Botox May Beat Cancer Concern in Race to Dermatologist

Aug. 29, 2007 — -- One patient is worried about wrinkles in her forehead. Another is concerned about a mole that she thinks may be showing signs of developing into skin cancer. Both make calls to their respective dermatologists for an appointment.

So who gets to see a doctor first?

According to a study published in the Journal of the American Academy of Dermatology on Tuesday, it's likely be the patient with the wrinkle woes — by a long shot.

In the survey, researchers called every board-certified dermatological practice in 12 metropolitan areas and posed as patients interested in botulinum toxin injections.

Lead study author Dr. Jack Resneck, an assistant professor of dermatology at the medical school of the University of California, San Francisco, and his colleagues found that the median wait time for a botulinum toxin jab appointment was eight days.

The researchers then compared this finding with previous research, which had found that the median wait time for an appointment to check a suspicious mole was 26 days.

Boston's 55-Day Wait

Practices in Boston led the pack in terms of the discrepancy between wait times. Researchers found that a wrinkle-injection patient would see a dermatologist 55 days earlier than a patient with a suspicious mole. In Little Rock, Ark., however, the difference amounted to only half a day though the wrinkle-injection patients still came out ahead.

"Wait times for this cosmetic treatment appear to be substantially shorter than those previously reported for patients with medical skin symptoms," the authors of the study wrote. "Even when patients report a changing mole [a potentially urgent indicator of malignancy] and are willing to pay out-of-pocket for a dermatology visit, the median wait time was 18 days longer than for botulinum toxin in these [cities]."

"Clearly a changing mole is more important than injections of Botox," said Dr. Alice Pentland, chair of the department of dermatology at the University of Rochester in Rochester, N.Y., who added that she felt the study was "well executed."

"It's an unfortunate finding," said Dr. Jeffrey Weinberg, assistant clinical professor of dermatology at Columbia University in New York. "Certainly cosmetic is a part of dermatology, and obviously we have to respect that. But my feeling is that this should be a wake-up call to dermatologists."

But not all dermatologists agreed that the study could be used to draw such a conclusion.

"For assessing access and wait times for Botox, the survey seems fine," said Dr. David Sawcer, assistant professor of dermatology at the University of Southern California. But he added, "In the comparisons it makes it is fraught with questions of poor reliability."

For one, he said, two different studies means two different sets of dermatologists. The studies were also done at different times, he said, further complicating a head-to-head comparison.

"Most simply, there may be more practitioners — dermatologists or physician assistants — who do Botox than check moles," he said.

However, Weinberg said regardless of these concerns the research still exposes an important issue for the field.

"Qualitatively the study still demonstrates that there's a problem," he said.

Reasons for the Wait

While the study delineated the differing wait times between these two categories of treatments, it was not designed to explain why these differences occurred.

"We can only speculate as to why patients requesting botulinum injections faced short wait times compared with those with a changing mole," the authors wrote in the study. "It is possible that some dermatologists or their receptionists may explicitly screen for patients requesting cosmetic services, or may reserve a set of separate appointment slots for cosmetic procedures."

The authors also suggested that since botulinum toxin jabs were often viewed as an "impulse buy," some dermatologists could feel pressure to schedule appointments for the procedure before patients changed their minds.

Weinberg said the disparity in wait times may be a sign that there simply aren't enough dermatologists who focus on noncosmetic work.

"I've always felt that dermatologists in every community need to ensure that the medical needs of the community are served," Weinberg said. "I think that this is an important issue that the field needs to think about."

Rochester's Pentland added that the study suggests that those working in dermatology practices other than the dermatologist must keep in mind noncosmetic cases.

"I believe the problem is due to insufficient training of front desk staff about the prioritization of patient visits," she said.

However, Dr. April Armstrong, a resident physician at the Harvard University dermatology program, said that the scheduling norms for most dermatologists, rather than any overt preferences, could lend more to the trend.

"It's a little more complicated than what the study portrays," she said. "A lot of times in dermatology we have one morning scheduled for cosmetic dermatology; the rest of the days are for medical dermatology."

Because botulinum injection appointments take as little as half the time necessary for the screening of a suspicious mole, the difference may simply be due to the fact that all of those who need wrinkle jabs can be fit into a dermatologist's schedule during the allotted time.

Getting a Doctor Fast

The good news is that wait times of a few weeks or more for skin cancer patients may not add up to significant progression of the disease if it is, indeed, present.

"Even if [the wait] is 26 days, this difference in time is not necessarily detrimental to the patient," Weinberg said.

But the issue of wait times for an appointment may still be an important one.

"Clearly at some point waiting will matter, and on the whole, the earlier the better," Sawcer said. "People with a suspicious mole should call around if they are worried and find a dermatologist with a sooner appointment or ask for cancellations. They will feel better being seen sooner, not least to be reassured."

USC's Sawcer added that there still exists a number of dermatologists who limit their practice of cosmetics, making them a great place for those with noncosmetic concerns to start looking. A quick call to the doctor's office, he said, can often determine the proportion of a dermatologist's practice devoted to procedures like botulinum toxin injections.

Weinberg said that patients who find themselves in emergency situations have a number of options at their disposal to get treatment in a more timely fashion.

"For anything that the patient considers to be an emergency, whether it is a changing mole or an infection, they can call and communicate with the staff that it is an emergency to try and get an appointment sooner," he said, adding that primary care doctors and emergency departments were other available options in certain cases.