Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(3):6122 1 Improving Melanoma Screening in Primary Care: The Experience of the Association of French General Practitioners Practicing Dermoscopy Julien Anriot1, Nadia Ikhlef2, Gérard Duru3, Sophie Darnis4, Pauline Scouarnec5, Younes Tamarat6, Mona Amini-Adle1, Luc Thomas2,3,7 1 Department of Dermatology, Centre Léon Bérard, Lyons, France 2 Dermatology department, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyons, France 3 Claude Bernard Lyon-1 University, Lyons, France 4 Delegation for Clinical Research and Innovation Centre Léon Berard, Lyons, France 5 Collège des Hautes Etudes en Médecine, Brest, France 6 Pediatric Department, Médipôle Hôpital Mutualiste, Médipôle Lyon Villeurbanne, Villeurbanne, France 7 Cancer Research Center of Lyon, Lyons, France Key words: Melanoma detection, Dermoscopy training, Primary Care screening, Social Media Education, General Practitioners Citation: Anriot J, Ikhlef N, Duru G, et al. Improving melanoma screening in primary care: the Experience of the Association of French General Practitioners Practicing Dermoscopy. Dermatol Pract Concept. 2025;15(3):6122. DOI: https://doi.org/10.5826/dpc.1503a6122 Accepted: June 10, 2025; Published: July 2025 Copyright: ©2025 Anriot et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. All authors had access to clinical material and revised the current version of the submitted manuscript. Corresponding author (Prof. Luc Thomas) endorses the scientific responsibility of the reported work herein. Corresponding Author: Luc Thomas, MD, PhD, Service de dermatologie, Centre Hospitalier Lyon Sud, 165 Chemin du Grand Revoyet, 69310 Pierre-Bénite, France. E-mail: luc.thomas@chu-lyon.fr Background: Melanoma constitutes an increasing global health burden. In the light of a growing shortage of dermatologists in several countries, primary care has emerged as an optimal setting for skin cancer screening. Historically, skin cancer detection in France was typically managed by derma- tologists, while general practitioners (GPs) were barely involved. In 2021, the Association of French GPs Practicing Dermoscopy was created to address this gap by promoting and legitimizing dermosco- py practice among primary care physicians. Objectives: To assess the number of melanomas detected by dermoscopy-trained GPs three years after the association’s foundation and to compare the melanomas’ histopathological characteristics to those documented in the existing literature. Methods: A survey was shared via Google® Forms with all the members of the association’s Face- book® account between 26 November 2024 and 26 December 2024. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(3):6122 Introduction Cutaneous melanoma is an increasingly significant public health concern worldwide. Although it accounts for only 10% of skin cancers, it is responsible for more than 75% of skin cancer-related mortality, and its incidence rate has been increasing for decades [1]. Early detection is essential to mitigate this burden [2-3]. Indeed, the five-year survival rate ranges from 91% to 95% when the Breslow thickness is less than one millimeter, and ranges from 63% to 79% when it reaches 2–4 mm, and even worse (less than 48%) above 4 mm. Due to a growing shortage of dermatologists in West- ern countries [4], primary care is increasingly recognized as a suitable setting for skin cancer screening [1,5,6]. Dermos- copy has shown benefits in early melanoma detection while minimizing excisions of benign lesions [7]. Its effectiveness in the early detection of melanoma is supported by level A evidence-based recommendations [8,9]. The Primary Care Dermatology Society in the UK [10] and the Skin Cancer College Australasia in Australia and New Zealand [11] are successful examples of general practitioners (GPs) organiz- ing themselves to participate in melanoma detection (with the notable help of dermoscopy) alongside dermatologists. In France, this activity remained uncommon, as mel- anoma diagnosis is historically under the responsibility of dermatologists. In 2021, the Association of French GPs Practicing Der- moscopy was created through the release of an open Face- book account [12], modeled after that of the International Dermoscopy Society, “Dermatoscopy” [13]. As of 10 November 2024, 2920 GPs have subscribed to the account. This study aimed to evaluate the number and character- istics of melanomas detected by trained GPs three years after the foundation of the association. Methods Study Population and Authorizations This study received approval from Centre Léon Berard insti- tutional ethics committee (R201-004-511). This retrospective study was conducted from 26 Novem- ber 2024 to 26 December 2024. A survey developed on Google Forms ([online computer software], Alphabet, 2023, Mountain View, USA) was dis- tributed to all subscribers of the Association’s Facebook ([online computer software], Meta, 2024, Menlo Park, California, USA) account on 26 November 2024, with a re- minder sent on 5 December. Participants were asked to complete the survey and up- load screenshots of anonymized histopathological reports of melanomas they had personally diagnosed; patients referred by other healthcare professionals for a suspicious lesion were excluded. Responses were sent to a designated Google Drive Folder ([online computer software], Alphabet, 2023, Mountain View, USA). The survey gathered the following information about GPs : sex, date of birth, start date of dermoscopy prac- tice, frequency of dermoscopy use, medical practice setting (self-employed, salaried, et cetera), practice location (urban, rural, et cetera). Participants who uploaded melanoma cases into the database with no survey completed were classified as “un- known” (n=9). GPs who completed the survey with no up- loaded melanoma cases were interpreted as GPs who had not diagnosed any melanoma. The study focused on the following histopathological characteristics: melanoma pathological subtype (superficial spreading melanoma (SSM), lentigo malignant melanoma (LMM), acro-lentiginous melanoma (ALM), nodular (NM), unclassifiable, metastatic) and Breslow’s thickness. Cases of melanocytic intraepithelial neoplasia (MIN)/ in- traepidermal atypical melanocytic proliferation of uncertain significance (IAMPUS) and melanocytic tumors of uncertain malignant potential (MELTUMP) cases were excluded to en- sure better comparability with historical series in the literature. Statistical Analysis Qualitative variables are described as frequencies and per- centages (n, %), and quantitative variables as medians and range (min–max). Results: A total of 85 general practitioners responded to the survey. They reported the detection of 266 melanomas, corresponding to a median of approximately 1.6 per year of dermoscopy practice (mean: 2.9). Of the detected melanomas, 39.5% (105/266) were in situ, while only 22.4% (36/161) had a Breslow thickness above 1 mm, which constitutes a substantial improvement compared to pre- viously reported data on GP-detected melanomas. Conclusions: Empowerment of primary care medicine through dermoscopy learning appears to be a promising way to overcome the relative shortage of diagnostic offer observed in several countries. Integrating skin cancer screening into a GP’s practice may contribute to early melanoma detection and support ongoing efforts to lower melanoma mortality. Original Article | Dermatol Pract Concept. 2025;15(3):6122 3 The mean and median Breslow thickness were evaluated on invasive melanomas only, since Breslow’s index does not apply to in situ melanomas. For comparisons with results from other cohorts [14-17], Fisher’s exact test was used when the theoretical value of each category was less than 5, and a chi2 was used when this value was equal to or greater 5. Results As of 26 December 2024, the Facebook account had 2920 subscribers (Figure 1). Among them, 69% (2015/2920) were female and 87% (2540/2920) were under under age 44 years. A total of 2773 (95%) resided in France, including 44 from Overseas Departments and Territories, with additional followers from French-speaking countries like Belgium (52), Algeria (44), Switzerland (7), Morocco (7), and Tunisia (5). Participants’ Characteristics A total of 85 GPs participated in this study (Table 1), of the 628 who viewed the Facebook post (13.5%), representing 2.9% of the total number of followers (85/2920). The median start of dermoscopy practice among partici- pants was June 2023 (Figure 2). Melanomas Diagnosed The mean Breslow thickness of melanomas detected in our study was 1.12 mm (median 0.5 mm) (Table 2). In 2000 (Table 3), the mean Breslow thickness was 1.9 mm for dermatologists (median 0.9 mm) and 2.9 mm for GPs (median 2.0 mm) [15]. In 2013, Grange et al. in France identified a mean Breslow thickness of 1.68 mm (median 0.85 mm) for melanomas de- tected by trained GPs [16]. In 2020, Lorier et al., also in France, analyzed the mel- anomas detected during consultation by dermatologists in private practice, finding a median Breslow index of 0.4 mm [17]. Our study identified: • a lower proportion of in situ melanomas than did Hay et al. [14] (39.5% vs 65%, P<0.001) • a higher proportion of in situ melanomas than did Grange et al. [16] (39.5% vs 28.2%, P<0.001) • A similar proportion of in situ melanomas than did Lorier et al. [17] (39.5% vs 43.8%, P=0.50) Our study identified: • a similar rate of Breslow thickness >1 mm among the in- vasive melanomas compared with Hay et al. [14] (22.4% vs 27.8%, P= 0.39) • a lower rate of Breslow thickness >1 mm among the in- vasive melanomas than did Grange et al. [16] (22.4% vs 42.6%, P<0.001). Our study identified a different distribution of histo- logic subtypes compared with Hay et al. [14] (P<0.001) and Richard et al. [15] (P<0.001), and one similar to that of Lorier et al. [17] (P=0.43) Figure 1. Flowchart of participants. Table 1. Characteristics of Participants.   Total (n=85) Sex   Male 27 (31.8%) Female 49 (57.6%) Unknown 9 (10.6%) Age 39.0 (med 37; min 28; max 63) Duration of practice in dermoscopy (years) 1.47 (med 1.25; min 0.1; max 6.3) Frequency of dermoscopy use   Every day 40 (47.1%) Several times per week 31 (36.5%) Several times per month 4 (4.7%) Several times per year 1 (1.1%) Unknown 9 (10.6%) Type of medical practice   Self-employed 69 (81.2%) Salaried 5 (5.9%) Mixed 2 (2.3%) Unknown 9 (10.6%) Location   Urban 29 (34.1%) Semi-rural 29 (34.1%) Rural 18 (21.2%) Unknown 9 (10.6%) 4 Original Article | Dermatol Pract Concept. 2025;15(3):6122 0 16 33 49 65 1/22 6/22 1/23 6/23 1/24 6/24 1/25 6/25 1/26 6/26 1/27 6/27 1/28 6/28 9/28 N um b er o f p ar tic ip an ts Date Figure 2. Number of participants practicing dermoscopy over time among the responders to the survey Table 2. Histopathological Characteristics of Diagnosed Melanomas.   Total (n=266) Type of melanoma   SSM (superficial spreading melanoma) 210 (78.9%) LMM (lentigo maligna melanoma) 30 (11.3%) ALM (acral lentiginous melanoma) 10 (3.8%) Nodular melanoma 8 (3.0%) Unclassifiable melanoma 7 (2.6%) Metastases of melanoma 1 (0.4%) Thickness   Proportion of in situ melanomas 39.5% (105/266) Proportion of melanomas with Breslow index >1 mm among the invasive melanomas 22.4% (36/161) Breslow index for invasive melanomas only 1.12 (Med 0.5; Min 0.1; Max 9) T of TNM classification Tis 39.5% (105/266) T1a 39.8% (106/266) T1b 7.2% (19/266) T2a 6.0% (16/266) T2b 1.1% (3/266) T3a 2.2% (6/266) T3b 0.4% (1/266) T4a 1.1% (3/266) T4b 2.7% (7/266) Original Article | Dermatol Pract Concept. 2025;15(3):6122 5 T ab le 3 . C om pa ri so n of M el an om a C ha ra ct er is ti cs in t hi s St ud y w it h Pr ev io us ly P ub lis he d St ud ie s. G Ps D er m at ol og is ts B ot h Pr es en t St ud y H ay e t al ( A us tr al ia N Z 2 02 2) ( 14 ) G ra ng e et a l. (F ra nc e 20 13 ) (1 6) R ic ha rd et a l. (F ra nc e 20 00 ) (1 5) R ic ha rd et a l. (F ra nc e 20 00 ) (1 5) L or ie r et a l. (F ra nc e 20 20 ) (1 7) R ic ha rd e t al . (F ra nc e 20 00 ) (1 5) M ea n B re sl ow T hi ck ne ss 1. 12 m m   1. 68 m m 2. 9 m m 1. 9 m m     M ed ia n B re sl ow T hi ck ne ss 0. 5 m m   0. 85 m m 2 m m 0. 9 m m 0. 4 m m   Pr op or ti on o f in s it u m el an om as 39 .5 % ( 10 5/ 26 6) 65 % ( 41 4/ 63 7) 28 .2 % ( 17 5/ 62 1)     43 .8 % ( 32 /7 3)   B re sl ow t hi ck ne ss > 1 m m a m on g in va si ve m el an om as 22 .4 % ( 36 /1 51 ) 27 .8 % ( 62 /2 23 ) 42 .6 % ( 19 0/ 44 6)         SS M 78 .9 % ( 21 0/ 26 6) 50 .2 % ( 32 0/ 63 7)       82 .2 % ( 60 /7 3) 71 .0 % ( 29 7/ 41 8) L en ti gi no us 15 .1 % ( 38 /2 66 ) 39 .1 % ( 24 9/ 63 7)       16 .4 % ( 12 /7 3) 5. 5% ( 23 /4 18 ) N od ul ar 3. 0% ( 7/ 26 6) 4. 2% ( 27 /6 37 )       0% ( 0/ 73 ) 20 .8 %  ( 87 /4 18 ) M et as ta si s 0. 4% ( 1/ 26 6) 1. 4% ( 9/ 63 7)           U nc la ss ifi ed 2. 6% ( 7/ 26 6) 2. 7% ( 17 /6 37 )       2. 6% ( 11 /4 18 ) 6 Original Article | Dermatol Pract Concept. 2025;15(3):6122 index less than 1 mm (57.4% in 2013 vs 77.6% in the pres- ent study). These findings suggest a significant improvement in mel- anoma detection, likely attributable to dermoscopy imple- mentation in general practice. Notably, Lorier et al.’s [17] evaluation of detected mel- anomas by dermatologists in France is consistent with our results. Using a similar study design, they reported a comparable median Breslow thickness and distribution of melanoma histological subtypes. This suggests that after appropriate training in dermoscopy, GPs can also achieve excellent performance in skin cancer screening and are qualified to perform such screening [19]. Developing this expertise may be crucial since a large proportion of patients consulted their GP in the year preceding a melanoma diag- nosis [20]. With a growing number of GPs participating in mela- noma detection, including approximately 20% in rural areas (significant, given the shortage of dermatologists in these lo- cations [21]), this could lead to a rapid increase in the num- ber of melanomas detected by GPs, since the median number of melanomas diagnosed per year was 1.7. Although this may seem low, melanoma remains rela- tively rare in general practice: with approximately 17,000 new cases per year and 52,291 GPs in France, the average GP encounters a new melanoma case only once every three years. Participants in our study detected melanomas at a rate three times higher than this national average. Half of the participants used dermoscopy daily, but this practice remained relatively new for most French GPs, with a median dermoscopy experience of only 1.5 years. Participants diagnosed an average of 3.2 melanomas each (median 2; min 0; max 36) (Figure 3). Each participant diagnosed a mean of 2.9 melanomas per year of dermoscopy practice (median 1.6; min 0; max 48). Discussion Early recognition of life-threatening skin tumors is a public health concern, but is nowadays made difficult by the grow- ing shortage of dermatologists in many European countries. Moreover, recent studies have underlined that Breslow thick- ness at melanoma detection is higher in areas of medical deprivation [18]. In France, we count 2592 dermatologists for 52291 general practitioners [4]. Australia and, to a lesser extent the UK, have chosen to involve general practitioners in skin cancer detection. In Australia, the majority of mel- anomas are diagnosed by GPs. This practice is very new in France, and still developing, despite some limitations, such as GPs’ lack of confidence in their own diagnostic abilities, despite good results [19]. The Association of French GPs Practicing Dermoscopy, created in 2021, now includes 2920 members. In this context, we conducted a survey to analyze the melanomas detected by Association members. Dermoscopy-trained GPs from the Association of French GPs Practicing Dermoscopy were able to detect early mela- nomas, with a notable improvement in the mean and median Breslow thickness compared to previously reported values in 2000 [15] and 2013 [16]. The proportion of in situ melano- mas increased (28.2% in 2013 vs 39.5% in present study), as did the proportion of invasive melanomas with Breslow 0 10 20 30 40 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 N um b er o f m el an om as d ia gn os ed General Practionners (each column represents one individual) Figure 3. Melanomas diagnosed per GP. Original Article | Dermatol Pract Concept. 2025;15(3):6122 7 Recall bias: Some survey questions relied on the GP’s ability to recall certain information, which could have led to slight inaccuracies in the reported start date of dermos- copy practice. This is a non-differential error, but it could result in an underestimation of the number of melanomas per participant, as some cases may have been forgotten or the pathology report may not have been forwarded to the general practitioner by the dermatologist who performed the excision. Allocation bias: The study specified that only melanomas diagnosed directly by a GP should be included. Some GPs, especially those who accept referrals from other GPs, may have included these as their own diagnoses. However, we provided clear guidance to avoid this issue. Future Directions The Association of French General Practitioners Practicing Dermoscopy has recently been created, and these promising results need to be confirmed with an extended follow-up of five years. Conclusion This study highlights the emerging role of general practi- tioners in the detection of cutaneous melanoma in France, three years after the creation of the Association of French General Practitioners Practicing Dermoscopy. Our findings indicate that identification of melanomas at an early stage is entirely possible for trained GPs. We believe that empowering GPs through a wider use of dermoscopy for skin examination could reduce inequalities in the diagnostic offer in France. Continued efforts to promote dermoscopy training among general practitioners appears to be essential since growing evidence demonstrates that proper training is key to obtaining adequate suspicious skin lesion triage and man- agement. Future research should aim to evaluate the long- term impact of such initiatives on melanoma detection rates and patient outcomes. By fostering a collaborative approach between GPs and dermatologists, enhanced early detection capabilities is expected and, ultimately, a reduced burden of melanoma in the community. References 1. Haute Autorité de Santé. Stratégie de diagnostic précoce du méla- nome : rapport stratégie de diagnostic précoce du mélanome. Up- dated October 2006. Accessed February 19 2023. https://www .has- sante.fr/upload/docs/application/pdf/rapport_strategie_de_ diagnostic_precoce_du_melanom e.pdf 2. Institut National du Cancer. Survie des personnes atteintes de can- cer en France métropolitaine 1989-2018 - Synthèse des résultats: tumeurs solides et hémopathies malignes. Updated August 23 Strengths and Limitations To date, most publications on skin cancer screening and diagnosis by general practitioners have been limited to: • assessing the use of dermoscopy by general practitioners in various countries [22,23,24,25,26,27] • evaluating general practitioners’ ability to detect sus- picious skin lesions and refer them to dermatologists [28,29,30] • Investigating the improvement in general practitioners’ skills after clinical and dermoscopy training of varying du- rations provided by dermatologists [31,32,33,34,35,36] • determining the required training duration for general practitioners to gain proficiency in skin cancer detec- tion [37] • exploring the benefits of tele-expertise in improving di- agnostic accuracy and reducing treatment delays for skin cancers [38] • developing computer-assisted diagnostic systems and al- gorithms with artificial intelligence to aid in the dermo- scopic image classification for general practitioners [39] Apart from the previously mentioned work from Aus- tralia, which aligns with a national health policy prioritiz- ing melanoma due to its prevalence, no study has examined in detail the actual contribution of general practitioners to the complete and independent diagnosis of cutaneous mel- anomas. This research thus represents a pioneering study in Europe, highlighting the legitimacy and significant role of general practitioners in skin cancer screening. The low participation rate, considering the number of the Facebook account followers, constitutes a limitation of this study. However, among the 2920 followers, not all are GPs (e.g., pediatricians, dermatologists, occupational doctors, physiotherapists, et cetera) or are replacement GPs or residents that may not have access to the final pathology reports of their cases. Additionally, some individuals (n=8) who were known to have diagnosed melanoma cases (previously published on the Facebook account, n=16) did not participate in this study. Recruitment bias: Respondents may have a greater inter- est in skin cancer detection, potentially increasing the repre- sentation of dermoscopy practice among GPs. However, this does not question the capabilities or outcomes achieved by GPs practicing dermoscopy. 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