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Meta-Analysis
. 2018 Dec 4;12(12):CD011901.
doi: 10.1002/14651858.CD011901.pub2.

Visual inspection and dermoscopy, alone or in combination, for diagnosing keratinocyte skin cancers in adults

Jacqueline Dinnes  1 , Jonathan J Deeks, Naomi Chuchu, Rubeta N Matin, Kai Yuen Wong, Roger Benjamin Aldridge, Alana Durack, Abha Gulati, Sue Ann Chan, Louise Johnston, Susan E Bayliss, Jo Leonardi-Bee, Yemisi Takwoingi, Clare Davenport, Colette O'Sullivan, Hamid Tehrani, Hywel C Williams; Cochrane Skin Cancer Diagnostic Test Accuracy Group
Affiliations
Meta-Analysis

Visual inspection and dermoscopy, alone or in combination, for diagnosing keratinocyte skin cancers in adults

Jacqueline Dinnes et al. Cochrane Database Syst Rev. .

Abstract

Background: Early accurate detection of all skin cancer types is important to guide appropriate management, to reduce morbidity and to improve survival. Basal cell carcinoma (BCC) is almost always a localised skin cancer with potential to infiltrate and damage surrounding tissue, whereas a minority of cutaneous squamous cell carcinomas (cSCCs) and invasive melanomas are higher-risk skin cancers with the potential to metastasise and cause death. Dermoscopy has become an important tool to assist specialist clinicians in the diagnosis of melanoma, and is increasingly used in primary-care settings. Dermoscopy is a precision-built handheld illuminated magnifier that allows more detailed examination of the skin down to the level of the superficial dermis. Establishing the value of dermoscopy over and above visual inspection for the diagnosis of BCC or cSCC in primary- and secondary-care settings is critical to understanding its potential contribution to appropriate skin cancer triage, including referral of higher-risk cancers to secondary care, the identification of low-risk skin cancers that might be treated in primary care and to provide reassurance to those with benign skin lesions who can be safely discharged.

Objectives: To determine the diagnostic accuracy of visual inspection and dermoscopy, alone or in combination, for the detection of (a) BCC and (b) cSCC, in adults. We separated studies according to whether the diagnosis was recorded face-to-face (in person) or based on remote (image-based) assessment.

Search methods: We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

Selection criteria: Studies of any design that evaluated visual inspection or dermoscopy or both in adults with lesions suspicious for skin cancer, compared with a reference standard of either histological confirmation or clinical follow-up.

Data collection and analysis: Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic thresholds were missing. We estimated accuracy using hierarchical summary ROC methods. We undertook analysis of studies allowing direct comparison between tests. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely-developed algorithm to assist diagnosis; and observer expertise.

Main results: We included 24 publications reporting on 24 study cohorts, providing 27 visual inspection datasets (8805 lesions; 2579 malignancies) and 33 dermoscopy datasets (6855 lesions; 1444 malignancies). The risk of bias was mainly low for the index test (for dermoscopy evaluations) and reference standard domains, particularly for in-person evaluations, and high or unclear for participant selection, application of the index test for visual inspection and for participant flow and timing. We scored concerns about the applicability of study findings as of 'high' or 'unclear' concern for almost all studies across all domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic.The detection of BCC was reported in 28 datasets; 15 on an in-person basis and 13 image-based. Analysis of studies by prior testing of participants and according to observer expertise was not possible due to lack of data. Studies were primarily conducted in participants referred for specialist assessment of lesions with available histological classification. We found no clear differences in accuracy between dermoscopy studies undertaken in person and those which evaluated images. The lack of effect observed may be due to other sources of heterogeneity, including variations in the types of skin lesion studied, in dermatoscopes used, or in the use of algorithms and varying thresholds for deciding on a positive test result.Meta-analysis found in-person evaluations of dermoscopy (7 evaluations; 4683 lesions and 363 BCCs) to be more accurate than visual inspection alone for the detection of BCC (8 evaluations; 7017 lesions and 1586 BCCs), with a relative diagnostic odds ratio (RDOR) of 8.2 (95% confidence interval (CI) 3.5 to 19.3; P < 0.001). This corresponds to predicted differences in sensitivity of 14% (93% versus 79%) at a fixed specificity of 80% and predicted differences in specificity of 22% (99% versus 77%) at a fixed sensitivity of 80%. We observed very similar results for the image-based evaluations.When applied to a hypothetical population of 1000 lesions, of which 170 are BCC (based on median BCC prevalence across studies), an increased sensitivity of 14% from dermoscopy would lead to 24 fewer BCCs missed, assuming 166 false positive results from both tests. A 22% increase in specificity from dermoscopy with sensitivity fixed at 80% would result in 183 fewer unnecessary excisions, assuming 34 BCCs missed for both tests. There was not enough evidence to assess the use of algorithms or structured checklists for either visual inspection or dermoscopy.Insufficient data were available to draw conclusions on the accuracy of either test for the detection of cSCCs.

Authors' conclusions: Dermoscopy may be a valuable tool for the diagnosis of BCC as an adjunct to visual inspection of a suspicious skin lesion following a thorough history-taking including assessment of risk factors for keratinocyte cancer. The evidence primarily comes from secondary-care (referred) populations and populations with pigmented lesions or mixed lesion types. There is no clear evidence supporting the use of currently-available formal algorithms to assist dermoscopy diagnosis.

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Conflict of interest statement

Jacqueline Dinnes: nothing to declare. Jonathan J Deeks: nothing to declare. Naomi Chuchu: nothing to declare. Rubeta N Matin: "my institution received a grant for a Barco NV commercially sponsored study to evaluate digital dermoscopy in the skin cancer clinic. My institution also received Oxfordshire Health Services Research Charitable Funds for carrying out a study of feasibility of using the Skin Cancer Quality of Life Impact Tool (SCQOLIT) in non melanoma skin cancer. I have received royalties for the Oxford Handbook of Medical Dermatology (Oxford University Press). I have received payment from Public Health England for the "Be Clear on Cancer" skin cancer report. I have no conflicts of interest to declare that directly relate to the publication of this work." Kai Yuen Wong: nothing to declare. Roger Benjamin Aldridge: nothing to declare. Alana Durack: nothing to declare. Abha Gulati: nothing to declare. Sue Ann Chan: nothing to declare. Louise Johnston: nothing to declare. Susan E Bayliss: nothing to declare. Jo Leonardi‐Bee: nothing to declare. Yemisi Takwoingi: nothing to declare. Clare Davenport: nothing to declare. Colette O'Sullivan: nothing to declare. Hamid Tehrani: nothing to declare. Hywel C Williams: I am director of the NIHR HTA Programme. HTA is part of the NIHR which also supports the NIHR systematic reviews programme from which this work is funded.

Figures

1
1
Sample photograph of superficial spreading melanoma(left), BCC (centre) and SCC (right). Copyright © 2012 Dr Rubeta Matin: reproduced with permission.
2
2
Dermatoscope. Copyright © 2018 HEINE Optotechnik: reproduced with permission.
3
3
Current clinical pathway for people with skin lesions.
4
4
PRISMA flow diagram.
5
5
Risk of bias and applicability concerns graph for in‐person studies: review authors' judgements about each domain presented as percentages across included studies
6
6
Risk of bias and applicability concerns summary for in‐person evaluations: review authors' judgements about each domain for each included study
7
7
Risk of bias and applicability concerns graph for image‐based evaluations: review authors' judgements about each domain presented as percentages across included studies
8
8
Risk of bias and applicability concerns summary for image‐based evaluations: review authors' judgements about each domain for each included study
9
9
In‐person evaluations of the accuracy of visual inspection and visual inspection plus dermoscopy (VI+Dermoscopy) according to BCC prevalence and use of a formal algorithm
10
10
Image‐based evaluations of the accuracy of visual inspection and dermoscopy alone according to BCC prevalence and use of a formal algorithm
11
11
Comparison of the accuracy of visual inspection with visual inspection plus dermoscopy (VI+Dermoscopy) for detection of BCC from in‐person studies
12
12
Paired comparisons of the accuracy of visual inspection with visual inspection plus dermoscopy for detection of BCC from in‐person studies
13
13
Comparison of the accuracy of image‐based visual inspection with image‐based dermoscopy for detection of BCC
14
14
Paired comparisons of the accuracy of visual inspection with visual inspection plus dermoscopy for detection of BCC from image‐based studies
15
15
Comparison of the accuracy of visual inspection for detection of BCC between in‐person and image‐based
16
16
Comparison of the accuracy of dermoscopy for detection of BCC between in‐person (VI+Dermoscopy) and image‐based (Dermoscopy alone)
17
17
Evaluations of the accuracy of visual inspection or dermoscopy for detecting invasive melanoma cSCC
18
18
Forest plot of tests: 27 Any ‐Visual inspection (in‐person), 29 Any ‐VI+Dermoscopy (in‐person).
19
19
Forest plot of tests: 28 Any ‐Visual inspection (image‐based), 30 Any‐Dermoscopy alone (image‐based).
20
20
Comparison of the accuracy of visual inspection with visual inspection plus dermoscopy (VI+Dermoscopy) for detection of any skin cancer (Any). SROC curve estimated only for in‐person visual inspection.
21
21
Comparison of the accuracy of image‐based visual inspection with image‐based dermoscopy (Dermoscopy alone) for detection of any skin cancer (Any)
22
22
Forest plot of tests: 1 BCC‐Visual Inspection (in‐person), 2 BCC‐Visual Inspection (image‐based).
23
23
Forest plot of tests: 3 BCC‐VI+Dermoscopy (in‐person), 4 BCC‐Dermoscopy alone (image‐based).
1
1. Test
BCC‐Visual Inspection (in‐person).
2
2. Test
BCC‐Visual Inspection (image‐based).
3
3. Test
BCC‐VI+Dermoscopy (in‐person).
4
4. Test
BCC‐Dermoscopy alone (image‐based).
5
5. Test
BCC‐VI ‐ no algorithm at any threshold (in‐person).
6
6. Test
BCC‐VI ‐ no algorithm at BCC possible (in‐person).
7
7. Test
BCC‐VI ‐ ABCD at threshold NR (in‐person).
8
8. Test
BCC‐VI ‐ Schwartzberg algorithm (in‐person).
9
9. Test
BCC‐VI ‐ no algorithm at any threshold (image‐based).
10
10. Test
BCC‐VI ‐ no algorithm at BCC possible (image‐based).
11
11. Test
BCC‐ VI+Dermoscopy no algorithm at NR (in‐person).
12
12. Test
BCC‐VI+Dermoscopy pattern analysis_obs_dx (in‐person).
13
13. Test
BCC‐ VI+Dermoscopy 3 point at >= (in‐person).
14
14. Test
BCC‐VI+Dermoscopy Two step_obs_dx (in‐person).
15
15. Test
BCC‐Dermoscopy ‐ no algorithm at any threshold (image‐based).
16
16. Test
BCC‐Dermoscopy ‐ pattern analysis at NR (image‐based).
17
17. Test
BCC‐Dermoscopy ‐ Menzies for BCC(rev)_obsdx (image‐based).
18
18. Test
BCC‐Dermoscopy ‐ Menzies for BCC(new) ‐ 1 char absent&>=1 other +ve (image‐based).
19
19. Test
BCC‐Dermoscopy ‐ 3 point checklist at >= 2 (image‐based).
20
20. Test
BCC‐Dermoscopy ‐ new SWS at >=1 (image‐based).
21
21. Test
BCC‐Dermoscopy ‐ Chaos/clues (image‐based).
22
22. Test
cSCC‐Visual inspection (in‐person).
23
23. Test
cSCC‐Dermoscopy alone (image‐based).
24
24. Test
cSCC‐VI ‐ no algorithm at NR (in‐person).
25
25. Test
cSCC‐Dermoscopy ‐ no algorithm at NR (image‐based).
26
26. Test
cSCC‐Dermoscopy ‐ SWS at >1 char (image‐based).
27
27. Test
Any ‐Visual inspection (in‐person).
28
28. Test
Any ‐Visual inspection (image‐based).
29
29. Test
Any ‐VI+Dermoscopy (in‐person).
30
30. Test
Any‐Dermoscopy alone (image‐based).
31
31. Test
KER‐VI ‐ no algorithm at NR (in‐person).
32
32. Test
KER‐VI ‐ ABCD at NR (in‐person).
33
33. Test
KER‐VI ‐ no algorithm at NR (image‐based).
34
34. Test
KER‐ VI+Dermoscopy no algorithm at NR (in‐person).
35
35. Test
KER‐VI+Dermoscopy ‐ 3 point at >=2 (in‐person).
36
36. Test
KER‐Dermoscopy ‐ no algorithm at any threshold (image‐based).
37
37. Test
KER‐Dermoscopy ‐ no algorithm at excise (image‐based).
38
38. Test
KER‐ Dermoscopy ‐ pattern at NR (image‐based).
39
39. Test
KER‐Dermoscopy‐ SWS (image‐based).
40
40. Test
KER‐Dermoscopy ‐ Chaos/Clues (image‐based).
41
41. Test
KER‐Dermoscopy ‐ Menzies for BCC(rev)_obsdx (image‐based).
42
42. Test
BCC‐VI ‐ experience ‐ high (in‐person).
43
43. Test
BCC‐VI ‐ experience ‐ mixed (in‐person).
44
44. Test
BCC‐VI ‐ experience ‐ NR (in‐person).
45
45. Test
BCC‐VI ‐ experience ‐ high (image‐based).
46
46. Test
BCC‐VI ‐ experience ‐ mixed (image‐based).
47
47. Test
BCC‐VI ‐ experience ‐ NR (image‐based).
48
48. Test
BCC‐VI+Dermoscopy ‐ experience ‐ high (in‐person).
49
49. Test
BCC‐VI+Dermsocopy ‐ experience ‐ NR (in‐person).
50
50. Test
BCC‐Dermoscopy ‐ experience ‐ high (image‐based).
51
51. Test
BCC‐Dermoscopy ‐ experience ‐ mixed (image‐based).
52
52. Test
BCC‐Dermoscopy ‐ experience ‐ trained (image‐based).
53
53. Test
BCC‐Dermoscopy ‐ experience ‐ NR (image‐based).
54
54. Test
BCC‐VI ‐ qualification ‐ Consultant expert (in‐person).
55
55. Test
BCC‐VI ‐ qualification ‐ Consultant (in‐person).
56
56. Test
BCC‐VI ‐ qualification ‐ Mixed (Secondary care) (in‐person).
57
57. Test
BCC‐VI ‐ qualification ‐ Consultant expert (image‐based).
58
58. Test
BCC‐VI ‐ qualification ‐ Consultant (image‐based).
59
59. Test
BCC‐VI+Dermoscopy ‐ qualification ‐ Consultant expert (in‐person).
60
60. Test
BCC‐VI+Dermoscopy ‐ qualification ‐ Consultant (in‐person).
61
61. Test
BCC‐Dermoscopy ‐ qualification ‐ Consultant expert (image‐based).
62
62. Test
BCC‐Dermoscopy ‐ qualification ‐ Consultant (image‐based).
63
63. Test
BCC‐Dermoscopy ‐ qualification ‐ Resident (image‐based).
64
64. Test
BCC‐Dermoscopy ‐ qualification ‐ Mixed (dermoscopy trained) (image‐based).
65
65. Test
cSCC‐VI ‐ experience ‐ mixed (in‐person).
66
66. Test
cSCC‐VI ‐ experience ‐ NR (in‐person).
67
67. Test
cSCC‐Dermoscopy ‐ experience ‐ trained (image‐based).
68
68. Test
cSCC‐Dermoscopy ‐ experience ‐ NR (image‐based).
73
73. Test
KER‐VI ‐ experience ‐ high (in‐person).
74
74. Test
KER‐VI ‐ experience ‐ mixed (in‐person).
75
75. Test
KER‐VI ‐ experience ‐ NR (in‐person).
76
76. Test
KER‐VI ‐ experience ‐ high (image‐based).
77
77. Test
KER‐VI ‐ experience ‐ NR (image‐based).
78
78. Test
KER‐VI+Dermoscopy ‐ experience ‐ trained (in‐person).
80
80. Test
KER‐VI+Dermoscopy ‐ experience ‐ NR (in‐person).
81
81. Test
KER‐Dermoscopy ‐ experience ‐ high (image‐based).
82
82. Test
KER‐Dermoscopy ‐ experience ‐ trained (image‐based).
83
83. Test
KER‐Dermoscopy ‐ experience ‐ NR (image‐based).
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Argenziano 2003 {published data only}
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Argenziano 2004a {published data only}
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Argenziano 2004b {published data only}
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Argenziano 2008 {published data only}
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Argenziano 2010 {published data only}
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Argenziano 2011b {published data only}
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Argenziano 2012 {published data only}
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