Article Text

Download PDFPDF

Diagnosing malignant melanoma in ambulatory care: a systematic review of clinical prediction rules
  1. Emma Harrington1,
  2. Barbara Clyne1,
  3. Nieneke Wesseling2,
  4. Harkiran Sandhu1,
  5. Laura Armstrong1,
  6. Holly Bennett1,
  7. Tom Fahey1
  1. 1HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
  2. 2Medical School, Radboud University, Nijmegen, Netherlands
  1. Correspondence to Dr Barbara Clyne; barbaraclyne{at}


Objectives Malignant melanoma has high morbidity and mortality rates. Early diagnosis improves prognosis. Clinical prediction rules (CPRs) can be used to stratify patients with symptoms of suspected malignant melanoma to improve early diagnosis. We conducted a systematic review of CPRs for melanoma diagnosis in ambulatory care.

Design Systematic review.

Data sources A comprehensive search of PubMed, EMBASE, PROSPERO, CINAHL, the Cochrane Library and SCOPUS was conducted in May 2015, using combinations of keywords and medical subject headings (MeSH) terms.

Study selection and data extraction Studies deriving and validating, validating or assessing the impact of a CPR for predicting melanoma diagnosis in ambulatory care were included. Data extraction and methodological quality assessment were guided by the CHARMS checklist.

Results From 16 334 studies reviewed, 51 were included, validating the performance of 24 unique CPRs. Three impact analysis studies were identified. Five studies were set in primary care. The most commonly evaluated CPRs were the ABCD, more than one or uneven distribution of Colour, or a large (greater than 6 mm) Diameter (ABCD) dermoscopy rule (at a cut-point of >4.75; 8 studies; pooled sensitivity 0.85, 95% CI 0.73 to 0.93, specificity 0.72, 95% CI 0.65 to 0.78) and the 7-point dermoscopy checklist (at a cut-point of ≥1 recommending ruling in melanoma; 11 studies; pooled sensitivity 0.77, 95% CI 0.61 to 0.88, specificity 0.80, 95% CI 0.59 to 0.92). The methodological quality of studies varied.

Conclusions At their recommended cut-points, the ABCD dermoscopy rule is more useful for ruling out melanoma than the 7-point dermoscopy checklist. A focus on impact analysis will help translate melanoma risk prediction rules into useful tools for clinical practice.

  • Melanoma
  • Clinical prediction rules
  • Systematic review

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Statistics from


  • Contributors EH, NW and BC drafted the manuscript. EH, NW and BC contributed to development of the selection criteria, the risk of bias assessment strategy and the data extraction criteria. EH developed the search strategy. HB, LA and HS contributed the data extraction and quality assessments. BC and TF read, provided feedback and approved the final manuscript.

  • Funding This systematic review is funded by the HRB Centre for Primary Care Research under grant number HRC/2014/1, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.