Patients' Views About Skin Self-examination After Treatment for Localized Melanoma

Telehealth follow-up consultations for melanoma patients during the COVID-19 pandemic: Patient and clinician satisfaction

INTRODUCTION

The COVID-19 pandemic caused rapid implementation of telehealth for melanoma follow-up care in Australia. This study explores Australian melanoma patients and clinicians' level of satisfaction with telehealth.

METHODS

A cross-sectional study was conducted across three specialist melanoma centres in Sydney, Australia. Melanoma patients (all stages) and clinicians completed mixed methods surveys seeking socio-demographic and clinical information and questionnaires to assess satisfaction with telehealth. Additionally, patients completed measures of quality of life, fear of cancer recurrence and trust in their oncologist. Patients and clinicians provided open-ended responses to qualitative questions about their perceptions of telehealth.

RESULTS

One hundred and fifteen patients and 13 clinicians responded to surveys. Telephone was used by 109 (95%) patients and 11 (85%) clinicians. Fifty-seven (50%) patients and nine (69%) clinicians preferred face-to-face consultations, 38 (33%) patients and 3 (23%) clinicians preferred a combination of face-to-face and telehealth consultations. Five (4%) patients and nil clinicians preferred telehealth consultations. Patients diagnosed with early-stage melanoma, using telehealth for the first time, who have lower trust in their oncologist, and having higher care delivery, communication and supportive care concerns were likely to report lower satisfaction with telehealth. Open-ended responses were consistent between patients and clinicians, who reported safety, convenience and improved access to care as major benefits, while identifying personal, interpersonal, clinical and system-related disadvantages.

DISCUSSION

While telehealth has been widely implemented during COVID-19, the benefits identified by patients and clinicians may extend past the pandemic. Telehealth may be considered for use in conjunction with face-to-face consultations to provide melanoma follow-up care.

Acceptability of a Hypothetical Reduction in Routinely Scheduled Clinic Visits Among Patients With History of a Localized Melanoma (MEL-SELF): Pilot Randomized Clinical Trial

BACKGROUND

After treatment for a localized melanoma, patients attend routinely scheduled clinics to monitor for new primary or recurrent melanoma. Patient-led surveillance (skin self-examination with patient-performed teledermoscopy) is an alternative model of follow-up that could replace some routinely scheduled visits.

OBJECTIVE

This study aims to assess the acceptability of a hypothetical reduction in routinely scheduled visits among participants of the Melanoma Self Surveillance (MEL-SELF) pilot randomized clinical trial of patient-led surveillance (intervention) versus usual care (control).

METHODS

Patients previously treated for localized melanoma in New South Wales who were participating in the MEL-SELF pilot randomized clinical trial were asked to respond to a web-based questionnaire at baseline and after 6 months on trial. We used mixed methods to analyze the data. The main outcome of interest was the acceptability of a hypothetical reduction in routinely scheduled visits for melanoma surveillance.

RESULTS

Of 100 randomized participants, 87 answered the questionnaire at baseline, 66 answered the questionnaire at 6 months, and 79 provided a free-text explanation at either time point. At 6 months, 33% (17/51) of the control group and 35% (17/49) of the intervention group indicated that a hypothetical reduction in routinely scheduled visits with all melanoma doctors was at least slightly acceptable (difference in proportions -1%, 95% CI -20% to 17%; P=.89). Participants suggested that prerequisites for a reduction in routinely scheduled visits would include that sufficient time had elapsed since the previous diagnosis without a new primary melanoma or recurrence, an unscheduled appointment could be made at short notice if the patient noticed something concerning, their melanoma doctor had suggested reducing their clinic visit frequency, and patients had confidence that patient-led surveillance was a safe and effective alternative. Participants suggested that a reduction in routinely scheduled visits would not be acceptable where they perceived a very high risk of new or recurrent melanoma, low self-efficacy in skin self-examination and in the use of technologies for the patient-led surveillance intervention, and where they had a preference for clinician-led surveillance. Some patients said that a partial reduction to once a year may be acceptable.

CONCLUSIONS

Some patients may be receptive to a reduction in routinely scheduled visits if they are assured that patient-led surveillance is safe and effective.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616001716459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371865&isReview=true; ClinicalTrials.gov NCT03581188; https://clinicaltrials.gov/ct2/show/NCT03581188.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1001/jamadermatol.2021.4704.

Exploring the views of patients' and their family about patient-initiated follow-up in head and neck cancer: A mixed methods study

OBJECTIVE

The objective of this work was to explore head and neck cancer (HNC) patients' and their family members' views on acceptability and feasibility of patient-initiated follow-up (PIFU), including concerns and anticipated benefits.

METHODS

Patients were recruited from UK HNC clinics, support groups and advocacy groups. They completed a survey (n = 144) and/or qualitative interview (n = 30), three with a family member. Qualitative data were analysed thematically, quantitative data using descriptive statistics.

RESULTS

Preference for follow-up care in HNC was complex and individual. Many patients thought PIFU could beneficially reallocate health care resources and encourage self-management. Patients' main concerns with PIFU were losing the reassurance of regular clinic appointments and addressing mental well-being needs within PIFU, possibly using peer support. Patients were concerned about their ability to detect recurrence due to lack of expertise and information. They emphasised the importance of a reliable, direct and easy urgent appointment service and of feeling supported and heard by clinicians. Patients believed family and friends need support.

CONCLUSION

PIFU may be feasible and acceptable for certain HNC patients, providing it addresses support for mental well-being, provides quick, reliable and direct clinician access and information on "red flag" symptoms, and ensures patients and their caregivers feel supported.

Evaluating a game-based randomized experiment to increase melanoma identification among adults living in the U.S

BACKGROUND

Although cutaneous melanoma diagnoses are rising, morbidity and mortality can be reduced through early detection. This investigation seeks to improve melanoma identification accuracy, attitudes, and intentions among a lay population by comparing the effectiveness of different melanoma identification training strategies and the effect of real-time decisional feedback on a melanoma identification task. We developed an innovative, game-based approach and hypothesize differences among frequently used melanoma identification training modalities (i.e, the Asymmetry/Border/Color/Diameter [ABCD] rule, the Ugly Duckling Rule [UDS], and a modality that combines them both, ABCDF (where the F stands for 'funny looking"), and investigate differences in types of immediate feedback on a melanoma identification task.

METHODS

We conducted a national online randomized experiment to test a 4 (melanoma training strategies: ABCD, UDS, ABCD-F, control) × 3 (feedback: Dermatological, Dermatological + Motivational, control) factorial design on melanoma identification, skin cancer beliefs (perceived susceptibility, severity, response efficacy, self-efficacy), attitudes, and prevention intentions.

RESULTS

ABCD training (p < .001) and UDS training (p = .05) resulted in significantly higher melanoma identification than the control. All training types resulted in significantly higher self-efficacy than the control (p = .02). Both Dermatological (p = .02) and Dermatological + Motivational feedback (p = .01) elicited significantly lower melanoma identification than the control condition, although this effect may be due to differences observed among participants who received UDS training. There was a significant main effect of feedback on self-efficacy (p = .002), where both Dermatological and Dermatological + Motivational feedback elicited higher levels of self-efficacy than the control.

CONCLUSIONS

Our results suggest that game-based ABCD and UDS training strategies could increase melanoma identification accuracy. Real-time feedback reduced accuracy, but was associated with increased self-efficacy related to melanoma detection outcomes.

Experiences of Patient-Led Surveillance, Including Patient-Performed Teledermoscopy, in the MEL-SELF Pilot Randomized Controlled Trial: Qualitative Interview Study

BACKGROUND

Current clinician-led melanoma surveillance models require frequent routinely scheduled clinic visits, with associated travel, cost, and time burden for patients. Patient-led surveillance is a new model of follow-up care that could reduce health care use such as clinic visits and medical procedures and their associated costs, increase access to care, and promote early diagnosis of a subsequent new melanoma after treatment of a primary melanoma. Understanding patient experiences may allow improvements in implementation.

OBJECTIVE

This study aims to explore patients' experiences and perceptions of patient-led surveillance during the 6 months of participation in the MEL-SELF pilot randomized controlled trial. Patient-led surveillance comprised regular skin self-examination, use of a mobile dermatoscope to image lesions of concern, and a smartphone app to track and send images to a teledermatologist for review, in addition to usual care.

METHODS

Semistructured interviews were conducted with patients previously treated for melanoma localized to the skin in New South Wales, Australia, who were randomized to the patient-led surveillance (intervention group) in the trial. Thematic analysis was used to analyze the data with reference to the technology acceptance model.

RESULTS

We interviewed 20 patients (n=8, 40% women and n=12, 60% men; median age 62 years). Patients who were more adherent experienced benefits such as increased awareness of their skin and improved skin self-examination practice, early detection of melanomas, and opportunities to be proactive in managing their clinical follow-up. Most participants experienced difficulty in obtaining clear images and technical problems with the app. These barriers were overcome or persevered by participants with previous experience with digital technology and with effective help from a skin check partner (such as a spouse, sibling, or friend). Having too many or too few moles decreased perceived usefulness.

CONCLUSIONS

Patients with melanoma are receptive to and experience benefits from patient-led surveillance using teledermoscopy. Increased provision of training and technical support to patients and their skin check partners may help to realize the full potential benefits of this new model of melanoma surveillance.

Assessing the Potential for Patient-led Surveillance After Treatment of Localized Melanoma (MEL-SELF): A Pilot Randomized Clinical Trial

IMPORTANCE

Patient-led surveillance is a promising new model of follow-up care following excision of localized melanoma.

OBJECTIVE

To determine whether patient-led surveillance in patients with prior localized primary cutaneous melanoma is as safe, feasible, and acceptable as clinician-led surveillance.

DESIGN, SETTING, AND PARTICIPANTS

This was a pilot for a randomized clinical trial at 2 specialist-led clinics in metropolitan Sydney, Australia, and a primary care skin cancer clinic managed by general practitioners in metropolitan Newcastle, Australia. The participants were 100 patients who had been treated for localized melanoma, owned a smartphone, had a partner to assist with skin self-examination (SSE), and had been routinely attending scheduled follow-up visits. The study was conducted from November 1, 2018, to January 17, 2020, with analysis performed from September 1, 2020, to November 15, 2020.

INTERVENTION

Participants were randomized (1:1) to 6 months of patient-led surveillance (the intervention comprised usual care plus reminders to perform SSE, patient-performed dermoscopy, teledermatologist assessment, and fast-tracked unscheduled clinic visits) or clinician-led surveillance (the control was usual care).

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of eligible and contacted patients who were randomized. Secondary outcomes included patient-reported outcomes (eg, SSE knowledge, attitudes, and practices, psychological outcomes, other health care use) and clinical outcomes (eg, clinic visits, skin surgeries, subsequent new primary or recurrent melanoma).

RESULTS

Of 326 patients who were eligible and contacted, 100 (31%) patients (mean [SD] age, 58.7 [12.0] years; 53 [53%] men) were randomized to patient-led (n = 49) or clinician-led (n = 51) surveillance. Data were available on patient-reported outcomes for 66 participants and on clinical outcomes for 100 participants. Compared with clinician-led surveillance, patient-led surveillance was associated with increased SSE frequency (odds ratio [OR], 3.5; 95% CI, 0.9 to 14.0) and thoroughness (OR, 2.2; 95% CI, 0.8 to 5.7), had no detectable adverse effect on psychological outcomes (fear of cancer recurrence subscale score; mean difference, -1.3; 95% CI, -3.1 to 0.5), and increased clinic visits (risk ratio [RR], 1.5; 95% CI, 1.1 to 2.1), skin lesion excisions (RR, 1.1; 95% CI, 0.6 to 2.0), and subsequent melanoma diagnoses and subsequent melanoma diagnoses (risk difference, 10%; 95% CI, -2% to 23%). New primary melanomas and 1 local recurrence were diagnosed in 8 (16%) of the participants in the intervention group, including 5 (10%) ahead of routinely scheduled visits; and in 3 (6%) of the participants in the control group, with none (0%) ahead of routinely scheduled visits (risk difference, 10%; 95% CI, 2% to 19%).

CONCLUSIONS AND RELEVANCE

This pilot of a randomized clinical trial found that patient-led surveillance after treatment of localized melanoma appears to be safe, feasible, and acceptable. Experiences from this pilot study have prompted improvements to the trial processes for the larger trial of the same intervention.

TRIAL REGISTRATION

http://anzctr.org.au Identifier: ACTRN12616001716459.

Optimizing Texting Interventions for Melanoma Prevention and Early Detection: A Latin Square Crossover RCT

INTRODUCTION

Text messaging is an effective way to reach large populations with health promotion support. This study aims to establish the optimal text messaging intervention to achieve behavior change in young adults at risk of skin cancer.

STUDY DESIGN

Latin square crossover RCT.

SETTING/PARTICIPANTS

Participants were women and men aged 18-40 years living in Queensland, Australia who owned a smartphone and had ≥2 skin cancer risk factors.

INTERVENTION

Participants were enrolled from December 2018 to February 2019 and completed an eligibility survey. Eligible participants were randomized to 4 different text message interventions using a Latin square design with varying personalization, interactivity, and message frequency (February 2019‒July 2019). Each intervention lasted for 1 month; between interventions, participants had a 1-week washout period in which they completed an online questionnaire. Participants completed a 6-month follow-up online survey in January 2020.

MAIN OUTCOME MEASURES

Measures included self-reported sun protection habits and sunburns.

RESULTS

A total of 277 (71.2% response rate) participants completed the 6-month follow-up. The sun protection habits index was significantly higher in all the 4 text messaging interventions (p<0.01 for each intervention) than at baseline, with similar sun protection habits improvements among all interventions (p=0.27). Sunburn rates decreased significantly over time (p<0.01 each intervention), with all the 4 interventions achieving reductions in sunburn rates during the intervention periods (p=0.78). Overall, the sunburn rates decreased from 40.3% at baseline to 7.0% at the end of the intervention, and at 6-month follow-up, it remained significantly below baseline levels at 23.5% (p<0.01).

CONCLUSIONS

Regular text messaging interventions result in significantly increased sun protection and decreased sunburn in young adults.

TRIAL REGISTRATION

This study is registered at the Australian and New Zealand Clinical Trials Registry ACTRN12618001299291.

Patients' Experiences of Using Skin Self-monitoring Apps With People at Higher Risk of Melanoma: Qualitative Study

BACKGROUND

Melanoma is the fourth most commonly diagnosed cancer in Australia. Up to 75% of melanomas are first detected by patients or their family or friends. Many mobile apps for melanoma exist, including apps to encourage skin self-monitoring to improve the likelihood of early detection. Previous research in this area has focused on their development, diagnostic accuracy, or validation. Little is known about patients' views and experiences of using these apps.

OBJECTIVE

This study aims to understand patients' views and experiences of using commercially available melanoma skin self-monitoring mobile apps for a period of 3 months.

METHODS

This qualitative study was conducted in two populations: primary care (where the MelatoolsQ tool was used to identify patients who were at increased risk of melanoma) and secondary care (where patients had a previous diagnosis of melanoma, stages T0-T3a). Participants downloaded 2 of the 4 mobile apps for skin self-monitoring (SkinVision, UMSkinCheck, Mole Monitor, or MySkinPal) and were encouraged to use them for 3 months. After 3 months, a semistructured interview was conducted with participants to discuss their experiences of using the skin self-monitoring mobile apps.

RESULTS

A total of 54 participants were recruited in the study, with 37% (20) of participants from primary care and 62% (34) from secondary care. Interviews were conducted with 34 participants when data saturation was reached. Most participants did not use the apps at all (n=12) or tried them once but did not continue (n=14). Only 8 participants used the apps to assist with skin self-monitoring for the entire duration of the study. Patients discussed the apps in the context of the importance of early detection and their current skin self-monitoring behaviors. A range of features of perceived quality of each app affected engagement to support skin self-monitoring. Participants described their skin self-monitoring routines and potential mismatches with the app reminders. They also described the technical and practical difficulties experienced when using the apps for skin self-monitoring. The app's positioning within existing relationships with health care providers was crucial to understand the use of the apps.

CONCLUSIONS

This study of patients at increased risk of melanoma highlights several barriers to engagement with apps to support skin self-monitoring. The results highlight the wide-ranging and dynamic influences on engagement with mobile apps, which extend beyond app design and relate to broader contextual factors about skin self-monitoring routines and relationships with health care providers.

Co-Design of a Trustworthy AI System in Healthcare: Deep Learning Based Skin Lesion Classifier

This paper documents how an ethically aligned co-design methodology ensures trustworthiness in the early design phase of an artificial intelligence (AI) system component for healthcare. The system explains decisions made by deep learning networks analyzing images of skin lesions. The co-design of trustworthy AI developed here used a holistic approach rather than a static ethical checklist and required a multidisciplinary team of experts working with the AI designers and their managers. Ethical, legal, and technical issues potentially arising from the future use of the AI system were investigated. This paper is a first report on co-designing in the early design phase. Our results can also serve as guidance for other early-phase AI-similar tool developments.

Review of educational tools for skin self-examination: A qualitative analysis of laypeople's preferences

ISSUE ADDRESSED

Skin self-examination (SSE) empowers individuals to be aware of their skin and to identify and present to a doctor with any suspicious lesions; however evidence-based, clear guidance for SSE is lacking.

METHODS

A new acronym entitled SCAN (Sore, Changing, Abnormal, New) was compiled to help laypeople recognise early signs of skin cancer. This study undertook a qualitative investigation on how well laypeople understand SCAN and other commonly used educational tools (ABCDE, AC, and "ugly duckling"), whether they have a preferred SSE tool, and whether pictorial presentations enhance their understanding.

RESULTS

Seven focus groups were conducted with 28 participants (age range 19-78 years), including 6 participants with a previous melanoma diagnosis. Among all the educational tools presented, SCAN was commonly described as the favoured to guide SSE. SCAN was perceived as patient-oriented due to its simplicity and use of easily understood words, while other tools, although perceived as positive in some aspects, were often identified as complex, difficult to understand and aimed towards clinician use. Pictorial presentations were desired as part of an educational tool; however, many also raised their potential disadvantages.

CONCLUSION

This was the first study to determine the patient perspective of SCAN and established a diverse range of potential quality indicators for SSE educational tools. SO WHAT?: The findings of this study suggest that current widely used SSE tools may not be the most effective to promote SSE. SCAN may be preferred, as it simplifies SSE by using lay language and is applicable to all skin cancers.

Patient Perspectives on the Use of Artificial Intelligence for Skin Cancer Screening: A Qualitative Study

Importance

The use of artificial intelligence (AI) is expanding throughout the field of medicine. In dermatology, researchers are evaluating the potential for direct-to-patient and clinician decision-support AI tools to classify skin lesions. Although AI is poised to change how patients engage in health care, patient perspectives remain poorly understood.

Objective

To explore how patients conceptualize AI and perceive the use of AI for skin cancer screening.

Design, Setting, and Participants

A qualitative study using a grounded theory approach to semistructured interview analysis was conducted in general dermatology clinics at the Brigham and Women's Hospital and melanoma clinics at the Dana-Farber Cancer Institute. Forty-eight patients were enrolled. Each interview was independently coded by 2 researchers with interrater reliability measurement; reconciled codes were used to assess code frequency. The study was conducted from May 6 to July 8, 2019.

Main Outcomes and Measures

Artificial intelligence concept, perceived benefits and risks of AI, strengths and weaknesses of AI, AI implementation, response to conflict between human and AI clinical decision-making, and recommendation for or against AI.

Results

Of 48 patients enrolled, 26 participants (54%) were women; mean (SD) age was 53.3 (21.7) years. Sixteen patients (33%) had a history of melanoma, 16 patients (33%) had a history of nonmelanoma skin cancer only, and 16 patients (33%) had no history of skin cancer. Twenty-four patients were interviewed about a direct-to-patient AI tool and 24 patients were interviewed about a clinician decision-support AI tool. Interrater reliability ratings for the 2 coding teams were κ = 0.94 and κ = 0.89. Patients primarily conceptualized AI in terms of cognition. Increased diagnostic speed (29 participants [60%]) and health care access (29 [60%]) were the most commonly perceived benefits of AI for skin cancer screening; increased patient anxiety was the most commonly perceived risk (19 [40%]). Patients perceived both more accurate diagnosis (33 [69%]) and less accurate diagnosis (41 [85%]) to be the greatest strength and weakness of AI, respectively. The dominant theme that emerged was the importance of symbiosis between humans and AI (45 [94%]). Seeking biopsy was the most common response to conflict between human and AI clinical decision-making (32 [67%]). Overall, 36 patients (75%) would recommend AI to family members and friends.

Conclusions and Relevance

In this qualitative study, patients appeared to be receptive to the use of AI for skin cancer screening if implemented in a manner that preserves the integrity of the human physician-patient relationship.