Identifying, Screening, and Diagnosing Melanoma in the Primary Care Clinic

In the United States, more than 100,000 new cases of invasive melanoma are reported each year, with nearly 7000 related deaths per year. Melanoma is very common, but it is detectable and treatable if caught early.

In her session at Practical Updates in Primary Care 2021, Sancy Leachman, MD, discussed everything a primary care provider needs to know about skin cancer, how to detect it early, and when to refer to dermatology. Dr Leachman is the chair of the Department of Dermatology at Oregon Health & Science University and the director of the Melanoma Program at the Knight Cancer Institute.

Who needs to be screened?

The first step is to risk-stratify patients. “Patients with risk factors for melanoma should be screened. You can schedule an annual screening or refer to dermatology for higher-risk patients,” Dr Leachman said.


Figure 1


Refer to a dermatologist when further testing is needed. Dermoscopy can view lesions at a higher magnification, reflectance confocal microscopy can view lesions at a cellular level in vivo, and total body photography can help track size and location of moles.

“Dermascopy improves accuracy, reduces unnecessary biopsies, and uncovers visually unobservable atypical features,” Dr Leachman said.

Which lesions need to be tested?

Any lesion that looks suspicious to you or your patient should be tested. The ABCDEs of melanoma have helped make the diagnosis:

  • Asymmetry
  • Border irregularity
  • Color irregularity
  • Diameter
  • Evolution


“The most important factor to evaluate a potential melanoma is change,” Dr Leachman said.

Some melanomas only have one of the aforementioned factors stacked against them.

How do you make a diagnosis?

“Atypical lesions should be biopsied or referred to dermatology,” Dr Leachman said.

Conducting a biopsy is the gold standard of diagnosis. Options include punch biopsies, shave biopsies, deep shave biopsies, or excision.


Figure 2


“Use of any method that permits removal of the entire lesion will accurately diagnose melanoma,” Dr Leachman said. “A biopsy that is not deep or wide enough could lead to misdiagnosis, and reflectance confocal microscopy or strategic sampling options are available for large lesions.”

—Amanda Balbi


Leachman S. Recognizing skin cancer in primary care. Talk presented at: Practical Updates in Primary Care 2021 Virtual Series; May 13-15, 2021; Virtual.