The role of accessibility policies and other determinants of health care provision in the initial prognosis of malignant melanoma: A cross-sectional study

Temporal Trends in the Incidence and Mortality of Skin Malignant Melanoma in China from 1990 to 2019

Purpose

Skin malignant melanoma (SMM) is one of the fastest-growing cancers in China, with a poor prognosis, high invasiveness, and high mortality rate. The aim of this study was to determine the long-term trends in the incidence and mortality of SMM in China between 1990 and 2019. Patients and Methods. Incidence and mortality data were extracted from the Global Burden of Disease Study 2019 and were analyzed using an age-period-cohort framework.

Results

The annual incidence net drifts were 3.523% (95% confidence interval (CI): 3.318% to 3.728%) and 3.779% (95% CI: 3.585% to 3.974%) for males and females, respectively, while the corresponding annual net drifts of mortality were −0.754% (95% CI: −1.073% to −0.435%) and –0.826% (95% CI: −1.164% to −0.487%). The local drift from 1990 to 2019 was highest in males aged from 25 to 29 years. After controlling for period deviations in a single birth cohort, the SMM incidence and mortality increased exponentially with age for both sexes. Similar increasing monotonic trends were found for period and cohort effects on the incidence, while a declining trend was found for mortality.

Conclusion

While the age-standardized mortality rate of SMM in China has decreased in both sexes over the past 30 years, the crude incidence rate, age-standardized incidence rate, and crude mortality rate have all increased. SMM may greatly threaten the health of the elderly in China due to the aging population. Appropriate changes should be made to raise the awareness, reduce the exposure to risk factors, and promote the early detection of SMM.

[Teledermatology in the Health Center West Area of Granada: From primary to specialized care]

INTRODUCTION

Teledermatology (TD) is a health tool based on the application of information and communication technologies (ICT) for the care of skin diseases at a distance, allowing a better connection between primary care professionals (PCP) and specialized care. The objective of this study was to analyze the characteristics of the teleconsultations made to our service in a period of 2years (January 1, 2018 to December 31, 2019).

MATERIAL AND METHODS

The data was obtained from a TD system with dermoscopy that allows teleconsultations to be carried out asynchronously. Data were analyzed over 24months. The variables studied were the health centre of origin, the diagnostic suspicion of the PCP, the time and type of response, and the clinical judgment issued by the dermatologist.

RESULTS

Between January 1, 2018 and December 31, 2019, a total of 3,294 teleconsultations were received. 24.76% were referred to the dermatology consultation, while 25.63% required subsequent follow-up electronically. The most frequent diagnostic suspicion by the PCP was that of benign pathology (54.71%). The most frequent dermatological clinical judgment was that of seborrheic keratosis (20.19%), followed by actinic keratosis (14.02%), acquired common melanocytic nevi (13.24%) and basal cell carcinoma (8.98%).

CONCLUSIONS

The TD system is a useful tool that allowed a quick response to a high percentage of consultations, helping to avoid unnecessary referrals and easy communication between primary and specialized care. It also allows prioritizing those patients with malignant tumour pathology.

Direct-to-consumer, store-and-forward teledermatology with dermoscopy using the pharmacist as patient point-of-contact

Objective(s)

To evaluate the frequency of nonmelanoma skin cancer (NMSC), NMSC precursors, and melanoma on a store-and-forward dermatology model featuring the pharmacist as the patient’s point-of-contact. The secondary objective was to define lesion changes and symptoms perceived by patients (clinical prediction rules by nonexpert observers) that can be predictive of malignity.

Methods

A cross-sectional study of teledermatology consultation was performed. All patients who underwent a teledermatology consultation between September 2018 and March 2020 were included. A patient could have more than 1 lesion per consultation. The object of the study was a defined dermatologic lesion. The differences between the variables were analyzed using a univariate model based on the chi-square test for independent qualitative variables and Fisher exact test in cases when the expected values in any of the cells of a contingency table were less than 5. Statistical significance was set at P < 0.05 (2-tailed).

Results

A total of 225 lesions in 218 patients were considered for this study; 53.8% (n = 121) of the lesions were classified as benign, 16.4% (n = 37) as dubious, 23.1% (n = 52) as NMSC precursors, 5.8% (n = 13) as NMSC, and 0.9% (n = 2) as melanomas. Of the reported clinical lesion changes, spontaneous pain, pruritus, surface texture changes, color changes, or form changes had no statistically significant relationship with the diagnostic group, whereas the presence of spontaneous bleeding (P = 0.015) and size changes (P = 0.026) were more frequently observed in the “dubious lesion” and “of oncological relevance lesion” groups.

Conclusion

This “direct-to-consumer,” store-and-forward teledermatology with dermoscopy model featuring the pharmacist as the patient’s point-of-contact is useful for the diagnosis of melanoma, NMSC, and NMSC precursors when backed by a robust dermatology service.

Occupational differences in standardized mortality ratios for non-melanotic skin cancer and melanoma in exposed areas among individuals with Fitzpatrick skin types III and IV

OBJECTIVE

The objective of this study was to identify subpopulations vulnerable to skin cancer by occupations, among individuals with Fitzpatrick skin types III and IV.

METHODS

Data were retrieved from the national mortality registry of Korean National Statistical Office (KNSO) from 1993 to 2012, including all medical certificates of death written and confirmed by physicians. Medical certificates of death from 1993 to 2012 were obtained from the national mortality registry of Korean National Statistical Office. These completed medical certificates are verified by the Korean Ministry of Government Administration and Home Affairs and formatted using 103 main and 236 specific causes of death as recommended by the World Health Organization. We calculated direct standardized mortality rate and standardized mortality ratio (SMR) using the indirect standardization method. The entire population as reflected in the 2005 national census was used as a reference population.

RESULTS

Of 594 deaths from skin cancer, 227 (38.2%) were from non-melanotic skin cancer (NMSC) and 367 (61.8%) from cutaneous melanoma (CM). Compared to office workers, agriculture/fishery/forestry workers had significantly higher SMRs for NMSC in men [SMR: 461, 95% confidential interval (CI): 329-583] and women (SMR: 575, 95% CI: 317-864). SMR was also increased in men who worked in exposed area (SMR of NMSC:553, 95% CI:222-1018, SMR of CM:453, 95% CI: 133-1009).

CONCLUSION

This is the first Asian study to suggest that agriculture/fishery/forestry workers have increased SMRs for NMSC and CM in exposed areas. Early diagnosis of skin cancer in this group is important.

Differences in cutaneous melanoma treatment and patient satisfaction

Although clinical guidelines exist, the management of patients with cutaneous melanoma (CM) is a complex process that may vary between different care providers with potential dysfunctions ultimately mirrored in the overall patient satisfaction. The aim of the present study was to investigate the CM management as related to lead times, surgical quality and diagnosis communication with the hypothesis that the care may differ between providers and disparities may impact patient satisfaction. Medical records of 181 patients were retrospectively analyzed with parallel patient satisfaction evaluation by telephone interviews. Overall mean lead times from initial diagnosis until completion of all surgery and histopathology reports were 80-100 days and delays occurred at every step of the process. General practitioners performed excision biopsies faster however this was mitigated by slower histopathology processing. University level CM care showed less lag time between excision biopsy, wide local excision for thick melanomas and histopathology confirmation. University level care operated with twice the surgical margin as compared to general practitioners and non-university level specialists. Male patients had larger excision biopsy margins and significantly shorter lead times than female patients. Patient satisfaction rates were generally higher in the academic hospitals as compared to general practitioners and non-university dermatology clinics. Surprisingly, there was no correlation between lead times and patient satisfaction. Taken together, CM show substantial variation and caution should be practiced when using patient satisfaction as a quality indicator.

Increasing Frequency of Seborrheic Keratosis Diagnoses as a Favorable Consequence of Teledermatology-Based Skin Cancer Screening: A Cross-sectional Study of 34,553 Patients

BACKGROUND

Screening of skin cancer by teledermatology (TD) has improved the early detection of skin cancer by enhancing access to skin cancer clinics.

OBJECTIVE

We sought to analyze how TD-based skin cancer screening has changed the frequency of consultations for benign lesions.

PATIENTS AND METHODS

A cross-sectional study including teleconsultations received during a 7-year period was conducted to analyze and compare the trendlines of each lesion type over the study period. Trendlines were analyzed using a linear regression model with the R-squared (R 2) test for goodness of fit.

RESULTS

A total of 34,553 teleconsultations were included in the study. Seborrheic keratoses, followed by benign melanocytic lesions, were the most frequent lesions diagnosed. The pick-up rate for malignant lesions was 1:8.6 teleconsultations. Seborrheic keratoses and precancerous lesions showed a positive trendline with good fit to the linear model (R 2 = 0.8 and R 2 = 0.8, respectively). Tis-T1 malignant melanoma (in situ melanoma or melanoma with a Breslow thickness <1 mm) showed an increasing trendline with moderate-to-low fit to the model (R 2 = 0.4).

CONCLUSIONS

TD-based screening of skin cancer is associated with an increasing rate of consultations involving seborrheic keratoses, which can be considered a consequence of improved access to dermatologists resulting from TD implementation.

Use of Lymph Node Ultrasound Prior to Sentinel Lymph Node Biopsy in 384 Patients with Melanoma: A Cost-Effectiveness Analysis

BACKGROUND AND OBJECTIVES

Locoregional lymph node ultrasound is not typically included in guidelines as part of the staging process prior to sentinel lymph node biopsy (SLNB). The objective of the present study was to make a clinical and economic analysis of lymph node ultrasound prior to SLNB.

MATERIALS AND METHODS

We performed a retrospective study of 384 patients with clinical stage I-II primary melanoma who underwent locorregional lymph node ultrasound (with or without ultrasound-guided biopsy) prior to SLNB between 2004 and 2015. We evaluated the reliability and cost-effectiveness of the strategy.

RESULTS

Use of locorregional lymph node ultrasound avoided SLNB in 23 patients (6%). Ultrasound had a sensitivity of 46% and specificity of 76% for the detection of metastatic lymph nodes that were not clinically palpable. False negatives were significantly more common in patients aged over 60 years and in tumors with a thickness of less than 2mm. The staging process using SLNB and ultrasound with ultrasound-guided biopsy produced an increase of €16.30 in the unit price. Our cost-effectiveness analysis identified the staging protocol with ultrasound and SLNB as the dominant strategy, with a lower cost-effectiveness ratio than the alternative, consisting of SLNB alone (8,095.24 vs. €28,605.00).

CONCLUSIONS

Ultrasound with ultrasound-guided biopsy for the diagnostic staging of melanoma prior to SLNB is a useful and cost-effective tool. This procedure does not substitute SLNB, though it does allow to avoid SLNB in a not insignificant proportion of patients.

Who detects melanoma? Impact of detection patterns on characteristics and prognosis of patients with melanoma

BACKGROUND

Despite the importance of early diagnosis, patients with cutaneous melanoma often seek consultation at advanced stages of the disease. The impact on prognosis according to who first detects the primary tumor has not been established.

OBJECTIVE

This study aims to determine who first detects melanoma, the reasons that patients with melanoma consult a doctor, and the impact of detection patterns on the characteristics and prognosis of melanoma.

METHODS

Seven hundred eighty-three patients with cutaneous melanoma who were diagnosed between 1996 and 2012 were included. Associations between who first noticed the melanoma (ie, self-detected, relatives, health care workers, or dermatologists), epidemiology, clinical presentation, histology, and patient outcomes were analyzed.

RESULTS

Most melanomas were self-detected (53%). Among these patients, 32% consulted because of bleeding, itching/pain, or nodule enlargement. There were more melanomas self-detected among women than among men, and these had a better prognosis. Men had significantly more melanomas on non-easily visible locations than women did. Among melanomas noticed by dermatologists, 80% were incidental findings. Self-detected melanomas were thicker and more frequently ulcerated, developed metastases more often, and were associated with more melanoma-related deaths.

CONCLUSIONS

Patients with melanomas detected by dermatologists had better prognoses than patients with self-detected melanomas. Patients with melanomas that were self-detected by women had better prognoses than those that were self-detected by men, especially for patients >70 years of age. This group might therefore be a logical target for melanoma detection education.

Yield of Computed Tomography at Baseline Staging of Melanoma

BACKGROUND

Current guidelines call for baseline imaging only for very high-risk (T4b) primary cutaneous melanomas.

OBJECTIVES

To estimate the frequency of computed tomography (CT) at baseline staging of primary cutaneous melanoma and the diagnostic yield of CT; and to describe the types and frequencies of incidentaloma findings.

MATERIAL AND METHODS

Cross-sectional study of cutaneous melanoma cases (tumor classifications Tis to T4bN0M0) attended between 2008 and 2014 in a specialized melanoma unit. Reports of CT scans performed during baseline staging were reviewed to determine the frequency of positive scan results, incidentaloma findings, unit cost for detection of metastasis, and factors associated with the decision to order CT.

RESULTS

CT results were available for 310 of the 419 patients included (73.99%). The tumor classifications were as follows: Tis, 17; T1, 137; T2, 71; T3, 48; and T4, 37. The CT results were negative in 81.61%, and incidentalomas were found in 18.06%. Additional primary tumors were found in 2 patients (0.64%), and metastasis was identified in one patient (0.32%). The cost of finding the case of metastasis was €71,234.90. A T2 tumor classification (odds ratio [OR], 8.73) and age under 70 years (OR, 3.53) were associated with greater likelihood of CT being ordered. Excision of the primary tumor in the melanoma unit (OR, 0.08) was associated with less likelihood of ordering CT.

CONCLUSIONS

The results for this patient series support current recommendations restricting CT at baseline to cases where there is high risk of metastasis (stagesiiC-iii).