Since the end of April 2015, the long-awaited evaluation report on the skin cancer screening programs offered by German health insurance providers is now finally available. We spoke with Dr. Ralph von Kiedrowski, Board Member of the German Dermatologist Association (German: Berufsverband Deutscher Dermatologen) on what the screening can accomplish and his take on the G-BA report.
Dr. von Kiedrowski, since July 1, 2008, skin cancer screening, that being a visual examination of patients without devices, is a benefit offered by German statutory health insurance providers. Yet the screening has just now been evaluated, even though, this was already supposed to take place in 2013. How could this happen?
Ralph von Kiedrowski: At the screening introduction, the German Federal Joint Committee decided an evaluation should occur 5 years into the program since this was a so-called test model. An Institute should have subsequently studied and summarized this huge amount of data right on schedule. Based on my knowledge, this order was initiated quite late, however.
The way Germany handles skin cancer screenings is unique in the world. Is there a comparison with other countries in terms of mortality rates of skin cancer?
von Kiedrowski: I would like to clarify something that is being mixed up during most discussions. When we talk about statutory skin cancer screening, we are talking about an early detection program that studies three entirely different skin tumors. This is not just about mortality rates. Right from the start, it was clear that measurable mortality rates could only be analyzed for one of the three targeted tumors and that a period of 5 years would not be sufficient.
However, there are international comparisons on the depth of penetration of a melanoma, which correlates directly with the survival rate. Overall, we show favorable rates here in Germany since skin cancer screenings have already been performed long before the statutory provision, that being before 2008. In comparison, at the introduction of the statutory skin cancer screening in Germany, the average depth of melanomas ranged between 0.5 and 0.6 millimeters. Melanomas thicker than one millimeter are critical with an increased risk of malignant melanoma cells spreading within the body. When you look at other European countries, the average depth of tumor penetration is at 3.5 millimeters in Poland for example. This is seven times thicker, which is also why there is a significantly increased mortality rate in this country. The average penetration is also increased in the Netherlands, which is why subsequent problems for patients are 30 percent more likely there and the mortality rate is increased.
Having said that, the point of the statutory skin cancer screening is prevention and an early diagnosis of so-called basal cell cancers. Yet it is not just about identifying a tumor. It is all about prevention, especially when it comes to types of basal cell carcinoma and squamous cell carcinoma. Young people need to learn about the risk of sun exposure and skin damage. Unfortunately, this is being completely neglected during discussions about the sense and nonsense of statutory skin cancer screenings. People only pay attention to the much less common malignant melanoma skin cancer and complain if mortality rates cannot be significantly reduced. That is nonsense.
One contentious issue among dermatologists is performing a screening. That’s why not all dermatologists offer the statutory screening but insist on using a dermatoscope instead – which leads to out-of-pocket expenses for people covered by statutory health insurance. What do you think of this perspective?
von Kiedrowski: This is definitely a discussion one needs to face. A screening exam is always just a screening. However, when a patient visits a specialist, he/she expects more than just a glimpse at naked skin. If you study the guidelines on the early detection of skin cancer, you know that an accurate diagnosis by a specialist is more likely with the use of reflectance confocal microscopy. From this specialist point of view, some dermatologists say they don’t like to use a simple screening. Of course, this must not lead to a vilification of statutory skin cancer screenings. However, you need to point out this difference to the patients. And this is a mistake on the part of policy makers and insurance companies, who neglect making this distinction clear.
The results of the evaluation are now available. How do you rate them?
von Kiedrowski: The data evaluation by the BQS Institute confirms the expectations and rebuts statements made by the ARD Kontraste Magazin1 (a German TV show) in particular. The large number of detected skin cancers are listed and the authors overall confirm the importance of the screenings. Ultimately, they also specify process improvement approaches as it pertains to data documentation and results recording related to patient referrals by family doctors in case of suspicious screenings. Only dermatologists are ultimately permitted to diagnose skin cancers and initiate treatment. And this was precisely the task of the assessment: a process evaluation versus an outcome evaluation. The Institute, therefore, concludes that the appraisal period in terms of a reduction in melanoma mortality rates is far too short and, therefore, no statement can be made on this subject matter. However, there is no doubt about the effectiveness of the test as a "mass screening" and also no doubt about its continuation. The numerous false statements made during the ARD’s Kontraste show depict "journalistic malpractice" that is unfortunately now being pursued and counteracted on a legal basis.
What do you expect to happen after the screening evaluation?
von Kiedrowski: The G-BA needs to now take action and focus on developing and introducing improvements in documentation and medical processes. The statutory skin cancer screening will continue to exist. I would hope that now the constant interference stops since it only confuses the public and puts the effects of early detection at risk. Incidentally, patient demand remains constant.