Diagnosing malignant melanoma in ambulatory care: a systematic review of clinical prediction rules

Abstract

Objectives: Malignant melanoma has high morbidity and mortality rates. Early diagnosis improves prognosis. Clinical prediction rules (CPRs) can be used to stratify patients with symptoms of suspected malignant melanoma to improve early diagnosis. We conducted a systematic review of CPRs for melanoma diagnosis in ambulatory care.

Design: Systematic review.

Data sources: A comprehensive search of PubMed, EMBASE, PROSPERO, CINAHL, the Cochrane Library and SCOPUS was conducted in May 2015, using combinations of keywords and medical subject headings (MeSH) terms.

Study selection and data extraction: Studies deriving and validating, validating or assessing the impact of a CPR for predicting melanoma diagnosis in ambulatory care were included. Data extraction and methodological quality assessment were guided by the CHARMS checklist.

Results: From 16 334 studies reviewed, 51 were included, validating the performance of 24 unique CPRs. Three impact analysis studies were identified. Five studies were set in primary care. The most commonly evaluated CPRs were the ABCD, more than one or uneven distribution of Colour, or a large (greater than 6 mm) Diameter (ABCD) dermoscopy rule (at a cut-point of >4.75; 8 studies; pooled sensitivity 0.85, 95% CI 0.73 to 0.93, specificity 0.72, 95% CI 0.65 to 0.78) and the 7-point dermoscopy checklist (at a cut-point of ≥1 recommending ruling in melanoma; 11 studies; pooled sensitivity 0.77, 95% CI 0.61 to 0.88, specificity 0.80, 95% CI 0.59 to 0.92). The methodological quality of studies varied.

Conclusions: At their recommended cut-points, the ABCD dermoscopy rule is more useful for ruling out melanoma than the 7-point dermoscopy checklist. A focus on impact analysis will help translate melanoma risk prediction rules into useful tools for clinical practice.

Keywords: Clinical prediction rules; Melanoma; PRIMARY CARE; Systematic review.

Figure 1

(A) Diagnostic accuracy ABCD rule with dermoscopy—pooled sensitivity and specificity (eight studies). (B) Summary receiver operating characteristic curves for ABCD rule of dermoscopy The circles represent individual studies and the size reflects the sample size. The red square represents the summary estimates of sensitivity and specificity and the dotted ellipses around this represent the 95% CI around the estimate. The 95% prediction region (amount of variation between studies) was wide, suggesting heterogeneity between studies. ABCD, Asymmetry, irregular Borders, more than one or uneven distribution of Colour, or a large (greater than 6 mm) Diameter; HSROC, hierarchical summary receiver operating characteristic.

Figure 2

(A) Diagnostic accuracy of 7-point checklist with dermoscopy—pooled sensitivity and specificity (11 studies). (B) Summary receiver operating characteristic curves for ABCD rule of dermoscopy The circles represent individual studies and the size reflects the sample size. The red square represents the summary estimates of sensitivity and specificity and the dotted ellipses around this represent the 95% CI around the estimate. The 95% prediction region (amount of variation between studies) was wide, suggesting heterogeneity between studies. ABCD, Asymmetry, irregular Borders, more than one or uneven distribution of Colour, or a large (greater than 6 mm) Diameter; HSROC, hierarchical summary receiver operating characteristic; ROC, receiver operating characteristic.