Increased distance to physician associated with thicker skin cancer at diagnosis

August 20, 2007

The farther patients travel to reach the physician who diagnoses their melanoma, the more likely they are to have thicker skin cancer at diagnosis, according to a report in the August issue of Archives of Dermatology, one of the JAMA/Archives journals.

"Survival for patients with melanoma is dependent on stage at diagnosis. As Breslow [depth of tumor cells in the skin] thickness increases, overall survival decreases," according to background information in the article. "Consequently, early diagnosis may substantially improve patient outcomes. Because melanoma can only be definitively diagnosed based on biopsy findings, diagnosis requires detection of the suspicious lesion and biopsy. Some primary care providers perform diagnostic biopsies, but many prefer to refer patients to dermatologists or surgeons."

Karyn B. Stitzenberg M.D., M.P.H., of the School of Public Health, University of North Carolina at Chapel Hill, and colleagues examined the effect of travel distance--and other factors such as age, sex, poverty rate, living in rural areas and the number of physicians in the area--on access to diagnosing clinicians for 615 patients with melanoma. Patients' Breslow thickness was also measured.

The median (midpoint) distance to a diagnosing physician was 8 miles. The median Breslow thickness was 0.6 millimeters. For each one-mile increase in distance, average Breslow thickness at diagnosis increased by 0.6 percent. Patients who traveled more than 15 miles had tumors 20 percent thicker than those of patients who traveled 15 miles or less. Patients from rural counties traveled an average 2.4 miles farther to their diagnosing clinician than those from metropolitan counties. Those from counties with at least one dermatologist traveled an average 8.3 miles less than those without a dermatologist in their counties.

Breslow thickness was also associated with age and poverty. "For each 1 percent increase in poverty rate, Breslow thickness increased by 1 percent. Breslow thickness was 19 percent greater for patients aged 51 to 80 years than for those aged 0 to 50 years and was 109 percent greater for patients older than 80 years than for those aged 0 to 50 years," the authors write. "Sex, rurality and supply of dermatologists were not associated with Breslow thickness."

"Further work is needed to characterize the determinants of distance to diagnosing provider, as well as the pathways and barriers to melanoma care," the authors conclude. "Once potential barriers are identified, interventions can be developed to minimize the effect of travel distance and other sociodemographic factors on access to melanoma care."
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(Arch Dermatol. 2007;143(8):991-998. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: This study was supported in part by a National Research Service Award Postdoctoral Traineeship from the Agency for Healthcare Research and Quality, sponsored by a grant from the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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