See, Hear, Feel

EP43: Dr. H. Peter Soyer on overdiagnosis, Fitzpatrick skin type, and emotional intelligence

January 04, 2023 Professor Christine J Ko, MD / Dr. H. Peter Soyer, MD Season 1 Episode 41
See, Hear, Feel
EP43: Dr. H. Peter Soyer on overdiagnosis, Fitzpatrick skin type, and emotional intelligence
Show Notes Transcript

Dr. H. Peter Soyer is a thoughtful voice in dermatology and dermatopathology who has been studying many different important issues like overdiagnosis and the utility of Fitzpatrick skin typing as a cancer risk factor. He also relates that emotional intelligence has been key throughout his career. Dr. H. Peter Soyer has over 30 years of experience in dermatology. He obtained his medical degree at the University of Graz. He has been the inaugural Chair in Dermatology at The University of Queensland since 2007. He has also been the Director of the Princess Alexandra Hospital Dermatology Department since 2008. His research areas include translational skin cancer research. He is internationally recognized and has particular expertise in dermoscopy and reflectance confocal microscopy. He has over 600 publications and an h-index of 70 (Google Scholar). He has been awarded numerous grants, including the Medical Research Future Fund Next Generation Clinical Researchers Program Practitioner Fellowship, the NHMRC Practitioner Fellowship, and the Australian Cancer Research Foundation Australian Centre of Excellence in Melanoma Imaging and Diagnosis. Here are links to some of his recent work: the Fitzpatrick scale and a call for diversity and inclusion, patient-led self-screening after a melanoma diagnosis, second opinions to reduce under- and over- calling of melanoma, and rethinking melanoma in situ and severely dysplastic nevi.

[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today I have the pleasure of speaking with Dr. H. Peter Soyer. Dr. Peter Soyer has over 30 years of experience in dermatology. He obtained his medical degree at the University of Graz. He has been the inaugural Chair in Dermatology at the University of Queensland since 2007, and he has also been the Director of the Princess Alexandra Hospital Dermatology Department since 2008. His research areas include translational skin cancer research, and he is internationally recognized with particular expertise in dermoscopy as well as reflectance confocal microscopy. He has over 600 publications with an H Index of 70 in Google Scholar, and he has been awarded numerous grants including the Medical Research Future Fund, Next Generation Clinical Researchers Program Practitioner Fellowship, the NHMRC Practitioner Fellowship, and the Australian Cancer Research Foundation Australian Center of Excellence in Melanoma Imaging and Diagnosis. It's a lot of awards, a lot of grants, a lot of publications. Very honored to speak with you today. Thank you for being willing. 

[00:01:07] H. Peter Soyer: Yeah, thank you so much, Christine. It's really my pleasure to have a conversation with you. Absolutely. 

[00:01:13] Christine Ko: Thank you. Would you be able to share a personal anecdote about yourself? 

[00:01:18] H. Peter Soyer: Yeah, people wouldn't think when they see me that I have done quite a few marathons and even once I did an Ironman, the real one. It just was under the time of 17 hours, which is the finishing time. Still I always make jokes that endurance and persistence is something which is quite relevant, not just in your personal life, but also particularly in research.

[00:01:43] Christine Ko: I think that's really true. Absolutely. Yeah. That's amazing. You've done a whole Ironman. 

[00:01:48] H. Peter Soyer: Yeah. 

[00:01:49] Christine Ko: One of the questions I wanted to ask you about is your opinion on the overdiagnosis of skin cancer. 

[00:01:54] H. Peter Soyer: Thank you so much for asking this question. This question is actually very close to my heart and we have a lot of internal discussions, but also research discussions around this because in our Australian Center of Excellence in Imaging and Diagnosis we have basically 15 3D total body systems. It's part of a 10 million grant from the Australian Cancer Research Foundation. And of course, with this kind of sophisticated, innovative imaging, the idea is, of course, to early diagnose melanoma, but then they also early detect all sorts of suspicious moles. And I'm obviously aware of the whole literature about it; the fantastic work from Ade Adewole on this topic, but also the fierce critiques from dermatologists about his work. 

[00:02:42] Overdiagnosis. A hundred percent is true, right? 

[00:02:45] Christine Ko: Yes. 

[00:02:45] H. Peter Soyer: This is no question to me. Overdiagnosis in skin cancer, particularly melanoma. This is across medicine in general, and particular, breast cancer and thyroid cancer, prostate cancer; they are quite exciting examples also. There's another component which I like to name overcalling, and this is histopathologic overcalling. This is certainly something which is very difficult because angst or fear plays a lot of role in this context for the patient, for the consumer, for the doctor, and of course also for the pathologist. And everyone is afraid about the underdiagnosis side. Many clinicians quite correctly argue it is better to excise more lesions than to miss one. I'm part of a European Union Horizon Grant. In a discussion, someone was speaking about unnecessary excisions, unnecessary biopsies, and our consumer representative was getting very excited, very angry about this because she was saying, My husband would be still alive if he would've had an "unnecessary" excision. And this is really the problem here. How can you make sure that underdiagnosis doesn't occur?

[00:04:07] Having said this, from a public health perspective, overdiagnosis is a huge issue. Just recently with colleagues from Australia, we did publish an article in the BJD. A perspective article. Do we need to rethink the diagnosis of melanoma in situ and severely dysplastic nevus?

[00:04:26] I'm now paraphrasing what we wrote, Will you support the need for robust discussion in both clinical and pathology communities? We concluded that such a discussion could be facilitated by an international summit on the topic, which would inform the next step towards achieving change in policy and practice, particularly for pathology diagnosis. 

[00:04:47] In Austria, I was working 20 years, basically hardcore in dermatopathology. I'm a European board certified dermatopathologist and I was one of the many fellows of the late Bernie Ackerman from New York University. I have written a book with him. Obviously 90% was written by him, but I did my fair share of work, as you can imagine. So I understand the subjectivities in the pathology diagnosis a bit. I'd just like to tell you a joke. I like to say in my presentations, Some pathologists are more malignant than others. It's not a very elegant statement, but I can tell you within the pathology community, we know who are the more malignant and who are the more benign, right?

[00:05:35] Christine Ko: Yes. 

[00:05:35] H. Peter Soyer: And this has nothing to do with how good they are. They're all extremely well trained, right? 

[00:05:40] Christine Ko: Yes. 

[00:05:40] H. Peter Soyer: And they're all very sophisticated. What I have witnessed with Bernie, we had discussions for one hour if it was a Spitz nevus or a melanoma. Then they found a consensus on Spitz nevus. He was in half a minute writing the report. Next day someone was saying, Bernie, can we discuss this case once more? And then they discussed it once more. Then the consensus was melanoma. And again, after a long discussion, Bernie was saying, Okay, I agree. I think we have to change the report. And then he was dictating the report and the criteria for melanoma now.

[00:06:15] Christine Ko: Yeah. 

[00:06:15] H. Peter Soyer: Which tells you, Christine, how subjective this is.

[00:06:19] Christine Ko: Yes. That's something that I definitely struggle with that what I see under the microscope, how I put different things together is subjective. Do you have any idea what we can do about that? Other than a robust discussion?

[00:06:36] H. Peter Soyer: I think to change these cultural things is very difficult. Having said this, with imaging and total body imaging, if a lesion doesn't change over three months, over six months, over a year, over two years, in God's sake, then this lesion has to be biologically benign. Even if there are some dermoscopic criteria of an in situ melanoma or superficial melanoma. 

[00:07:02] The recent data in Australia, Christine, we had last year 17,000 invasive melanoma, but 29,000 in situ melanoma. Can you imagine? I can just tell you also based on my personal experience, my patients who have an in situ melanoma, they are as anxious and concerned as if they would have an invasive melanoma. 

[00:07:25] Christine Ko: Yeah. 

[00:07:25] H. Peter Soyer: And then if I tell them, Please don't worry, an in situ melanoma is basically handled, or let's say 99%, they think, Yeah, Peter is just kind. He just wants to tell me that I shouldn't worry. But they are still worried. So this communication is a very difficult issue, right? 

[00:07:46] Christine Ko: Yes.

[00:07:46] H. Peter Soyer: And this is, therefore, so important. And obviously public health people see it in a different way than clinicians.

[00:07:56] Christine Ko: I completely agree with you and melanoma in situ but also we know in dermatology, for example, basal cell carcinoma, which I don't really think is overdiagnosed, necessarily, because it's histologically pretty straightforward. Basal cell carcinoma doesn't really harm patients in terms of metastasis. Certain cancers are more slow growing and indolent. So just because melanoma in situ does do well doesn't mean that it's not cancer. It's just hard because we don't have great biomarkers of prognosis. Like which ones, when I look at a slide, which ones are really going to not do well versus even a thinly invasive melanoma. 

[00:08:43] H. Peter Soyer: Exactly. I think it's fair to say, as you mentioned, Christine, we are not yet there. 

[00:08:48] Christine Ko: Yeah. Definitely an area that needs to be worked on, and I thank you for your research in that.

[00:08:54] We're gonna move on now to talk about skin color, the Fitzpatrick scale, and something called the ITA measurement, which is a mathematical formula, a way to actually measure skin color, differences in skin color. And Peter's done a lot of work in that. Can you talk about that? 

[00:09:12] H. Peter Soyer: Thank you. It's actually a topic which we have discussed internally quite a lot. We think that the Fitzpatrick skin typing has not been developed with the goal to be a cancer risk factor, right? It was developed for the specific purpose of predicting reactivity of white skin, to psoralen, ultraviolet treatment. Fitzpatrick, he was a chief dermatologist at Harvard. And in its original form it is just type one to four and not even five and six; this was included later to represent people of Asian and African heritage. But they even have here a problem, Christine. Because East Asians very often have whiter skin than I have, yes. And I make often these sort of jokes. I'm not sure if they're politically correct, but one my collaborators, she is originally from China. She has a whiter skin than I. And what are we calling her Fitzpatrick type? And then this question, how do you tan? You know that in some, particularly in some Asian cultures, people are not going into the sun. Yeah?

[00:10:18] Christine Ko: Yep. 

[00:10:20] H. Peter Soyer: They're simply not going right? You see them walking with the umbrella, umbrella with the sun.

[00:10:24] Christine Ko: Yeah, absolutely. 

[00:10:26] H. Peter Soyer: Even between Fitzpatrick two and three, it's a lot of crossover, and some don't know because they don't go into the sun. So I'm a strong critic of this. At the end of the day, the measurement of the skin tone, or the skin color, is a better way. The question is how you do this. There are these colorimeters from a few companies on the market, which then provide you exact data. There is this concept of the Individual Typology Angle, which basically can be extracted out of images. I think it's the way of the future because then you can still say this skin classification, if you call it now tone or color. From very light, light, intermediate, tan, brown, and dark. Yeah?

[00:11:14] Christine Ko: Yeah. Yep. 

[00:11:15] H. Peter Soyer: And then if we look at both of us, we may realize that my skin is probably intermediate and yours light. Yeah?

[00:11:21] Christine Ko: Yes. 

[00:11:22] H. Peter Soyer: But it takes out the ethnicity and racial dimension of this. 

[00:11:27] Christine Ko: Yes. 

[00:11:28] H. Peter Soyer: And I think this is one way to go. The 3D total body imaging or the total body imaging is so relevant; it will allow you to automatically diagnose and extract the ITA. Yeah. And then of course, it's the issue, Where you measure it? Quite complicated for a variety of reasons. In our research now, we are measuring 10 different body sites with a standard colorimeter. And then obviously we are extracting the ITA and seek to correlate it. 

[00:12:00] This concept of Fitzpatrick to think Asian is five and six is completely wrong. 

[00:12:05] Christine Ko: There's a range. 

[00:12:06] H. Peter Soyer: No one would think that someone from South Italy is not a Caucasian, but in God sake, they may have a very tanned skin. We have to change our way of thinking. At the end of the day, skin color classification can be done quite well just on certain body areas. 

[00:12:24] Christine Ko: Based on your experience, what do you think, what would you guess correlates the best with skin cancer risk? The color of skin from the buttocks or the armpit area or maybe it's the contrast between that color and their forearm suggesting how much damage they've got?

[00:12:42] H. Peter Soyer: It's a very good question. I think the color alone gives you just one direction. The difference, this delta between constitutional and facultative is a very important marker for keratinocyte cancer. Yeah. I'm not so convinced that this is a relevant marker for melanoma. I really think for melanoma comes in definitely the number of moles. And then of course also hair color, eye color. The other aspect I think in the future will be of uppermost relevance is the polygenic risk score. It works already quite well in breast cancer. It works quite well in cardiovascular risk. A lot of research is happening in polygenic risk and mental health.

[00:13:26] Christine Ko: That's cool. I've been seeing transplant patients for the last couple of years, and I've been wondering through seeing them, not every very light skin patient with transplant gets skin cancer, but some of them do get quite a few, and I've been wondering exactly how to risk stratify them a little bit more. 

[00:13:44] H. Peter Soyer: Yeah. I think there are some preliminary works around the polygenic risk score in organ transplant recipients; just recently has been published. But I agree with your observation. Not everyone who has a transplant and is on a high immune suppression medication gets skin cancer. Certainly sun exposure, chronic sun damage, plays a role. I think a lot of work needs to be done. But I'm very confident that we are able to tackle this.

[00:14:13] Christine Ko: Yes. Very exciting. Thank you for all that work you're doing. So you went from Austria to Australia. Can you talk about emotional intelligence and the role that it played in your career? 

[00:14:26] H. Peter Soyer: Emotional intelligence plays a huge role. Probably one of the most important aspects in the career of a medical person, for people who have a job where you have to deal with people, right? Patients, allied health workers, colleagues, researchers. This plays a major role. Some people get emotional intelligence obviously from their parents, from their teachers. Yeah. And then of course you have to develop it over the years.

[00:14:57] Christine Ko: Yes. Do you have any final thoughts? 

[00:15:00] H. Peter Soyer: No, Christine, I just enjoyed talking with you, and obviously thank you for selecting topics which are very close to my heart, the overdiagnosis issues, the issue of Fitzpatrick. I really enjoyed talking with you.

[00:15:15] Christine Ko: Yes, I did as well. Thank you very much.