Total Body Photography: A Valid Approach For Improving Patient Care The DermEngine Team Is there any evidence that mole mapping helps our patients — have there been any prospective, randomized controlled trials to show that mole mapping helps to detect malignant melanoma early and increases patient survival? First, it is important to note that mole mapping is a medical record, not a therapy. The physician determines whether or not a lesion should be removed. This decision is based on multiple factors and total body photography provides an opportunity for the physician to incorporate an objective assessment of lesion change into the decision-making process. This is not unlike using the medical record to identify changes in laboratory values, EKGs or radiological studies. The appropriate question should be, “Do data on lesion change impact patient care?” One aspect of patient care is melanoma detection. Melanomas result when the proliferation of melanocytic cells becomes uncontrolled. Thus, biologically, a growing melanocytic lesion should be considered worrisome for melanoma. In a controlled study by Thomas et al evaluating the ABCDE criteria, “E” (enlargement) was the only statistically positive increasing feature that could differentiate melanomas from dysplastic nevi.2 In recent studies following concerning lesions with dermoscopy, melanomas have been found to increase in size, often in an asymmetric manner.3-5 With total body photography, non-uniform and growing lesions were found to be statistically more likely to be melanoma.6 There is therefore sufficient information to suggest that data on lesion change is important in melanoma detection. Total body Photography Software DermEngine Reducing Biopsies A second important aspect of patient care is the reduction of unnecessary biopsies. Annually, a large number of benign dysplastic (atypical) nevi are removed unnecessarily. In one paper advocating the removal of nevi with clinical signs of dysplasia as a mechanism to reduce melanoma risk, 136 benign lesions were removed for every melanoma in patients with a previous melanoma diagnosis; 577 benign lesions were removed for every melanoma in patients without a previous melanoma history.7 Biologically, a lesion that has stopped growing is unlikely to be malignant. In dermoscopy studies, lesion stability has been used to successfully differentiate between benign and malignant lesions.3,4 Clinicians who utilize total body photography in patient follow-up report relatively low benign/malignant ratios some at or below 3 to 1.8,9 Overall annual biopsy rates per total body imaging patient have been reported at approximately 0.15 and 0.08.6,8 These studies strongly suggest that data on lesion stability reduces unnecessary biopsies and associated morbidity. A third important aspect of patient care is impact on survival. Since few patients with thin melanomas die, differences in survival data will be difficult to obtain. In melanoma vaccine trials, most do not even accept patients with thin melanomas due to the low likelihood of events. Almost all melanomas removed by physicians using full body imaging are thin.8,9 When compared to the community, tumors removed by physicians who incorporate total body photography into their practices tend to have thinner Breslow’s depths8 and thus there may be a survival advantage. Increasing Patient Satisfaction A fourth not well-quantified aspect of patient care is patient involvement, satisfaction, and reduction of anxiety with total body photography. It is my impression that patients given a copy of their photos feel more secure having data at their fingertips, feel more involved in their own care, have less anxiety, and are more satisfied with the data-based approach to follow-up. As Dr. Goldenberg suggested in his article, the patient (or family member) often initially identifies the melanoma, so it is important that he or she have the full body imaging data on hand to use for confirmation of change. In summary, data do exist detailing how mole mapping helps our patients. These data support “change” as the most important discriminator in melanoma detection, and lack of change as a critical determinate for avoiding unnecessary biopsies. Total body photography medical records provide objective data on lesion change, it’s up to the physician and patient to determine if they want this information available when deciding whether a lesion should be removed. The Issue of Cost The cost of total body photography should be covered by a patient’s medical insurance. The new AMA CPT category I code status (96904) for full body imaging (defined as “whole body integumentary photography, for monitoring of high-risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma”) validates the service, and the hope is that it will result in improved coverage. Many insurance companies now cover MoleMap CD/total body photography services, and the trend has been very positive over the last few years. Covering total body imaging should be a win/win for the insurance companies if done properly. If used appropriately, it will markedly reduce unnecessary biopsies while allowing the detection of thin melanomas. Healthcare costs Digital Health At Duke, the cost of a punch excision, surgical tray, pathology processing, and professional fees easily exceeds $500. The cost of a MoleMapCD is $395. Thus, if total body photography eliminates the need for one biopsy, it pays for itself and will build additional value by continuing to spare the patient future unnecessary biopsies and/or excisions. In order to gain the greatest potential from full body imaging, it should be used primarily on patients most likely to have numerous biopsies. This includes patients with dysplastic nevi, especially those with a personal or family history of melanoma and highly anxious melanoma patients worried about every skin lesion. Documented lesion stability gained through comparison with an established baseline can prevent most unnecessary biopsies. However, particularly in children and young adults, be aware that acquired nevi also have a growth phase, so it is important that the physician be comfortable with incorporating other features in addition to growth in determining whether a lesion needs to be removed. This is best done by first examining a patient from from head to toe, identifying unusual moles (those that are clinically different from other moles identified by the patients