitivity and specificity to detect new and altered moles. Our results suggest that baseline digital photography as an adjunct to SSE improves the diagnos- tic accuracy of patients performing SSE. Providing pa- tients with photographs may encourage patients to more carefully monitor their lesions and may enable patients to better detect suspicious changes in their lesions. Accepted for publication May 14, 2003. This study was presented in abstract form at the 62nd Annual Meeting of the Society of Investigative Dermatol- ogy, May 9-11, 2001, Chicago, Ill. We are grateful to the patients at Memorial Sloan- Kettering Cancer Center for their participation in this study. We thank Alexis Liebel, MD, for her helpful comments and suggestions during the revising of the manuscript. Corresponding author: Susan A. Oliveria, ScD, Der- matology Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021 (e-mail: oliveri1@mskcc.org). REFERENCES 1. Breslow A. Thickness cross-sectional areas and depth of invasion in the prog- nosis of cutaneous melanoma. Ann Surg. 1970;172:902-908. 2. Margolis DJ, Halpern AC, Rebbeck T, et al. Validation of a melanoma prognostic model. Arch Dermatol. 1998;134:1597-1601. 3. Sahin S, Rao B, Kopf AW, et al. Predicting ten-year survival of patients with pri- mary cutaneous melanoma: corroboration of a prognostic model. Cancer. 1997; 80:1426-1431. 4. Breslow A. Tumor thickness, level of invasion and node dissection in stage I cu- taneous melanoma. Ann Surg. 1975;182:572-575. 5. NIH Consensus conference: diagnosis and treatment of early melanoma. JAMA. 1992;268:1314-1319. 6. Koh HK, Geller AC, Miller DR, Lew RA. The early detection of and screening for melanoma: international status. Cancer. 1995;75:674-683. 7. Weinstock MA. Early detection of melanoma. JAMA. 2000;284:886-889. 8. Koh HK, Miller DR, Geller AC, Clapp RW, Mercer MB, Lew RA. Who discovers melanoma? patterns from a population-based survey. J Am Acad Dermatol. 1992; 26:914-919. 9. Miller DR, Geller AC, Wyatt SW, et al. Melanoma awareness and self- examination practices: results of a United States survey. J Am Acad Dermatol. 1996;34:962-970. 10. Berwick M, Begg CB, Fine J, Roush GC, Barnhill RL. Screening for cutaneous melanoma by skin self-examination. J Natl Cancer Inst. 1996;88:17-23. 11. Muhn CY, From L, Glied M. Detection of artificial changes in mole size by skin self-examination. J Am Acad Dermatol. 2000;42:754-759. 12. Dawid M, Pehamberger H, Wolff K, Binder M, Kittler H. Evaluation of the abil- ity of patients to identify enlarging melanocytic nevi. Arch Dermatol. 2002;138: 984-985. 13. Elder DE, Goldman LI, Goldman SC, Greene MH, Clark WHJ. Dysplastic nevus syndrome: a phenotypic association of sporadic cutaneous melanoma. Cancer. 1980;46:1787-1794. 14. Holly EA, Kelly JW, Shpall SN, Chiu SH. Number of melanocytic nevi as a major risk factor for malignant melanoma. J Am Acad Dermatol. 1987;17:459-468. 15. Nordlund JJ, Kirkwood J, Forget BM, et al. Demographic study of clinically atypi- cal (dysplastic) nevi in patients with melanoma and comparison subjects. Can- cer Res. 1985;45:1855-1861. 16. Swerdlow AJ, English J, MacKie RM, et al. Benign melanocytic naevi as a risk factor for malignant melanoma. BMJ. 1986;292:1555-1559. 17. Tucker MA, Halpern A, Holly EA, et al. Clinically recognized dysplastic nevi: a cen- tral risk factor for cutaneous melanoma. JAMA. 1997;277:1439-1444. 18. Rhodes AR, Harrist TJ, Day CL, Mihm MCJ, Fitzpatrick TB, Sober AJ. Dysplastic melanocytic nevi in histologic association with 234 primary cutaneous melano- mas. J Am Acad Dermatol. 1983;9:563-574. 19. Shriner DL, Wagner RFJ, Glowczwski JR. Photography for the early diagnosis of malignant melanoma in patients with atypical moles. Cutis. 1992;50:358-362. 20. Slue WEJ. Total body photography for melanoma surveillance. N Y State J Med. 1992;92:494-495. 21. Tiersten AD, Grin CM, Kopf AW, et al. Prospective follow-up for malignant mela- noma in patients with atypical-mole (dysplastic-nevus) syndrome. J Dermatol Surg Oncol. 1991;17:44-48. 22. Halpern AC. The use of whole body photography in a pigmented lesion clinic. Dermatol Surg. 2000;26:1175-1180. 23. Shriner DL, Wagner RFJ. Photographic utilization in dermatology clinics in the United States: a survey of university-based dermatology residency programs. J Am Acad Dermatol. 1992;27:565-567. 24. Slue W, Kopf AW, Rivers JK. Total-body photographs of dysplastic nevi. Arch Dermatol. 1988;124:1239-1243. 25. Edmondson PC, Curley RK, Mardsen RA, Robinson D, Allaway SL, Willson CD. Screening for malignant melanoma using instant photography. J Med Screen. 1999;6:42-46. 26. Hanrahan PF, Hersey P, Menzies SW, Watson AB, D’Este CA. Examination of the ability of people to identify early changes of melanoma in computer-altered pigmented skin lesions. Arch Dermatol. 1997;133:301-311. 27. Bloch DA. Comparing two diagnostic tests against the same ‘gold standard’ in the same sample. Biometrics. 1997;53:73-85. 28. Vecchio T. Predictive value of a single diagnostic test in unselected populations. N Engl J Med. 1966;274:1171-1173. (REPRINTED) ARCH DERMATOL / VOL 140, JAN 2004 WWW.ARCHDERMATOL.COM 62 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021