Disability attribution in skin cancer: analysis of clinical decision-making profiles

Objectives: To analyze how dermatologists and dermatopathologists weigh different clinical criteria when attributing statutory disability certification for skin cancer at a disability threshold of ≥ 60%, a threshold associated with statutory benefits, and to identify underlying decision-making profiles. Methods: A cross-sectional observational study was conducted, based on a structured questionnaire administered to physicians practicing in Portugal. Criteria considered relevant for the issuance of a disability certificate and the 5-year survival threshold associated with clinical decision-making were assessed. Exploratory hierarchical cluster analysis was used to identify decision-making profiles, with evaluation of solution cohesion, stability, and separation. Associations between criteria, decision-making profiles, and tumor types were analyzed using appropriate association tests. The hierarchical structure of clinical decision-making was further explored using χ2 automatic interaction detection (CHAID) analysis. Results: A total of 155 physicians responded. Two distinct decision-making profiles were identified: a predominant restrictive profile, primarily centered on criteria associated with advanced oncological disease, and a permissive profile, which consistently attributed greater relevance to complementary criteria, including tumor size or extent and anatomical location. This variability followed recognizable clinical patterns and was not associated with respondents’ professional characteristics. The permissive profile adopted higher 5-year survival thresholds to justify disability certification. CHAID analysis confirmed the presence of a structured decision hierarchy, with morphological and anatomical criteria acting as initial discriminators. Conclusion: Despite a uniform legal framework, clinical decision-making in disability attribution for skin cancer shows substantial heterogeneity, organized into distinct decision-making profiles. These findings suggest that clearer hierarchical structuring of clinical criteria is feasible and may promote a more proportionate and equitable attribution of statutory disability benefits, better aligning social protection with clinically meaningful disability.