Diagnosing skin cancer in primary care: how do mainstream general practitioners compare with primary care skin cancer clinic doctors?

Insights into Melanoma Clinical Practice: A Perspective for Future Research

BACKGROUND

Early diagnosis is the key to improving outcomes for patients with melanoma, and this requires a standardized histological assessment approach. The objective of this survey was to understand the challenges faced by clinicians when assessing melanoma cases, and to provide a perspective for future studies.

METHODS

Between April 2022 and February 2023, national and international dermatologists, pathologists, general practitioners, and laboratory managers were invited to participate in a six-question online survey. The data from the survey were assessed using descriptive statistics and qualitative responses.

RESULTS

A total of 54 responses were received, with a 51.4% (n = 28) full completion rate. Of the respondents, 96.4% reported ambiguity in their monthly melanoma diagnosis, and 82.1% routinely requested immunohistochemistry (IHC) testing to confirm diagnosis. SOX10 was the most frequently requested marker, and most respondents preferred multiple markers over a single marker. Diagnostic and prognostic tests, as well as therapeutic options and patient management, were all identified as important areas for future research.

CONCLUSIONS

The respondents indicated that the use of multiple IHC markers is essential to facilitate diagnostic accuracy in melanoma assessment. Survey responses indicate there is an urgent need to develop new biomarkers for clinical decision making at multiple critical intervention points.

Predictive factors of sun protection behaviour among global airline pilots

BACKGROUND

Airline pilots face significant ultraviolet radiation exposure resulting in an increased risk of sun damage and skin cancers. We aimed to evaluate sun-protective practices and associated factors among airline pilots.

METHODS

We disseminated an online questionnaire evaluating the use of sunscreen, sunglasses, hats and protective clothing during daytime hours in the cockpit and during outdoor activities to 346 global commercial airline pilots, and we received 220 completed responses. The Pearson chi-squared test or Fisher's exact test where necessary were used to determine possible factors associated with the use of sun-protective practices. Potential confounders were adjusted for using multivariate analyses.

RESULTS

The most common sun protective behaviour was the wearing of sunglasses during daytime flights (89.5%), followed by the use of caps during outdoor activities (47.7%). More pilots applied sunscreen during daytime flights (14.1%) compared with walk-arounds (8.2%). Males were less likely to use sunscreen during flights (adjusted odds ratio, aOR = 0.76), use sunscreen for walk-arounds (aOR = 0.175) and wear long sleeves (aOR = 0.013). Pilots who flew less than 30 h a month in high latitude regions were less likely to use a cap or hat outdoors (aOR = 0.419) or use sunscreen during walk-arounds (aOR = 0.241). Younger pilots were also less likely to use caps or hats outdoors (aOR = 0.446).

CONCLUSION

Male pilots and those who spent less time in high latitudes were less likely to practice sun protection. Targeted educational efforts may be implemented to reduce occupational ultraviolet exposure.

Systematic development of quality indicators for skin cancer management in primary care: a mixed-methods study protocol

INTRODUCTION

Australia has the highest incidence of skin cancer in the world, with two out of three Australians expected to be diagnosed with skin cancer in their lifetime. Such incidence necessitates large-scale, effective skin cancer management practices. General practitioners (in mainstream practice and in skin cancer clinics) play an important role in skin cancer care provision, making decisions based on relevant evidence-based guidelines, protocols, experience and training. Diversity in these decision-making practices can result in unwarranted variation. Quality indicators are frequently implemented in healthcare contexts to measure performance quality at the level of the clinician and healthcare practice and mitigate unwarranted variation. Such measurements can facilitate performance comparisons between peers and a standard benchmark, often resulting in improved processes and outcomes. A standardised set of quality indicators is yet to be developed in the context of primary care skin cancer management.

AIMS

This research aims to identify, develop and generate expert consensus on a core set of quality indicators for skin cancer management in primary care.

METHODS

This mixed-methods study involves (1) a scoping review of the available evidence on quality indicators in skin cancer management in primary care, (2) identification and development of a core set of quality indicators through interviews/qualitative proforma surveys with participants, and (3) a focus group involving discussion of quality indicators according to Nominal Group Technique. Qualitative and quantitative data will be collected and analysed using thematic and descriptive statistical analytical methods.

ETHICS AND DISSEMINATION

Approval was granted by the university's Research Ethics Committee (HREC no. 520211051532420). Results from this study will be widely disseminated in publications, study presentations, educational events and reports.

Pathways from Diagnosis to Death from Keratinocyte Cancer in Kidney Transplant Recipients

BACKGROUND

Kidney transplant recipients are at increased risk of developing and dying from keratinocyte cancer. We aimed to describe the clinical course of keratinocyte cancer-related deaths in a cohort of kidney transplant recipients.

METHODS

In kidney transplant recipients transplanted between 1995 and 2014 in Queensland, Australia, we ascertained keratinocyte cancer deaths by searching national transplant and state death registries to March 2020. Deceased transplant recipients' medical records were reviewed to assess features of the primary lesion of the fatal keratinocyte cancer, metastases, and clinical information before death.

RESULTS

Of 658 kidney transplant recipient deaths, 49 (7%) were due to keratinocyte cancer, and medical records were available for 36 (73%). One death was due to basal cell carcinoma, and 35 were from squamous cell carcinoma (SCC), primarily from the head and neck (24; 69%). The most common site of metastasis was the lungs (21; 58%). Median time (minimum, maximum) from the diagnosis of primary SCC to metastasis was 5 months (0, 29). After this, the median time to death was 9 months (1, 50).

CONCLUSION

Fatal keratinocyte cancers overwhelmingly arise on the head and neck, with lungs the most common metastasis site. The short time from diagnosis of primary to death indicates the aggressive nature of these keratinocyte cancers.

Diagnostic accuracy of basal cell carcinoma in dermatology setting in Serbia: A single-center study

Background/Aim. The growing incidence of skin tumors requires an accurate diagnosis. Dermoscopy, especially in vivo, enhances the diagnosis of basal cell carcinoma (BCC). Total body skin examination (TBSE), a visual inspection of the patient?s total body surface, is considered a basic step in the dermatological exam, especially in skin cancer screening. However, TBSE is still a matter of debate regarding its expediency in a real clinical setting. The aim of this study was to analyze the diagnostic accuracy of BCC detected and treated by referred dermatologists. Methods. The retrospective analysis included a five-year period of BCC detection during TBSE by visual inspection and dermoscopy. We calculated sensitivity, specificity and positive predictive value for BCC using histopathological results as the correct diagnosis. Results. Out of 3,346 biopsied skin tumors, 49.58% were malignant and 50.42% benign. The most common malignant tumor was BCC, accounting for 84.09%. Localization of BCCs was mainly on the trunk (38.92%) and the H-zone of the face (37.63%). Other localizations were face (non-H-zone) (6.67%), neck (3.01%), scalp (3.37%), arms (6.88%) and limbs (3.51%). Of all BCCs, 0.83% were recurrent BCC. The sensitivity for the diagnosis of BCC was 97.71%, and the positive predictive value was 95.08%. Conclusion. In the dermatology setting, TBSE and visual inspection with in vivo dermoscopy result in a very good diagnostic performance of BCC.

Melanoma Awareness Among Medical Students

Melanoma is the most aggressive skin cancer. Since diagnosis is visual, it is critical to evaluate if students acquire enough knowledge for early detection during medical school. To assess the melanoma knowledge of first-year (freshman) and sixth-year (senior) medical students, in a Brazilian Institution. It was a transversal and quantitative study. A questionnaire with sociodemographic data, knowledge about melanoma, and the habit of skin self-exam was filled out by medical students. A total of 128 first-year and 122 seniors students were included. All the sixth-year students knew melanoma as a skin cancer compared with 46.09% of the first-year students. Melanoma clinical characteristics were known by 30.51% of the freshman and 97.54% of seniors. However, they did not know the most usual site of melanoma occurrence (79.66% of first-year students and 24.59% of senior). About the skin self-exam, only 50% of first-year students and 53.28% of senior had the habit of doing it sometimes. Medical school was effective in providing knowledge about melanoma and its features. However, this was not reflected in an increase in the number of students that did the skin self-exam, which indicates the need for new approaches in teaching.

Using deep learning for dermatologist-level detection of suspicious pigmented skin lesions from wide-field images

A reported 96,480 people were diagnosed with melanoma in the United States in 2019, leading to 7230 reported deaths. Early-stage identification of suspicious pigmented lesions (SPLs) in primary care settings can lead to improved melanoma prognosis and a possible 20-fold reduction in treatment cost. Despite this clinical and economic value, efficient tools for SPL detection are mostly absent. To bridge this gap, we developed an SPL analysis system for wide-field images using deep convolutional neural networks (DCNNs) and applied it to a 38,283 dermatological dataset collected from 133 patients and publicly available images. These images were obtained from a variety of consumer-grade cameras (15,244 nondermoscopy) and classified by three board-certified dermatologists. Our system achieved more than 90.3% sensitivity (95% confidence interval, 90 to 90.6) and 89.9% specificity (89.6 to 90.2%) in distinguishing SPLs from nonsuspicious lesions, skin, and complex backgrounds, avoiding the need for cumbersome individual lesion imaging. We also present a new method to extract intrapatient lesion saliency (ugly duckling criteria) on the basis of DCNN features from detected lesions. This saliency ranking was validated against three board-certified dermatologists using a set of 135 individual wide-field images from 68 dermatological patients not included in the DCNN training set, exhibiting 82.96% (67.88 to 88.26%) agreement with at least one of the top three lesions in the dermatological consensus ranking. This method could allow for rapid and accurate assessments of pigmented lesion suspiciousness within a primary care visit and could enable improved patient triaging, utilization of resources, and earlier treatment of melanoma.

Restructuring Skin Cancer Care in Ontario: A Provincial Plan

There is a global rise in skin cancer incidence, resulting in an increase in patient care needs and healthcare costs. To optimize health care planning, costs, and patient care, Ontario Health developed a provincial skin cancer plan to streamline the quality of care. We conducted a systematic review and a grey literature search to evaluate the definitions and management of skin cancer within other jurisdictions, as well as a provincial survey of skin cancer care practices, to identify care gaps. The systematic review did not identify any published comprehensive skin cancer management plans. The grey literature search revealed skin cancer plans in isolated regions of the United Kingdom (U.K.), National Institute for Health and Care Excellence (NICE) guidelines for skin cancer quality indicators and regional skin cancer biopsy clinics, and wait time guidelines in Australia and the U.K. With the input of the Ontario Cancer Advisory Committee (CAC), unique definitions for complex and non-complex skin cancers and the appropriate cancer services were created. A provincial survey of skin cancer care yielded 44 responses and demonstrated gaps in biopsy access. A skin cancer pathway map was created and a recommendation was made for regional skin cancer biopsy clinics. We have created unique definitions for complex and non-complex skin cancer and a skin cancer pathways map, which will allow for the implementation of both process and performance metrics to address identified gaps in care.

On Naevi and Melanomas: Two Sides of the Same Coin?

Benign naevi are closely linked to melanoma, as risk factors, simulators, or sites of melanoma formation. There is a heavy genetic overlap between the two lesions, a shared environmental influence of ultraviolet radiation, and many similar cellular features, yet naevi remain locally situated while melanomas spread from their primary site and may progress systemically to distal organs. Untangling the overlapping contributors and predictors of naevi and melanoma is an ongoing area of research and should eventually lead to more personalized prevention and treatment strategies, through the development of melanoma risk stratification tools and early detection of evolving melanomas. This will be achieved through a range of complementary strategies: risk-adjusted primary prevention counseling; the use of lesion imaging technologies such as sequential 3D total body photography and consumer-performed lesion imaging; artificial intelligence deep phenotyping and clinical assistance; a better understanding of genetic drivers of malignancy, risk variants, clinical genetics, and polygenic effects; and the interplay between genetics, phenotype and the environment.

Computer-aided classification of suspicious pigmented lesions using wide-field images

BACKGROUND AND OBJECTIVE

Early identification of melanoma is conducted through whole-body visual examinations to detect suspicious pigmented lesions, a situation that fluctuates in accuracy depending on the experience and time of the examiner. Computer-aided diagnosis tools for skin lesions are typically trained using pre-selected single-lesion images, taken under controlled conditions, which limits their use in wide-field scenes. Here, we propose a computer-aided classifier system with such input conditions to aid in the rapid identification of suspicious pigmented lesions at the primary care level.

METHODS

133 patients with a multitude of skin lesions were recruited for this study. All lesions were examined by a board-certified dermatologist and classified into "suspicious" and "non-suspicious". A new clinical database was acquired and created by taking Wide-Field images of all major body parts with a consumer-grade camera under natural illumination condition and with a consistent source of image variability. 3-8 images were acquired per patient on different sites of the body, and a total of 1759 pigmented lesions were extracted. A machine learning classifier was optimized and build into a computer aided classification system to binary classify each lesion using a suspiciousness score.

RESULTS

In a testing set, our computer-aided classification system achieved a sensitivity of 100% for suspicious pigmented lesions that were later confirmed by dermoscopy examination ("SPL_A") and 83.2% for suspicious pigmented lesions that were not confirmed after examination ("SPL_B"). Sensitivity for non-suspicious lesions was 72.1%, and accuracy was 75.9%. With these results we defined a suspiciousness score that is aligned with common macro-screening (naked eye) practices.

CONCLUSIONS

This work demonstrates that wide-field photography combined with computer-aided classification systems can distinguish suspicious from non-suspicious pigmented lesions, and might be effective to assess the severity of a suspicious pigmented lesions. We believe this approach could be useful to support skin screenings at a population-level.

Meta-analysis of number needed to treat for diagnosis of melanoma by clinical setting

OBJECTIVE

To provide a formal statistical comparison of the efficacy of melanoma detection among different clinical settings.

METHODS

A systematic review and meta-analysis of all relevant observational studies on number needed to treat (NNT) in relation to melanoma was performed in MEDLINE. We performed a random-effects model meta-analysis and reported NNTs with 95% confidence intervals (CIs). The subgroup analysis was related to clinical setting.

RESULTS

In all, 29 articles including a total of 398,549 biopsies/excisions were analyzed. The overall NNT was 9.71 (95% CI, 7.72-12.29): 22.62 (95% CI, 12.95-40.10) for primary care, 9.60 (95% CI, 6.97-13.41) for dermatology, and 5.85 (95% CI, 4.24-8.27) for pigmented lesion specialists.

LIMITATIONS

There is heterogeneity in data reporting and the possibility of missing studies. In addition, the incidence of melanoma varies among clinical settings, which could affect NNT calculations.

CONCLUSION

Pigmented lesion specialists have the lowest NNT, followed by dermatologists, suggesting that involving specialists in the diagnosis and treatment of pigmented skin lesions can likely improve patient outcomes.

Detection of Malignant Melanoma Using Artificial Intelligence: An Observational Study of Diagnostic Accuracy

Background

Malignant melanoma can most successfully be cured when diagnosed at an early stage in the natural history. However, there is controversy over screening programs and many advocate screening only for high-risk individuals.

Objectives

This study aimed to evaluate the accuracy of an artificial intelligence neural network (Deep Ensemble for Recognition of Melanoma [DERM]) to identify malignant melanoma from dermoscopic images of pigmented skin lesions and to show how this compared to doctors' performance assessed by meta-analysis.

Methods

DERM was trained and tested using 7,102 dermoscopic images of both histologically confirmed melanoma (24%) and benign pigmented lesions (76%). A meta-analysis was conducted of studies examining the accuracy of naked-eye examination, with or without dermoscopy, by specialist and general physicians whose clinical diagnosis was compared to histopathology. The meta-analysis was based on evaluation of 32,226 pigmented lesions including 3,277 histopathology-confirmed malignant melanoma cases. The receiver operating characteristic (ROC) curve was used to examine and compare the diagnostic accuracy.

Results

DERM achieved a ROC area under the curve (AUC) of 0.93 (95% confidence interval: 0.92-0.94), and sensitivity and specificity of 85.0% and 85.3%, respectively. Avoidance of false-negative results is essential, so different decision thresholds were examined. At 95% sensitivity DERM achieved a specificity of 64.1% and at 95% specificity the sensitivity was 67%. The meta-analysis showed primary care physicians (10 studies) achieve an AUC of 0.83 (95% confidence interval: 0.79-0.86), with sensitivity and specificity of 79.9% and 70.9%; and dermatologists (92 studies) 0.91 (0.88-0.93), 87.5%, and 81.4%, respectively.

Conclusions

DERM has the potential to be used as a decision support tool in primary care, by providing dermatologist-grade recommendation on the likelihood of malignant melanoma.

Evaluation of the Number-Needed-to-Biopsy Metric for the Diagnosis of Cutaneous Melanoma: A Systematic Review and Meta-analysis

Importance

To date, no concerted effort has been made to date to evaluate the literature on number-needed-to-biopsy (NNB) metrics, particularly to account for the differences in clinician type and melanoma prevalence in certain geographic locations.

Objective

To review and synthesize worldwide data for NNB for the diagnosis of cutaneous melanoma.

Data Source

MEDLINE, Embase, and PubMed databases were searched for English-language articles published worldwide from January 1, 2000, to November 28, 2018.

Study Selection

A total of 46 studies were included that addressed NNB for at least 3681 clinicians worldwide and included 455 496 biopsied tumors and 29 257 melanomas; primary care practitioner (PCP) data were only available from Australia.

Data Extraction and Synthesis

Articles were screened for eligibility, and possible overlapping data sets were resolved. Data extracted included clinician specialization, use of dermoscopy, geographic region and location-specific health care system, study design, number of benign tumors, number of melanomas, and NNB. The review followed the PRISMA guidelines.

Main Outcome and Measures

The NNB for the diagnosis of cutaneous melanoma.

Results

A total of 46 studies were included that addressed NNB for at least 3681 clinicians worldwide and included 455 496 biopsied tumors and 29 257 melanomas; primary care practitioner (PCP) data were only available from Australia. The reported NNB ranged from 2.2 to 287, and the weighted mean NNB for all included publications was 15.6. The exclusion of publications structured as all biopsied tumors, owing to variable data characterization, resulted in reported NNB ranging from 2.2 to 30.5, with a global weighted mean NNB of 14.8 for all clinicians, 7.5 for all dermatologists, 14.6 for Australian PCPs, and 13.2 for all US-based dermatological practitioners, including dermatologists and advanced practice professionals. The summary effect size (ES) demonstrates that a mean 4% of biopsies demonstrated melanoma for study stratum A (all biopsied skin tumors, ES, 0.04; 95% CI, 0.03-0.05), and a mean 12% of biopsies demonstrated melanoma for study strata B (melanocytic tumors on pathology review, ES, 0.12; 95% CI, 0.10-0.14) and C (clinical concern for melanoma, ES; 0.12; 95% CI, 0.09-0.14).

Conclusions and Relevance

The existing NNB for cutaneous melanoma appeared to vary widely worldwide, lacking standardization in the metric and its reporting, and according to clinician characteristics as well; the NNB of US-based clinicians may warrant further exploration.

Keratinocyte cancer excisions in Australia: Who performs them and associated costs

BACKGROUND/OBJECTIVE

To describe the clinical settings in which keratinocyte cancers are excised in Queensland and describe the types of practitioners who excise them; to examine costs; and to identify predictors of hospital admission.

METHODS

We used linked data for participants from the QSkin study (n = 43 794), including Medicare claims and Queensland hospital admissions relating to treatment episodes for incident keratinocyte cancers from July 2011 to June 2015. We used multinomial logistic regression to measure associations between demographic and clinical characteristics and treatment setting. The median costs of Medicare claims (AU$) were calculated.

RESULTS

During 4 years of follow-up, there were 18 479 skin cancer excision episodes among 8613 people. Most excisions took place in private clinical rooms (89.7%), the remainder in hospitals (7.9% private; 2.4% public). Compared with other anatomical sites, skin cancers on the nose, eyelid, ear, lip, finger or genitalia were more likely to be treated in hospitals than in private clinical rooms (public hospital OR 5.7; 95%CI 4.5-7.2; private hospital OR 8.3; 95%CI 7.3-9.4). Primary care practitioners excised 83% of keratinocyte cancers, followed by plastic surgeons (9%) and dermatologists (6%). The median Medicare benefit paid was $253 in private clinical rooms and $334 in private hospitals. Out-of-pocket payments by patients treated in private hospitals were fourfold higher than those in private clinical rooms ($351 vs $80).

CONCLUSIONS

Most keratinocyte cancers are excised in primary care, although more than 10% of excisions occur in hospital settings.

Substitution of low-risk skin cancer hospital care towards primary care: A qualitative study on views of general practitioners and dermatologists

BACKGROUND

Rising healthcare expenditures places the potential for substitution of hospital care towards primary care high on the political agenda. As low-risk basal cell carcinoma (BCC) care is one of the potential targets for substitution of hospital care towards primary care the objective of this study is to gain insight in the views of healthcare professionals regarding substitution of skin cancer care, and to identify perceived barriers and potential strategies to facilitate substitution.

METHODS

A qualitative study was conducted consisting of 40 interviews with dermatologists and GPs and three focus groups with 18 selected GPs with noted willingness regarding substitution of skin cancer care. The interviews and focus groups focused on general views, perceived barriers and potential strategies to facilitate substitution of skin cancer care, using predefined topic lists. All sessions were audio-taped, transcribed verbatim and analyzed using the program AtlasTi.

RESULTS

GPs were generally positive regarding substitution of skin care whereas dermatologists expressed more concerns. Lack of trust in GPs to adequately perform skin cancer care and a preference of patients for dermatologists are reported as barriers by dermatologists. The main barriers reported by GPs were a lack of confidence in own skills to perform skin cancer care, a lack of trust from both patients and dermatologists and limited time and financial compensation. Facilitating strategies suggested by both groups mainly focused on improving GPs' education and improving the collaboration between primary and secondary care. GPs additionally suggested efforts from dermatologists to increase their own and patients' trust in GPs, and time and financial compensation. The selected group of GPs suggested practical solutions to facilitate substitution focusing on changes in organizational structure including horizontal referring, outreach models and practice size reduction.

CONCLUSIONS

GPs and, to lesser extent, dermatologists are positive regarding substitution of low-risk BCC care, though report substantial barriers that need to be addressed before substitution can be further implemented. Aside from essential strategies such as improving GPs' skin cancer education and time and financial compensation, rearranging the organizational structure in primary care and between primary and secondary care may facilitate effective and safe substitution of low-risk BCC care.

Visual inspection for diagnosing cutaneous melanoma in adults

BACKGROUND

Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. History-taking and visual inspection of a suspicious lesion by a clinician is usually the first in a series of 'tests' to diagnose skin cancer. Establishing the accuracy of visual inspection alone is critical to understating the potential contribution of additional tests to assist in the diagnosis of melanoma.

OBJECTIVES

To determine the diagnostic accuracy of visual inspection for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults with limited prior testing and in those referred for further evaluation of a suspicious lesion. Studies were separated according to whether the diagnosis was recorded face-to-face (in-person) or based on remote (image-based) assessment.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: CENTRAL; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Test accuracy studies of any design that evaluated visual inspection in adults with lesions suspicious for melanoma, compared with a reference standard of either histological confirmation or clinical follow-up. We excluded studies reporting data for 'clinical diagnosis' where dermoscopy may or may not have been used.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated summary sensitivities and specificities per algorithm and threshold using the bivariate hierarchical model. We investigated the impact of: in-person test interpretation; use of a purposely developed algorithm to assist diagnosis; and observer expertise.

MAIN RESULTS

We included 49 publications reporting on a total of 51 study cohorts with 34,351 lesions (including 2499 cases), providing 134 datasets for visual inspection. Across almost all study quality domains, the majority of study reports provided insufficient information to allow us to judge the risk of bias, while in three of four domains that we assessed we scored concerns regarding applicability of study findings as 'high'. Selective participant recruitment, lack of detail regarding the threshold for deciding on a positive test result, and lack of detail on observer expertise were particularly problematic.Attempts to analyse studies by degree of prior testing were hampered by a lack of relevant information and by the restricted inclusion of lesions selected for biopsy or excision. Accuracy was generally much higher for in-person diagnosis compared to image-based evaluations (relative diagnostic odds ratio of 8.54, 95% CI 2.89 to 25.3, P < 0.001). Meta-analysis of in-person evaluations that could be clearly placed on the clinical pathway showed a general trade-off between sensitivity and specificity, with the highest sensitivity (92.4%, 95% CI 26.2% to 99.8%) and lowest specificity (79.7%, 95% CI 73.7% to 84.7%) observed in participants with limited prior testing (n = 3 datasets). Summary sensitivities were lower for those referred for specialist assessment but with much higher specificities (e.g. sensitivity 76.7%, 95% CI 61.7% to 87.1%) and specificity 95.7%, 95% CI 89.7% to 98.3%) for lesions selected for excision, n = 8 datasets). These differences may be related to differences in the spectrum of included lesions, differences in the definition of a positive test result, or to variations in observer expertise. We did not find clear evidence that accuracy is improved by the use of any algorithm to assist diagnosis in all settings. Attempts to examine the effect of observer expertise in melanoma diagnosis were hindered due to poor reporting.

AUTHORS' CONCLUSIONS

Visual inspection is a fundamental component of the assessment of a suspicious skin lesion; however, the evidence suggests that melanomas will be missed if visual inspection is used on its own. The evidence to support its accuracy in the range of settings in which it is used is flawed and very poorly reported. Although published algorithms do not appear to improve accuracy, there is insufficient evidence to suggest that the 'no algorithm' approach should be preferred in all settings. Despite the volume of research evaluating visual inspection, further prospective evaluation of the potential added value of using established algorithms according to the prior testing or diagnostic difficulty of lesions may be warranted.

Visual inspection and dermoscopy, alone or in combination, for diagnosing keratinocyte skin cancers in adults

BACKGROUND

Early accurate detection of all skin cancer types is important to guide appropriate management, to reduce morbidity and to improve survival. Basal cell carcinoma (BCC) is almost always a localised skin cancer with potential to infiltrate and damage surrounding tissue, whereas a minority of cutaneous squamous cell carcinomas (cSCCs) and invasive melanomas are higher-risk skin cancers with the potential to metastasise and cause death. Dermoscopy has become an important tool to assist specialist clinicians in the diagnosis of melanoma, and is increasingly used in primary-care settings. Dermoscopy is a precision-built handheld illuminated magnifier that allows more detailed examination of the skin down to the level of the superficial dermis. Establishing the value of dermoscopy over and above visual inspection for the diagnosis of BCC or cSCC in primary- and secondary-care settings is critical to understanding its potential contribution to appropriate skin cancer triage, including referral of higher-risk cancers to secondary care, the identification of low-risk skin cancers that might be treated in primary care and to provide reassurance to those with benign skin lesions who can be safely discharged.

OBJECTIVES

To determine the diagnostic accuracy of visual inspection and dermoscopy, alone or in combination, for the detection of (a) BCC and (b) cSCC, in adults. We separated studies according to whether the diagnosis was recorded face-to-face (in person) or based on remote (image-based) assessment.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Studies of any design that evaluated visual inspection or dermoscopy or both in adults with lesions suspicious for skin cancer, compared with a reference standard of either histological confirmation or clinical follow-up.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic thresholds were missing. We estimated accuracy using hierarchical summary ROC methods. We undertook analysis of studies allowing direct comparison between tests. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely-developed algorithm to assist diagnosis; and observer expertise.

MAIN RESULTS

We included 24 publications reporting on 24 study cohorts, providing 27 visual inspection datasets (8805 lesions; 2579 malignancies) and 33 dermoscopy datasets (6855 lesions; 1444 malignancies). The risk of bias was mainly low for the index test (for dermoscopy evaluations) and reference standard domains, particularly for in-person evaluations, and high or unclear for participant selection, application of the index test for visual inspection and for participant flow and timing. We scored concerns about the applicability of study findings as of 'high' or 'unclear' concern for almost all studies across all domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic.The detection of BCC was reported in 28 datasets; 15 on an in-person basis and 13 image-based. Analysis of studies by prior testing of participants and according to observer expertise was not possible due to lack of data. Studies were primarily conducted in participants referred for specialist assessment of lesions with available histological classification. We found no clear differences in accuracy between dermoscopy studies undertaken in person and those which evaluated images. The lack of effect observed may be due to other sources of heterogeneity, including variations in the types of skin lesion studied, in dermatoscopes used, or in the use of algorithms and varying thresholds for deciding on a positive test result.Meta-analysis found in-person evaluations of dermoscopy (7 evaluations; 4683 lesions and 363 BCCs) to be more accurate than visual inspection alone for the detection of BCC (8 evaluations; 7017 lesions and 1586 BCCs), with a relative diagnostic odds ratio (RDOR) of 8.2 (95% confidence interval (CI) 3.5 to 19.3; P < 0.001). This corresponds to predicted differences in sensitivity of 14% (93% versus 79%) at a fixed specificity of 80% and predicted differences in specificity of 22% (99% versus 77%) at a fixed sensitivity of 80%. We observed very similar results for the image-based evaluations.When applied to a hypothetical population of 1000 lesions, of which 170 are BCC (based on median BCC prevalence across studies), an increased sensitivity of 14% from dermoscopy would lead to 24 fewer BCCs missed, assuming 166 false positive results from both tests. A 22% increase in specificity from dermoscopy with sensitivity fixed at 80% would result in 183 fewer unnecessary excisions, assuming 34 BCCs missed for both tests. There was not enough evidence to assess the use of algorithms or structured checklists for either visual inspection or dermoscopy.Insufficient data were available to draw conclusions on the accuracy of either test for the detection of cSCCs.

AUTHORS' CONCLUSIONS

Dermoscopy may be a valuable tool for the diagnosis of BCC as an adjunct to visual inspection of a suspicious skin lesion following a thorough history-taking including assessment of risk factors for keratinocyte cancer. The evidence primarily comes from secondary-care (referred) populations and populations with pigmented lesions or mixed lesion types. There is no clear evidence supporting the use of currently-available formal algorithms to assist dermoscopy diagnosis.

Dermoscopy, with and without visual inspection, for diagnosing melanoma in adults

BACKGROUND

Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Although history-taking and visual inspection of a suspicious lesion by a clinician are usually the first in a series of 'tests' to diagnose skin cancer, dermoscopy has become an important tool to assist diagnosis by specialist clinicians and is increasingly used in primary care settings. Dermoscopy is a magnification technique using visible light that allows more detailed examination of the skin compared to examination by the naked eye alone. Establishing the additive value of dermoscopy over and above visual inspection alone across a range of observers and settings is critical to understanding its contribution for the diagnosis of melanoma and to future understanding of the potential role of the growing number of other high-resolution image analysis techniques.

OBJECTIVES

To determine the diagnostic accuracy of dermoscopy alone, or when added to visual inspection of a skin lesion, for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults. We separated studies according to whether the diagnosis was recorded face-to-face (in-person), or based on remote (image-based), assessment.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: CENTRAL; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Studies of any design that evaluated dermoscopy in adults with lesions suspicious for melanoma, compared with a reference standard of either histological confirmation or clinical follow-up. Data on the accuracy of visual inspection, to allow comparisons of tests, was included only if reported in the included studies of dermoscopy.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated accuracy using hierarchical summary receiver operating characteristic (SROC),methods. Analysis of studies allowing direct comparison between tests was undertaken. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely developed algorithm to assist diagnosis; observer expertise; and dermoscopy training.

MAIN RESULTS

We included a total of 104 study publications reporting on 103 study cohorts with 42,788 lesions (including 5700 cases), providing 354 datasets for dermoscopy. The risk of bias was mainly low for the index test and reference standard domains and mainly high or unclear for participant selection and participant flow. Concerns regarding the applicability of study findings were largely scored as 'high' concern in three of four domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic.The accuracy of dermoscopy for the detection of invasive melanoma or atypical intraepidermal melanocytic variants was reported in 86 datasets; 26 for evaluations conducted in person (dermoscopy added to visual inspection), and 60 for image-based evaluations (diagnosis based on interpretation of dermoscopic images). Analyses of studies by prior testing revealed no obvious effect on accuracy; analyses were hampered by the lack of studies in primary care, lack of relevant information and the restricted inclusion of lesions selected for biopsy or excision. Accuracy was higher for in-person diagnosis compared to image-based evaluations (relative diagnostic odds ratio (RDOR) 4.6, 95% confidence interval (CI) 2.4 to 9.0; P < 0.001).We compared accuracy for (a), in-person evaluations of dermoscopy (26 evaluations; 23,169 lesions and 1664 melanomas),versus visual inspection alone (13 evaluations; 6740 lesions and 459 melanomas), and for (b), image-based evaluations of dermoscopy (60 evaluations; 13,475 lesions and 2851 melanomas),versus image-based visual inspection (11 evaluations; 1740 lesions and 305 melanomas). For both comparisons, meta-analysis found dermoscopy to be more accurate than visual inspection alone, with RDORs of (a), 4.7 (95% CI 3.0 to 7.5; P < 0.001), and (b), 5.6 (95% CI 3.7 to 8.5; P < 0.001). For a), the predicted difference in sensitivity at a fixed specificity of 80% was 16% (95% CI 8% to 23%; 92% for dermoscopy + visual inspection versus 76% for visual inspection), and predicted difference in specificity at a fixed sensitivity of 80% was 20% (95% CI 7% to 33%; 95% for dermoscopy + visual inspection versus 75% for visual inspection). For b) the predicted differences in sensitivity was 34% (95% CI 24% to 46%; 81% for dermoscopy versus 47% for visual inspection), at a fixed specificity of 80%, and predicted difference in specificity was 40% (95% CI 27% to 57%; 82% for dermoscopy versus 42% for visual inspection), at a fixed sensitivity of 80%.Using the median prevalence of disease in each set of studies ((a), 12% for in-person and (b), 24% for image-based), for a hypothetical population of 1000 lesions, an increase in sensitivity of (a), 16% (in-person), and (b), 34% (image-based), from using dermoscopy at a fixed specificity of 80% equates to a reduction in the number of melanomas missed of (a), 19 and (b), 81 with (a), 176 and (b), 152 false positive results. An increase in specificity of (a), 20% (in-person), and (b), 40% (image-based), at a fixed sensitivity of 80% equates to a reduction in the number of unnecessary excisions from using dermoscopy of (a), 176 and (b), 304 with (a), 24 and (b), 48 melanomas missed.The use of a named or published algorithm to assist dermoscopy interpretation (as opposed to no reported algorithm or reported use of pattern analysis), had no significant impact on accuracy either for in-person (RDOR 1.4, 95% CI 0.34 to 5.6; P = 0.17), or image-based (RDOR 1.4, 95% CI 0.60 to 3.3; P = 0.22), evaluations. This result was supported by subgroup analysis according to algorithm used. We observed higher accuracy for observers reported as having high experience and for those classed as 'expert consultants' in comparison to those considered to have less experience in dermoscopy, particularly for image-based evaluations. Evidence for the effect of dermoscopy training on test accuracy was very limited but suggested associated improvements in sensitivity.

AUTHORS' CONCLUSIONS

Despite the observed limitations in the evidence base, dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants, particularly in referred populations and in the hands of experienced users. Data to support its use in primary care are limited, however, it may assist in triaging suspicious lesions for urgent referral when employed by suitably trained clinicians. Formal algorithms may be of most use for dermoscopy training purposes and for less expert observers, however reliable data comparing approaches using dermoscopy in person are lacking.

General practice registrars' clinical exposure to dermatological procedures during general practice training: a cross-sectional analysis

Australian general practitioners (GPs) commonly manage dermatological conditions requiring procedures. GP registrars have limited pre-vocational training exposure to dermatology and find skin problems challenging. We aimed to establish the prevalence, nature and associations of GP registrars' performance of skin procedures. We conducted a cross-sectional analysis from the Registrar Clinical Encounters in Training cohort study. Multivariable logistic regression was used to establish associations of our outcome (skin procedures, both including and excluding cryotherapy). Independent variables included patient and doctor demographics, diagnoses/problems managed and registrars' recourse to in-consultation assistance/information. A total of 1161 registrars provided data on 166,988 consultations, recording 2927 skin procedures (16.7% of all procedures; performed in 1.7% of consultations). Cryotherapy, excision, punch biopsy and shave biopsy were most common. More complex procedures were performed infrequently. Significant associations of performing procedures included rural/remote location (compared to major city), male patients, patient age 65+ (compared to age 15-34) and registrars seeking in-consultation information/assistance. Skin procedures were less likely for Aboriginal patients or those from non-English-speaking backgrounds. For non-cryotherapy procedures, rurality was not significantly associated, but significant differences were found between training regions. In summary, GP registrars perform fewer dermatological procedures compared to established GPs. Findings will inform GP vocational training in skin procedures.

Knowledge, attitudes and skills in melanoma diagnosis among doctors: a cross sectional study from Sri Lanka

OBJECTIVES

This study aimed to assess the knowledge, attitudes and skills of non-specialist doctors on timely referral of suspicious lesions for melanoma diagnosis.

RESULTS

One hundred and twenty-three doctors (mean age; 30.4 years, SD ± 8.015) were enrolled. Very few (3.3%) correctly stated all four types of melanoma. Only 8.1% of the total sample had been trained to perform a total body examination for skin cancer detection and a majority (110/123) had never performed one. Almost all (95.2%) were not confident in using a dermatoscope for examination of a skin lesion. Only 17.9% of participants had discussed skin cancer/melanoma risk reduction with patients. Only 13.8% had educated at least one patient regarding skin self-examination for suspicious skin lesions. Knowledge and clinical skills regarding melanoma recognition was unsatisfactory in our sample. Urgent attention is needed to bridge the gap in knowledge and clinical skills on this topic.

Estimated Healthcare Costs of Melanoma in Australia Over 3 Years Post-Diagnosis

BACKGROUND

Skin cancer exerts a large and growing burden on health systems. With new pharmacotherapies for metastatic melanoma now available, a contemporary understanding of the cost burden of melanoma control is warranted.

OBJECTIVE

To comprehensively assess the healthcare costs of malignant melanoma diagnosis and treatment in Australia, over 3 years after diagnosis.

METHODS

We developed a decision-analytic model and micro-costing method to estimate the mean cost per patient for melanoma, incorporating all diagnostic and treatment modalities used in Australia (2017 AU$). By using the de-identified 10% sample of Medicare Benefits Scheme, we analysed health service use and supplemented our analyses with published estimates. We took a health system cost perspective, and addressed input uncertainty with sensitivity analyses.

RESULTS

The mean annual cost per patient for melanoma stage 0/I/II was AU$1681 (US$1175) rising to AU$37,729 (US$26,365) for stage III resectable, and AU$115,109 (US$80,440) for stage III unresectable/IV. Three-year costs for stage III unresectable/IV were AU$187,720. Nationally, the annual estimated cost for treatment of all new cases of in situ and invasive melanomas was AU$201 million (95% CI: AU$187 to AU$216 million). When we included treatments for presumptive melanoma later found to be benign lesions, the estimated annual cost burden reached AU$272 million.

CONCLUSION

With rapidly rising treatment costs, there is a need to consider a comprehensive melanoma control strategy that includes primary prevention of skin cancers and cost-effective sun protection initiatives.

A Systematic Review of Training to Improve Melanoma Diagnostic Skills in General Practitioners

Australia has the highest incidence of melanoma in the world. General practitioners encounter melanoma in 9.9 per 10,000 clinical encounters and play a key role in diagnosis. A systematic review was conducted to study the efficacy of training methods to improve general practitioners' diagnostic skills in melanoma. Article abstracts (1307) were screened, from a Medline search. Four trials met our criteria and were highly variable in their intervention methods and outcome measures. The Cochrane risk of bias tool was used to assess study quality with only one good, one poor, and two of questionable quality. Our results showed limited evidence via one study that training of general practitioners in surface microscopy improved melanoma diagnosis, from a clinical (naked eye) pre-intervention score of 54.6 % to a post-intervention surface microscopy score of 75.9 % in 74 general practitioners. Future work should explore the barriers to implementing this strategy in clinical practice.

Doctors' recognition and management of melanoma patients' risk: An Australian population-based study

BACKGROUND

Guidelines recommend that health professionals identify and manage individuals at high risk of developing melanoma, but there is limited population-based evidence demonstrating real-world practices.

OBJECTIVE

A population-based, observational study was conducted in the state of New South Wales, Australia to determine doctors' knowledge of melanoma patients' risk and to identify factors associated with better identification and clinical management.

METHODS

Data were analysed for 1889 patients with invasive, localised melanoma in the Melanoma Patterns of Care study. This study collected data on all melanoma diagnoses notified to the state's cancer registry during a 12-month period from 2006 to 2007, as well as questionnaire data from the doctors involved in their care.

RESULTS

Three-quarters (74%) of patients had doctors who were aware of their risk factor status with respect to personal and family history of melanoma and the presence of many moles. Doctors working in general practice, skin cancer clinics and dermatology settings had better knowledge of patients' risk factors than plastic surgeons. Doctors were 15% more likely to know the family history of younger melanoma patients (<40years) than of those ≥80 years (95% confidence interval 4-26%). Early detection-related follow-up advice was more likely to be given to younger patients, by doctors aware of their patients' risk status, by doctors practising in plastic surgery, dermatology and skin cancer clinic settings, and by female doctors.

CONCLUSION

Both patient-related and doctor-related factors were associated with doctors' recognition and management of melanoma patients' risk and could be the focus of strategies for improving care.

A Fast-Track Referral System for Skin Lesions Suspicious of Melanoma: Population-Based Cross-Sectional Study from a Plastic Surgery Center

Introduction. To minimize delay between presentation, diagnosis, and treatment of cutaneous melanoma (CM), a national fast-track referral system (FTRS) was implemented in Denmark. The aim of this study was to analyze the referral patterns to our department of skin lesions suspicious of melanoma in the FTRS. Methods. Patients referred to the Department of Plastic Surgery and Breast Surgery in Zealand University Hospital were registered prospectively over a 1-year period in 2014. A cross-sectional study was performed analyzing referral patterns, including patient and tumor characteristics. Results. A total of 556 patients were registered as referred to the center in the FTRS for skin lesions suspicious of melanoma. Among these, a total of 312 patients (56.1%) were diagnosed with CM. Additionally, 41 (7.4%) of the referred patients were diagnosed with in situ melanoma. Conclusion. In total, 353 (63.5%) patients had a malignant or premalignant melanocytic skin lesion. When only considering patients who where referred without a biopsy, the diagnostic accuracy for GPs and dermatologists was 29% and 45%, respectively. We suggest that efforts of adequate training for the referring physicians in diagnosing melanocytic skin lesions will increase diagnostic accuracy, leading to larger capacity in secondary care for the required treatment of malignant skin lesions.

Photoacoustic Imaging in Oncology: Translational Preclinical and Early Clinical Experience

Photoacoustic imaging has evolved into a clinically translatable platform with the potential to complement existing imaging techniques for the management of cancer, including detection, characterization, prognosis, and treatment monitoring. In photoacoustic imaging, tissue is optically excited to produce ultrasonographic images that represent a spatial map of optical absorption of endogenous constituents such as hemoglobin, fat, melanin, and water or exogenous contrast agents such as dyes and nanoparticles. It can therefore provide functional and molecular information that allows noninvasive soft-tissue characterization. Photoacoustic imaging has matured over the years and is currently being translated into the clinic with various clinical studies underway. In this review, the current state of photoacoustic imaging is presented, including techniques and instrumentation, followed by a discussion of potential clinical applications of this technique for the detection and management of cancer. (©) RSNA, 2016.

Assessment of clinical diagnostic accuracy compared with pathological diagnosis of basal cell carcinoma

Background:

Basal cell carcinoma (BCC) is the most common type of skin cancer, afflicting light skin more than dark skin people. This malignancy metastasizes rarely and has unique histological properties.

Aims and Objectives:

We focused on the accuracy of clinical diagnoses of BCC by specialists.

Materials and Methods:

Patients’ information for 4-year period between 2007 and 2011 was extracted from files at a Pathology Department. The results were analyzed using the Chi-square method and SPSS software.

Results:

From 367 referred cases dermatologists diagnosed 41% as direct BCC cases, 43.4% through excluding other skin diseases, 4% incorrectly and 1.11% unidentified. For other specialists (including plastic surgeons, ophthalmologists, general surgeons, and general practitioners) these were respectively 47.8%, 22.4%, 6.3% and 23.5%. Dermatologists had diagnosed 107 cases of all skin diseases as BCC through clinical examination of which 78.5% were correctly and 21.5% incorrectly diagnosed. The same parameters for all other specialists were respectively 77.36% and 22.64%. Diagnostic sensitivity, positive reportability, clinical conjecture indicator (CCI) and clinical diagnostic indicator were respectively 84.4%, 78.5%, 121.5% and 75.6%; whereas for other specialists these indicators were 70 among cases diagnosed by dermatologists as BCC, where pathological results showed other causes. The most common diagnosis by pathologists and other specialists was reported as squamous cell carcinoma (SCC). Among cases not diagnosed by dermatologists as BCC, where pathological results indicated BCC, the most common clinical diagnosis was malignant melanoma by dermatologists and SCC by other specialists.

Conclusion:

Dermatologists diagnosed BCC with higher sensitivity and positive reportability; also, CCIs and clinical diagnostic correctness was higher among dermatologists. The necessity for consulting with dermatologists and referring all skin diseases samplings to pathologist is thus clearly visible.

Basal cell carcinomas on sun-protected vs. sun-exposed body sites: a comparison of phenotypic and environmental risk factors

BACKGROUND

Basal cell carcinoma (BCC) is the most commonly diagnosed cancer in White populations. There are indications that risk factors for BCC may differ according to the anatomic site of the tumour but this is not well understood.

PURPOSE

To compare phenotypic and environmental risk factors for BCCs arising on sun-protected sites with that of those on sun-exposed sites.

METHODS

We conducted a case-case study in which people who had been diagnosed with incident BCC were recruited between February 2012 and September 2013 in Brisbane, Australia.

RESULTS

Fair skin (OR: 4.50; 95% CI: 1.22, 16.59), having more than 15 lesions frozen/burnt off compared to less than 5 (OR: 5.68; 95% CI: 1.78, 18.08) and severe acne (OR: 5.25; 95% CI: 1.34, 20.56) were associated with increased risk of BCC on sun-protected sites. The presence of more than 5 nevi on the body was associated with decreased risk (OR: 0.28; 95% CI: 0.11, 0.71).

CONCLUSIONS

BCCs on sun-protected sites arise as a result of excessive sun exposure, most likely combined with phenotypic susceptibility. The strong negative association with nevi also suggests that there are constitutional factors that underlie the propensity for BCCs to arise on these body sites.

A pilot trial of mobile, patient-performed teledermoscopy

BACKGROUND

Early detection by skin self-examination (SSE) could improve outcomes for melanoma. Mobile teledermoscopy may aid this process.

OBJECTIVES

To establish the clinical accuracy of SSE plus mobile teledermoscopy vs. clinical skin examination (CSE) and to test whether providing people with detailed SSE instructions improves accuracy.

METHODS

Men and women aged 50-64 years (n = 58) performed SSE plus mobile teledermoscopy in their homes between May and November 2013 and were given technical instructions plus detailed SSE instructions (intervention) or technical instructions only (control). Within 3 months, they underwent a CSE. Outcome measures included (i) body sites examined, lesions photographed, and missed; (ii) sensitivity of SSE plus mobile teledermoscopy vs. in-person CSE using either patients or lesions as denominator; and (iii) concordance of telediagnosis with CSE.

RESULTS

Overall 49 of 58 randomized participants completed the study, and submitted 309 lesions to the teledermatologist. Intervention-group participants were more likely to submit lesions from their legs compared with controls (P = 0·03), with no other differences. Eleven participants (22%) did not photograph 14 pigmented lesions that the dermatologist considered worthwhile photographing or monitoring. The sensitivity of SSE plus mobile teledermoscopy was 82% using the patient as denominator and 42% using the lesion as denominator. There was substantial agreement between telediagnosis and CSE (κ = 0·90), accounting for differential diagnoses.

CONCLUSIONS

SSE plus mobile teledermoscopy is promising for surveillance of particular lesions even without detailed SSE instructions. However, in the format tested in this study, consumers may overlook lesions and send many nonpigmented lesions. This investigation demonstrates that high-quality dermoscopic images can be taken by patients at home with high accuracy.

Clinical performance of the Nevisense system in cutaneous melanoma detection: an international, multicentre, prospective and blinded clinical trial on efficacy and safety

BACKGROUND

Even though progress has been made, the detection of melanoma still poses a challenge. In light of this situation, the Nevisense electrical impedance spectroscopy (EIS) system (SciBase AB, Stockholm, Sweden) was designed and shown to have the potential to be used as an adjunct diagnostic tool for melanoma detection.

OBJECTIVES

To assess the effectiveness and safety of the Nevisense system in the distinction of benign lesions of the skin from melanoma with electrical impedance spectroscopy.

METHODS

This multicentre, prospective, and blinded clinical study was conducted at five American and 17 European investigational sites. All eligible skin lesions in the study were examined with the EIS-based Nevisense system, photographed, removed by excisional biopsy and subjected to histopathological evaluation. A postprocedure clinical follow-up was conducted at 7 ± 3 days from the initial measurement. A total of 1951 patients with 2416 lesions were enrolled into the study; 1943 lesions were eligible and evaluable for the primary efficacy end point, including 265 melanomas - 112 in situ and 153 invasive melanomas with a median Breslow thickness of 0·57 mm [48 basal cell carcinomas (BCCs) and seven squamous cell carcinomas (SCCs)].

RESULTS

The observed sensitivity of Nevisense was 96·6% (256 of 265 melanomas) with an exact one-sided 95% lower confidence bound estimated at 94·2% and an observed specificity of 34·4%, and an exact two-sided 95% confidence bound estimated at 32·0-36·9%. The positive and negative predictive values of Nevisense were 21·1% and 98·2%, respectively. The observed sensitivity for nonmelanoma skin cancer was 100% (55 of 48 BCCs and seven SCCs) with an exact two-sided 95% confidence bound estimated at 93·5-100·0%.

CONCLUSIONS

Nevisense is an accurate and safe device to support clinicians in the detection of cutaneous melanoma.

Diagnostic accuracy of malignant melanoma according to subtype

BACKGROUND/OBJECTIVE

Although there has been improvement in clinical diagnosis of pigmented superficial spreading melanomas (SSM), less common melanoma subtypes have different clinical features and may be more difficult to diagnose. The objective was to assess diagnostic accuracy for different melanoma subtypes.

METHODS

A retrospective review was made of a random selection of SSM, nodular melanomas (NM), desmoplastic melanomas (DM) and acral lentiginous melanomas (ALM) biopsied between February 2001 and May 2012 and referred to the Victorian Melanoma Service. Clinical differential diagnoses listed on pre-operative biopsy pathology request forms were recorded. Sensitivity for the diagnosis of melanoma was used as a marker of diagnostic accuracy.

RESULTS

In total 111 SSM, 121 NM, 43 DM and 30 ALM were biopsied by 222 clinicians. Whereas diagnostic sensitivity for SSM and ALM were similar (77%, 95% CI 69-85% and 73%, 95% CI 58-89%, respectively) diagnostic sensitivity was lower for NM (41%, 95% CI 33-50%) and DM (21%, 95% CI 9-33%). Both NM and DM were diagnosed at greater tumour thickness (median 3.0 mm and 4.0 mm) than SSM and ALM (both median 1.0 mm). Amelanosis was associated with lower diagnostic sensitivity for SSM (0 vs 82%, P < 0.01), NM (19 vs 51%, P < 0.01) andDM (10 vs 32%, P = 0.07). Dermatologists were more accurate than non-dermatologists for NM (diagnostic sensitivity 57 vs 32%, P < 0.01) and ALM (diagnostic sensitivity 94 vs 43%, P = 0.02).

CONCLUSIONS

Misdiagnosis of melanoma varies according to subtype and is particularly problematic for NM, DM and hypopigmented melanomas. Greater awareness of the different criteria required to diagnose these melanomas is needed.

Redefining the number needed to excise

The number needed to excise (NNE) is a metric used to convey the efficiency of dermatological practice by serving as a gauge for the diagnostic accuracy of melanoma. Rather than an NNE for melanoma alone, we assert that the NNE should measure all skin cancer types and we present data on NNE from two clinical sites demonstrating the utility and trends in NNE over time.

Effect of adding a diagnostic aid to best practice to manage suspicious pigmented lesions in primary care: randomised controlled trial

OBJECTIVES

To assess whether adding a novel computerised diagnostic tool, the MoleMate system (SIAscopy with primary care scoring algorithm), to current best practice results in more appropriate referrals of suspicious pigmented lesions to secondary care, and to assess its impact on clinicians and patients.

DESIGN

Randomised controlled trial.

SETTING

15 general practices in eastern England.

PARTICIPANTS

1297 adults with pigmented skin lesions not immediately diagnosed as benign.

INTERVENTIONS

Patients were assessed by trained primary care clinicians using best practice (clinical history, naked eye examination, seven point checklist) either alone (control group) or with the MoleMate system (intervention group).

MAIN OUTCOME MEASURES

Appropriateness of referral, defined as the proportion of referred lesions that were biopsied or monitored. Secondary outcomes related to the clinicians (diagnostic performance, confidence, learning effects) and patients (satisfaction, anxiety). Economic evaluation, diagnostic performance of the seven point checklist, and five year follow-up of melanoma incidence were also secondary outcomes and will be reported later.

RESULTS

1297 participants with 1580 lesions were randomised: 643 participants with 788 lesions to the intervention group and 654 participants with 792 lesions to the control group. The appropriateness of referral did not differ significantly between the intervention or control groups: 56.8% (130/229) v 64.5% (111/172); difference -8.1% (95% confidence interval -18.0% to 1.8%). The proportion of benign lesions appropriately managed in primary care did not differ (intervention 99.6% v control 99.2%, P=0.46), neither did the percentage agreement with an expert decision to biopsy or monitor (intervention 98.5% v control 95.7%, P=0.26). The percentage agreement with expert assessment that the lesion was benign was significantly lower with MoleMate (intervention 84.4% v control 90.6%, P<0.001), and a higher proportion of lesions were referred (intervention 29.8% v control 22.4%, P=0.001). Thirty six histologically confirmed melanomas were diagnosed: 18/18 were appropriately referred in the intervention group and 17/18 in the control group. Clinicians in both groups were confident, and there was no evidence of learning effects, and therefore contamination, between groups. Patients in the intervention group ranked their consultations higher for thoroughness and reassuring care, although anxiety scores were similar between the groups.

CONCLUSIONS

We found no evidence that the MoleMate system improved appropriateness of referral. The systematic application of best practice guidelines alone was more accurate than the MoleMate system, and both performed better than reports of current practice. Therefore the systematic application of best practice guidelines (including the seven point checklist) should be the paradigm for management of suspicious skin lesions in primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN79932379.

The impact of subspecialization and dermatoscopy use on accuracy of melanoma diagnosis among primary care doctors in Australia

BACKGROUND

Dermatoscopy improves accuracy of melanoma diagnosis, but the impact of subspecialization in skin cancer practice among general practitioners on melanoma diagnostic accuracy is not known.

OBJECTIVE

To assess the impact of dermatoscopy use and subspecialization on the accuracy of melanoma diagnosis by general practitioners.

METHODS

We did a prospective study on the Skin Cancer Audit Research Database and measured melanoma 'number needed to treat' (NNT), with 21,900 lesions excised to diagnose 2367 melanomas.

RESULTS

Melanoma NNT fell from a high of 17.0 (95% confidence interval [CI] 14.5-20.7) among general practitioners with a generalist practice to 9.4 (CI 8.9-10.1) among those with a specific interest in skin cancer, and 8.5 (CI 8.1-9.0) among those practicing only skin cancer medicine (P < .0001). Melanoma NNT fell from a high of 14.6 (CI 12.0-18.6) among dermatoscopy low/non-users to 10.9 (CI 9.8-12.4) among medium users, and 8.9 (CI 8.6-9.3) among high users (P < .0001). The association between NNT and practice type remained (P < .0001) when adjusted for dermatoscopy use and other variables. The association between NNT and dermatoscopy use disappeared (P = .41) when adjusted for practice type and other variables.

LIMITATIONS

There is selection bias with respect to participating doctors and completeness and accuracy of data are not independently verified in the Skin Cancer Audit Research Database (SCARD).

CONCLUSIONS

General practitioners who subspecialize in skin cancer have a higher use of dermatoscopy and diagnose melanoma with greater accuracy than their generalist counterparts.

Minor surgery activity in primary care

OBJECTIVE

The aim of this study was to describe the activity in our Outpatient Minor Surgery unit during its first five-year period.

DESIGN

Retrospective descriptive study.

METHODS

It was carried out in two centres of a Basic Health Area with a catchment area of 73,000 inhabitants.

PARTICIPANTS

Patients who underwent surgery from January 2002 to December 2007 were included in the research.

MAIN OUTCOME MEASURES

Information on the sociodemographic data of the patients, characteristics of the lesions, risk factors, treatment and its complications was gathered.

RESULTS

A total of 2317 surgical procedures was performed on 1520 patients. The mean was 46 years old and 52% were men. The concordance between clinical and anatomopathological diagnosis was 81%. There were complications in 5% of them. The main pathologies were: epidermoid cysts (22%), nevus (20%) and fibromas (18%). They were mainly located in the back (24%), superior extremities (14%) and head (11%). In 73% mepivicaine was used as anaesthetic. The most current techniques used were: incision (36%), curettage (33%) and fusiform excision (28%). Less than 1% had malignant lesions, 50% of which were not diagnosed clinically. The mean waiting time was 30 days. Ninety-two percent had the informed consent.

CONCLUSIONS

Minor surgery in primary care is feasible and has a good clinicopathological concordance and minimum complications, but some malignant lesions are overlooked in the diagnosis based exclusively on clinical criteria.

2-Week wait referrals in suspected skin cancer: does an instructional module for general practitioners improve diagnostic accuracy?

The two-week wait (2WW) scheme in the United Kingdom for suspected skin cancer has been criticised for having low pick up rates, with a high proportion of clinically benign lesions being referred as suspicious. We studied the referral patterns of skin cancer to our hospital under the 2WW initiative, and aimed to quantify the effect of a targeted continuing medical education (CME) module on improving diagnostic accuracy. All referrals to our hospital (dermatology and plastic surgery) under the 2WW rule were audited between July and September 2006. A targeted CME module was sent to GPs describing and illustrating common lesions. After 11 months, all 2WW referrals were prospectively studied between August and October 2007. The main outcome measure was the percentage of correctly referred squamous cell carcinomas (SCCs) and melanomas. 237 referrals were made between July and August 2006, and 223 referrals between August and October 2007. The proportion of appropriately referred skin cancers (SCCs and melanomas) was 23.2% before CME, and 20.6% after CME. There were no differences in pick up rates before and after the CME amongst suspected SCCs (21.1% vs. 29.7%) or melanomas (24.6% vs. 15.1% respectively). Referrals to Plastic Surgery were more likely to be confirmed histologically as melanomas or SCCs (23.6% and 33.7% respectively) than those made to Dermatology (17.5% and 15.3% respectively). The proportion of correctly suspected skin malignancies under the 2WW initiative remains low despite education. A targeted CME module sent to GPs fails to improve pick up rates. There is a need for continuing dermatology training amongst referring physicians.

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Surgical excision of skin cancer: the importance of training

Background Skin cancers are the most common malignancy in New Zealand and their treatment imparts a huge burden on the healthcare system both in terms of the cost of surgical intervention and in treatment delivery (estimates are in excess of NZ$33 million per annum for the year 2000). Currently in New Zealand, skin cancers are excised by dermatologists, general practitioners (GPs), GPs with a special interest in skin surgery (GPSIs) and specialist surgeons with diverse training backgrounds including ear, nose and throat, ophthalmic and general surgeons. To date there is scant literature evaluating complete excision rates following surgical treatment of skin cancer between these vocational groups. Objectives To review retrospectively pathology reports from all skin excisions sent to one private pathology laboratory over three consecutive months. The aim was to investigate the margins of excision and completeness of skin cancer surgery performed by each vocational group. Methods A retrospective analysis of skin pathology reports was undertaken for a 3-month period between April and June 2007. Raw data obtained from the pathology reports included diagnosis, completeness of excision, size of specimens, body site and vocational group of the medical practitioner performing the surgery. Results In total, 1532 lesions were excised: 432 benign and 1100 malignant. Six hundred and seven were from the head and neck. Dermatologists excised 276 lesions of which 93% were malignant, 55% were from the head and neck, and 0% were incompletely excised. GPs excised 633 lesions: 63% malignant, 30% head and neck, 23% incomplete excision of malignant lesions. GPSIs excised 368 lesions: 71% malignant, 35% head and neck, 21.5% incomplete malignant excision. Specialist surgeons excised 255 lesions: 72% malignant, 53% head and neck, 20% incomplete malignant excision. Conclusion GPs and GPSIs excised more benign lesions and had higher incomplete excision rates of skin cancer surgery than dermatologists. Incomplete excision rates for the vocational groups ranged from 0% to 45% depending on site and pathology.