Offering a Total Mucocutaneous Examination

Offering a Total Mucocutaneous Examination During the Medical Encounter…….."

It is appropriate for physicians of any specialty (especially dermatologists) to offer their patients total body skin exams. Patients who reject such offers are putting themselves at risk for untimely early deaths. An appropriate total body skin exam must include inspection of the beasts, genitalia, and anus. Dr. Arthur Rhodes who was Dr. Cal Day’s mentor at Harvard Dermatology, expressed these sentiments in a February 12, 2012 letter to Dr. Day. The following are excerpts from Dr. Rhodes letter.

"February 15, 2012


Re:  Offering a Total Mucocutaneous Examination During the Medical Encounter…….."

Dr. Arthur R. Rhodes "……..Background"


"I am currently Professor of Dermatology in the Department of Dermatology, Rush Medical College and Rush University, and Senior Attending with Admitting Privileges in the Department of Dermatology at Rush University Medical Center. At Rush, I am Director of the Melanoma Surveillance Clinic, Director of Pediatric Dermatology, and Director of the 4th Year Medical Student Elective in Dermatology. I am a general dermatologist, board certified in Dermatology (1978) and board certified in internal medicine. (1972). I have been in my current position since September 1999, and practicing medicine since 1969. From 1989 to 1999,1 was Professor of Dermatology at the University of Pittsburgh School of Medicine, and Senior Attending with Admitting Privileges in the Department of Dermatology at the University of Pittsburgh Medical Center. During that period, I was Director of the Melanoma Surveillance Clinic and conducted a full time practice in general dermatology and pediatric dermatology. I also directed the Student Course in Dermatology at the University of Pittsburgh School of Medicine. From 1978 through 1989,I was-on the full-time faculty in the Department of Dermatology at Harvard Medical School, initially as Instructor in Dermatology from 1978-1978, Assistant Professor of Dermatology from 1979-1988, and then as Associate Professor from 1988-1989, when I left Boston to go to Pittsburgh. In Boston, I was Chief of the Division of Dermatology in the Department of Medicine at Boston Children's Hospital from 1978-1987. During this period from 1978-1987,I was a junior attending in the Pigmented Lesion Clinic at Massachusetts General Hospital. From 1987 through 1989,I was full-time attending at Massachusetts General Hospital where I was Chief of Pediatric Dermatology, Director of the In-Patient Dermatology Service, Director of the In-Patient Consultation Service, and co-Director of the Pigmented Lesion/Melanoma Clinic.Also during this time period, I was Director of the Course in Dermatology for Second YearMedical Students at Harvard Medical School.

My Relationship to …. Dr. Calvin Day

Dr. Day was a fellow in dermatology in the Massachusetts General Hospital/Harvard Dermatology from 1978 thru 1982. He underwent a specialized training tract in skin cancer and was known as the "Melanoma Fellow". While he was a fellow, Dr. Day conducted clinical research in melanoma, and he was co-author of multiple studies, including some of my own research studies dealing with the precursor nature of congenital nevi and dysplastic melanocytic nevi in the development of melanoma. Dr. Day was a resident under my charge at Boston's Chidren's Hospital as well. I have never seen someone work as hard, day and night, on clinical research projects as Dr. Day. During the time I knew Dr. Day, I found him to be meticulously honest, careful, and thorough both in patient care and clinical research. During the time I knew Dr. Day and supervised his care of patients and oversaw the clinical research, we conducted together, I found his character and behavior above reproach.

Medical Record on "Patient X" (Name redacted for privacy)

Dr. Day asked me to review his medical record on "Patient X" as well as the related sworn statements and police report. I have found that his care was careful, well documented, and appropriate. The comments of "Patient X" refer to his comprehensive mucocutaneous examinations. The type of comprehensive examination that he was taught at Harvard, demanded by his faculty attendings (including Dr. Thomas B. Fitzpatrick, his chairman, and myself) includes inspection of the breasts, anus, and genitalia. I have been sent the records of "Patient X" and have found the recordings of the history and physical examinations to be complete and appropriate. The overview and close-up photographs in these records are also deemed to be necessary and appropriate for current and future care of the individual. A picture is worth a thousand words. Given "Patient X" high risk for developing melanoma of the skin, a complete mucocutanous examination is recommended every 6 to 12 months for life.

Comments Regarding General Medical Practice and Patient Care.

A significant proportion of dermatologists do not conduct a total mucocutaneous examination for reasons of time, embarrassment, and lack of reimbursement. Most general physicians do not conduct a full mucocutaneous examination of their patients for the same reason. Lack of a full mucocutaneous examination of sites difficult to see by patients and even loved ones will guarantee a delayed diagnosis of malignancies in these relatively hidden sites of the anus and genitalia. Patients may not be familiar with comprehensive examinations based on prior experience, and the necessity of the examination needs to be explained to patients who are offered such a complete examination on the first medical encounter and subsequent encounters, particularly if a patient is found to be at high risk for developing melanoma. In order to determine melanoma/skin cancer risk, a complete mucocutaneous examination should be conducted on the first patient encounter. There is no excuse for not offering this examination to patients. Patients always have the option of refusal, which should be documented in the patient record.

What I Teach Residents and Fellows Regarding Total Mucocutaneous Examinations in the Care of Patients

I was the protege of numerous luminaries in dermatology including Thomas B. Fitzpatrick, Irvin Freedberg, Kenneth Arndt, Howard Baden, John Parrish, Martin C. Mihm, Raymond Barnhill, George Murphy, AB Ackerman, Wallace Clark, David Elder, and Antoinette Hood, among other professors current and long gone. I was also the protégé of medical and surgical oncologists including Ben Cosimi, John Raker, William Wood, and John Kirkwood. I have been directed by my teachers, and I have in turn directed my students and residents (regardless of specialty), to offer a full mucocutaneous examination on all new patients, regardless of their chief complaint, to detect early and curable melanoma, as well as other tumors and indications of systemic illness. The skin is the window to our bodies. In my opinion, not to offer this valuable examination is an indication of laziness, embarrassment, a self-professed lack of experience in recognizing skin cancer/melanoma, or a need to see as many patients as possible in the shortest time period with the primary purpose being monetary gain rather than the patient's welfare.

Usefulness of the Total Mucocutaneous Examination.

All melanomas of the skin appear as a new or changing mole. The vast majority of melanomas occur in relatively sun-protected skin, including mucous membranes. About 10% of melanomas or less are a direct result of sun-exposure (lentigo maligna type melanoma, developing from suninduced freckles), while 40% develop in association with dysplastic melanocytic nevi. About 5% of melanomas in whites occur on the palms of the hands, soles of the feet, nail beds of the hands and feet, anus, and external genitalia (minor and major labia in women, and penis and scrotum of men). In persons who have darkly pigmented skin, about half of the melanomas occur on the palms of the hands, soles of the feet, nail beds of the hands and feet, anus, and external genitalia (minor and major labia in women, and penis and scrotum of men). People who have melanomas in these relatively ignored sites present with advanced melanomas, with a resulting lower survival rate, directly related to ignorance and delayed diagnosis. If all physicians offered (and conducted) a complete mucocutaneous examination on every new patient and then periodically on selected patients determined to be at high risk for developing melanoma of the skin, then there would be almost no deaths from melanoma. The anus and genitalia are relatively inconspicuous sites to patients and physicians. It is almost impossible to do a careful self-examination of these sites for both men and women. Most women readily admit that they rarely examine their own genitalia. Both men and women do not examine their own anus. It is embarrassing to request such examinations by our friends, family members, or even intimate partners. If physicians do not examine these sites, then potentially serious issues will go unnoticed until it is too late for cure, especially melanoma and squamous cell cancer of the vulvae, penis, and anus. If there is no examination of the total mucocutaneous surface, which is part and parcel of the general examination, that should be conducted on all patients regardless of medical specialty, then there can be no diagnosis of a skin cancer, including melanoma. It should be recalled that Farah Fawcett, the famous movie star, died of anal squamous cell carcinoma. I have also diagnosed squamous cell carcinomas of the anus and female genitalia, and squamous cell carcinoma of the uncircumcised penis, in patients who were unaware of their tumors. Early tumors are generally asymptomatic. Both melanoma and squamous cell carcinoma are potentially lethal tumors that are curable if discovered and treated in an early phase of development. Most deaths from melanoma are preventable if all physicians routinely conducted total mucocutaneous examinations. Unfortunately, most general physicians defer the total mucocutaneous examination for reasons stated above. If most patients understood the importance of a total mucocutaneous examination, they would demand this critical examination even from their general physicians. Should general physicians be referring all of their patients to dermatologists for a total mucocutaneous examination to exclude melanoma/skin cancer? In fact, that is what is happening today. While 25% of the chief complaints for general physicians relate to skin issues, very few general physicians have any formal training in skin disease. Very few gynecologists, urologists, and pediatricians have significant training in skin disease, which includes epidemiology, gross morphologic, diagnosis, and histopathologic features of more than 2000 conditions., including atypical/dysplastic nevi, melanoma, squamous cell cancer, basal cell cancer, and lymphoma. Mucocutaneous conditions of the anus and genitalia, including sexually transmitted diseases and sexual disorders, are part and parcel of a dermatologist's training and comprise significant attention in modern textbooks of dermatology and dermatopathology. There is even a specialty within dermatology relating to conditions'of the female genitalia. If dermatologists do not conduct total mucocutaneous examinations to detect early melanoma, other skin cancers, as well as other important skin diseases, who will? Physician-detected melanomas tend to be thinner and more curable than patient detected melanomas. Unfortunately, 75% of all melanomas are self-detected by patients or their loved ones. In recent surveys, only 10% of persons report ever having had an examination of their skin during the prior year, even though about 80% of the same persons had seen a physician during that period. A complete examination is 6 times more likely to detect melanoma compared to a localized examination during skin cancer screening clinics.

All dermatologists, and all general physicians, should be offering their new patients a full mucocutaneous examination to detect not only melanoma and .other skin cancers, but also important skin diseases about which patients are unaware or too embarrassed to mention, including diseases of the anus and external genitalia. Patients are becoming more educated about this need. During the past 10'years, women in particular are specifically requesting a full mucocutaneous examination, including anus and genitalia. Even men are beginning to spontaneously report to dermatologists requesting a full mucocutaneous examination during the past 5 years. This phenomenon of screening and early detection, plus the ripple effect of public education during major skin cancer screening campaigns sponsored by national medical organizations, is responsible for the continued rise in the incidence of melanoma. At the same time, there has been a drop in melanoma-related mortality in all age groups except older men. This phenomenon of falling mortality during an initial period of rising incidence also has been seen in cervical cancer in'women (Pap smears), breast cancers in women (mammograms), and colon cancer in men and women (colonoscopy). A total mucocutaneous examination does not require X-rays, a speculum, or flexible colonoscope. There is no excuse for not offering a full mucocutaneous examination for all new patients, regardless of medical specialty.

Summary and Conclusions

 We are currently unable to prevent melanoma except for the minority of melanomas caused by excessive sun exposure. The only cure for melanoma currently is diagnosis of the tumor in an early phase of development and timely adequate excision, in a pre-metastatic phase of development, before the tumor has had a chance to spread to internal organs. This goal can only be achieved if patients are examined in places where melanomas occur, namely, anywhere on the mucocutaneous surface, including anus and genitalia. No person should die of melanoma. However, this goal will only be achieved through education of physicians to offer all new patients a total mucocutaneous examination (including the anus and genitalia) to detect not only early/curable melanoma but also to detect persons at high risk based on the presence of numerous moles and high risk moles. The evidence is incontrovertible that high-risk persons require a periodic full mucocutaneous examination for life, including sites that are not easily amenable to self-examination. A recent article was written by Caren Campbell and Dr. Lawrence Parish, relevant to the issues discussed above and published this month (Modesty and the Skin: Why They Shouldn't Mix. SKINmed 2012:10:6-7. A central thought in this article is that your modesty may be responsible for an untimely demise………….

Yours Truly,

Dr. Arthur R. Rhodes, MD MPH