Factors related to non-attendance in a population based melanoma screening program

A systematic review and synthesis of qualitative and quantitative studies evaluating provider, patient, and health care system-related barriers to diagnostic skin cancer examinations

Melanoma-screening examinations support early diagnosis, yet there is a national shortage of dermatologists and most at-risk patients lack access to dermatologic care. Primary care physicians (PCPs) in the United States often bridge these access gaps, and thus, play a critical role in the early detection of melanoma. However, most PCPs do not offer skin examinations. We conducted a systematic review and searched Ovid MEDLINE, EMBASE, and the Cochrane Library from 1946 to July 2019 to identify barriers for skin screening by providers, patients, and health systems following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Of 650 abstracts initially identified, 111 publications were included for full-text review and 48 studies met the inclusion criteria. Lack of dermatologic training (89.4%), time constraints (70%), and competing comorbidities (51%) are the most common barriers reported by PCPs. Low perceived risk (69%), long delays in appointment (46%), and lack of knowledge about melanoma (34.8%) are most frequently reported patient barriers. Qualitative reported barriers for health system are lack of public awareness, social prejudice leading to tanning booth usage, public surveillance programs requiring intensive resources, and widespread ABCD evaluation causing delays in seeking medical attention for melanomas. Numerous barriers remain that prevent the implementation of skin screening practices in clinical practice. A multi-faceted combination of efforts is essential for the execution of acceptable and effective skin cancer-screening practices, thus, increasing early diagnosis and lowering mortality rates and burden of disease for melanoma.

Canadian Burden of Skin Disease From 1990 to 2017: Results From the Global Burden of Disease 2017 Study [Formula: see text]

Background

Skin diseases can have high morbidity that can be costly to society and individuals. To date, there has been no comprehensive assessment of the burden of skin disease in Canada.

Objectives

To evaluate the burden of 18 skin and subcutaneous diseases from 1990 to 2017 in Canada using the Global Burden of Disease (GBD) data.

Methods

The 2017 GBD study measures health loss from 359 diseases and injuries in 195 countries; we evaluated trends in population health in Canada from 1990 to 2017 using incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs). Data are presented as rates (per 100 000), counts, or percent change with the uncertainty interval in brackets.

Results

From 1990 to 2017 for all skin diseases, DALY rates increased by 8% to 971 per 100 000 (674-1319), YLD rates increased by 8% to 897 per 100 000 (616-1235), YLL rates increased by 4% to 74 per 100 000 (53-89), and death rates increased by 18% to 5 per 100 000 (3-6). DALY rates for melanoma increased by 2% to 54 per 100 000 (39-68), for keratinocyte carcinoma by 14% to 17 per 100 000 (16-19), and for skin and subcutaneous disease by 8% to 900 per 100 000 (619-1233). The observed over expected ratios were higher for skin and subcutaneous disease (1.37) and keratinocyte carcinoma (1.17) and were lower for melanoma (0.73).

Conclusions

The burden of skin disease has increased in Canada since 1990. These results can be used to guide health policy regarding skin disease in Canada.

Coping styles in decision-making among men and women diagnosed with malignant melanoma

Early care seeking is important for prognosis of malignant melanoma. Coping styles in decision-making to seek care can relate to prognosis since avoidant strategies could delay care seeking. The aim of this study was to compare self-reported coping styles in decision-making between men and women diagnosed with malignant melanoma. We used the Swedish version of the Melbourne Decision-Making Questionnaire to assess coping styles. Men generally scored higher in buck-passing while women and those living without a partner scored higher in hypervigilance. This knowledge could be used in the development of preventive programmes with intention to reach those who delay care seeking.

Skin examination behavior: the role of melanoma history, skin type, psychosocial factors, and region of residence in determining clinical and self-conducted skin examination

OBJECTIVE

To examine the frequency and correlates of skin examination behaviors in an international sample of individuals at varying risk of developing melanoma.

DESIGN

A cross-sectional, web-based survey.

SETTING

Data were collected from the general population over a 20-month period on behalf of the Melanoma Genetics Consortium (GenoMEL).

PARTICIPANTS

A total of 8178 adults from Northern (32%), Central (33%), and Southern (14%) Europe, Australia (13%), and the United States (8%).

MAIN OUTCOME MEASURES

Self-reported frequency of skin self-examination (SSE) and clinical skin examination (CSE).

RESULTS

After adjustment for age and sex, frequency of skin examination was higher in both Australia (odds ratio [OR]SSE=1.80 [99% CI, 1.49-2.18]; ORCSE=2.68 [99% CI, 2.23-3.23]) and the United States (ORSSE=2.28 [99% CI, 1.76-2.94]; ORCSE=3.39 [99% CI, 2.60-4.18]) than in the 3 European regions combined. Within Europe, participants from Southern Europe reported higher rates of SSE than those in Northern Europe (ORSSE=1.61 [99% CI, 1.31-1.97]), and frequency of CSE was higher in both Central (ORCSE=1.47 [99% CI, 1.22-1.78]) and Southern Europe (ORCSE=3.46 [99% CI, 2.78, 4.31]) than in Northern Europe. Skin examination behavior also varied according to melanoma history: participants with no history of melanoma reported the lowest levels of skin examination, while participants with a previous melanoma diagnosis reported the highest levels. After adjustment for region, and taking into account the role of age, sex, skin type, and mole count, engagement in SSE and CSE was associated with a range of psychosocial factors, including perceived risk of developing melanoma; perceived benefits of, and barriers to, skin examination; perceived confidence in one's ability to engage in screening; and social norms. In addition, among those with no history of melanoma, higher cancer-related worry was associated with greater frequency of SSE.

CONCLUSIONS

Given the strong association between psychosocial factors and skin examination behaviors, particularly among people with no history of melanoma, we recommend that greater attempts be made to integrate psycho-education into the fabric of public health initiatives and clinical care, with clinicians, researchers, and advocacy groups playing a key role in guiding individuals to appropriate tools and resources.

Malignant melanoma: gender patterns in care seeking for suspect marks

AIMS AND OBJECTIVES

Gender patterns in self-detection of melanoma are not sufficiently highlighted in the literature. The aim of the study was to identify specific patterns in the decision-making process to seek care for suspect melanoma, as narrated by women and men.

BACKGROUND

Females have a more favourable prognosis than males and also a higher level of perceived susceptibility and a higher level of knowledge about melanoma. Women are, furthermore, more prone to participate in screening.

METHOD

Thirty patients (15 women and 15 men) with a mean age of 55.5 years and diagnosed with malignant melanoma were interviewed about their decisions to seek care for suspect skin marks. The interviews were transcribed and analysed with qualitative content analysis.

RESULTS

Care-seeking behaviour for suspect melanoma was influenced by gender constructions. Men seldom or never acknowledged interest in attention to bodily changes, but when they became aware of changes, they often took a quick decision and sought an expert's assessment. Men were compliant with wives' and relatives' advice about seeking care. All women reported that they paid attention to bodily changes, but they often delayed care seeking, due to family responsibilities and emotional struggles. The women also attempted self-care remedies, such as applying ointment, before seeking professional care.

CONCLUSIONS

There are gender-specific patterns that may influence decision making in the care-seeking process. Such patterns are important to identify, since health care professionals must take these factors into account in communicating with men and women.

RELEVANCE TO CLINICAL PRACTICE

Nurses and in particular those working in telephone counselling, are often at the frontlines, deciding who can have access to health services. They are ideally placed to tackle the issue of gender constructions in the development of effective health care services.

Skin cancer-related prevention and screening behaviors: a review of the literature

Primary prevention and early detection continue to be of paramount importance in addressing the public health threat of skin cancer. The aim of this systematic review was to provide a comprehensive overview of the prevalence and correlates of skin cancer-related health behaviors in the general population. To achieve this aim, 91 studies published in international peer-reviewed journals over the past three decades were reviewed and synthesized. Reported estimates of sunscreen use varied considerably across studies, ranging from 7 to 90%. According to self-report, between 23 and 61% of individuals engage in skin self-examination at least once per year, and the documented prevalence of annual clinical skin examination ranges from 8 to 21%. Adherence to sun protection and screening recommendations is associated with a range of factors, including: female gender, sun-sensitive phenotype, greater perceived risk of skin cancer, greater perceived benefits of sun protection or screening, and doctor recommendation for screening. The literature suggests that a large proportion of the general population engage in suboptimal levels of sun protection, although there is substantial variability in findings. The strongest recommendation to emerge from this review is a call for the development and widespread use of standardized measurement scales in future research, in addition to more studies with a population-based, multivariate design. It is also recommended that specific targeted interventions are developed to increase the prevalence of preventative and early intervention behaviors for the control of skin cancer.

Complexity of attrition in the treatment of obesity: clues from a structured telephone interview

OBJECTIVES

To investigate the causes of attrition reported by obese patients treated by medical centres.

DESIGN

Observational study.

SETTING

Obese patients enrolled in a long-term study involving 18 Italian medical centres.

PARTICIPANTS

A total of 940 obese patients (727 female; mean age, 49 years; mean BMI, 38.6 kg/m2).

MEASUREMENTS

Causes of attrition reported by dropouts during a structured telephone interview.

RESULTS

After a median observation period of 41 months (range, 25-50), 766 of 940 patients (81.5%) discontinued treatment. Sixty-two per cent of total dropout occurred in the first year of follow-up. Seventy-four per cent of dropouts reported a single primary reasons for treatment interruption. Two primary reasons were reported by 22.4% of patients, and three reasons by 3.4%. Practical difficulties, alone or in combination, were reported by more than half of dropouts (55%), and were the leading cause of attrition followed by perceived failure of treatment. Among practical difficulties, family problems or problems at work and logistics, coupled with health problems other than obesity, were the most frequent reasons of attrition, but also a perceived sense of abandonment or a bad interaction with therapists were frequently reported.

CONCLUSION

Practical difficulties and psychological problems are the most important reasons of attrition reported by patients. A therapeutic alliance addressing these issues has a large potential to reduce treatment interruption and to improve outcome in obesity.

Who attends skin cancer clinics within a randomized melanoma screening program?

BACKGROUND

Screening may reduce morbidity and mortality associated with melanoma, although in the absence of randomized-controlled trials, this remains unproven.

METHODS

As part of a randomized community-based trial of melanoma screening in Queensland, Australia, sociodemographic characteristics, skin cancer risk factors and attitudes towards skin cancer associated with attendance at screening clinics and reasons for attendance or non-attendance were examined. A telephone survey was conducted among 743 attendees and 298 non-attendees.

RESULTS

After adjustment, the following factors were associated with clinic attendance: age 40-49 years, having fair skin, a personal history of skin cancer or melanoma or concern about a specific spot or mole, and no recent whole-body skin examination by a doctor. The main reasons for attendance were "to see if I have melanoma", "to have a suspicious mole checked" or "to have a whole-body skin examination". The main reasons for non-attendance were lack of knowledge about the clinics, no time or being away while the clinics were held and having had a skin check in the recent past. Overall, 77% of non-attendees compared to 65% of attendees stated they planned to participate in future screening.

CONCLUSIONS

The results suggest that we were able to attract both men and women equally to a skin screening clinic, along with those at all levels of education and indicate the importance of using well-designed promotional materials to attract community members to skin screening clinics. Future work should test strategies to remove barriers to participation in skin screening identified in this study.

Patients' experience of the diagnosis and treatment of skin cancer

PURPOSE

This paper describes the experience of being diagnosed with skin cancer from the perspective of patients.

BACKGROUND

Despite the number of people with newly-diagnosed skin cancer increasing each year, the psychological impact of receiving such a diagnosis has received little attention. Research in this area is sporadic and has predominantly focused on malignant melanoma and used a quantitative approach.

METHOD

Sixteen patients were interviewed about their experiences of being diagnosed with malignant melanoma, basal cell carcinoma or squamous cell carcinoma. The interview transcripts were analysed using thematic content analysis.

FINDINGS

Similar themes for the two non-melanoma forms of skin cancer patients emerged. Information and knowledge of skin cancer appeared as a key theme, and influenced experiences in a variety of different ways. Patients with malignant melanoma recounted similar experiences to those with basal cell carcinoma or squamous cell carcinoma. People with malignant melanoma, however, used a wider variety of strategies in order to cope with the diagnosis. Satisfaction with the care experienced by each of the three groups played a crucial role in minimizing the experience for the patients.

CONCLUSIONS

Patients with skin cancer should not be conceived as a homogeneous group, but one in which there are a number of diagnoses which differ in prognosis, and so may result in a variety of different consequences and thus experiences for patients.

Increased effectiveness of targeted skin cancer screening in the Veterans Affairs population of Northern California

BACKGROUND

Skin cancer screening in populations at increased risk may be more useful than mass screening. We assessed the effectiveness of screening a targeted population in the Veterans Affairs Palo Alto Health Care System (VAPAHCS) for skin cancer/precancer detection and follow-up.

METHODS

We studied the demographics, presumptive diagnoses, and outcome of 374 participants in free screening clinics conducted over a 3-year period in multiple northern California sites. The number of attendees with presumptive actinic keratosis (AK), basal cell carcinoma (BCC), squamous cell carcinoma (SCC), dysplastic nevus (DN), and melanoma was noted.

RESULTS

Three hundred sixty-two males and 12 females were screened (mean age 63.4 years); 74% were Caucasian. Two hundred three individuals (54%) had a positive screen including 139 (52%) with presumptive AK, 41 (11%) with BCC, 9 (2%) with SCC, and 14 (4%) with DN versus potential melanoma. One hundred one (50%) of referred individuals were subsequently evaluated by VAPAHCS dermatologists. Biopsy was performed in 34/36 cases (94%), with a positive predictive value of 62% in patients with suspected BCC, 43% for SCC, 37.5% for DN and 12.5% for melanoma.

CONCLUSIONS

Targeting a predominantly elderly Caucasian population with minimal to no prior dermatologic care yielded high rates of detection for precancers, skin cancer, and atypical nevi, and resulted in an increased percentage of pathologically confirmed nonmelanoma skin cancer, particularly BCC, compared to prior screening studies and population-based cancer registries.

Detection of nodular and superficial spreading melanoma with tumour thickness < or = 2.0 mm--an interview study

Differences regarding signs and symptoms between nodular melanoma (NM) and superficial spreading melanoma (SSM) with a tumour thickness < or = 2.00 mm were studied. Reasons for seeking medical attention were also investigated. Semi-structured interviews were conducted with 22 patients with NM diagnosed between 1994 and 1999 and 32 patients with SSM, matched to the NM patients with respect to age at diagnosis, gender and tumour thickness. NM were smaller in diameter, and 5 of 6 patients reporting a diameter <5 mm had NM. NM were more often new lesions than SSM, which more often had developed from pre-existing naevi. In most cases (61%), the melanoma was first detected by the patient and in 17% it was detected by the patient in combination with a family member. The most important reasons to seek medical attention were a change in the lesion or a symptom (65%), followed by encouragement from others to seek medical attention. Twenty-four patients (44%) had no symptoms of melanoma prior to diagnosis. Our results have important implications for prevention. It should be emphasized in public education that melanomas may have a diameter <6 mm and that family members have an important role in detection of melanoma and in motivating medical advice.

Audit of a melanoma screening day in the U.K.: clinical results, participant satisfaction and perceived value

BACKGROUND

The incidence of cutaneous malignant melanoma (MM) has risen significantly over the last 50 years in caucasian populations. Mortality is related to the Breslow thickness of the lesion, and early detection followed by complete surgical excision is crucial to reducing this. Skin screening events have been advocated as a means of detecting greater numbers of MMs in the earlier and thinner stages.

OBJECTIVES

To assess the feasibility and effectiveness of this approach in the U.K.

METHODS

The Department of Dermatology, Singleton Hospital, Swansea, U.K. offered a 1-day melanoma screening event in summer 1998 at which 832 consecutive individuals were seen. A postal questionnaire 1 year after the event audited participant perceived value and satisfaction.

RESULTS

Three MMs were identified (yield 1 : 277), all < 0.75 mm in thickness. Despite high participant satisfaction and perceived value, the pick-up rate of malignancy was significantly lower than at rapid access pigmented lesion clinics.

CONCLUSIONS

In a country such as the U.K., with comprehensive health coverage and a low incidence of MM, triage for melanoma and referral to specialists by general practitioners may be more cost and time effective.

Screening for skin cancer

CONTEXT

Malignant melanoma is often lethal, and its incidence in the United States has increased rapidly over the past 2 decades. Nonmelanoma skin cancer is seldom lethal, but, if advanced, can cause severe disfigurement and morbidity. Early detection and treatment of melanoma might reduce mortality, while early detection and treatment of nonmelanoma skin cancer might prevent major disfigurement and to a lesser extent prevent mortality. Current recommendations from professional societies regarding screening for skin cancer vary.

OBJECTIVE

To examine published data on the effectiveness of routine screening for skin cancer by a primary care provider, as part of an assessment for the U.S. Preventive Services Task Force.

DATA SOURCES

We searched the MEDLINE database for papers published between 1994 and June 1999, using search terms for screening, physical examination, morbidity, and skin neoplasms. For information on accuracy of screening tests, we used the search terms sensitivity and specificity. We identified the most important studies from before 1994 from the Guide to Clinical Preventive Services, second edition, and from high-quality reviews. We used reference lists and expert recommendations to locate additional articles.

STUDY SELECTION

Two reviewers independently reviewed a subset of 500 abstracts. Once consistency was established, the remainder were reviewed by one reviewer. We included studies if they contained data on yield of screening, screening tests, risk factors, risk assessment, effectiveness of early detection, or cost effectiveness.

DATA EXTRACTION

We abstracted the following descriptive information from full-text published studies of screening and recorded it in an electronic database: type of screening study, study design, setting, population, patient recruitment, screening test description, examiner, advertising targeted at high-risk groups or not targeted, reported risk factors of participants, and procedure for referrals. We also abstracted the yield of screening data including probabilities and numbers of referrals, types of suspected skin cancers, biopsies, confirmed skin cancers, and stages and thickness of skin cancers. For studies that reported test performance, we recorded the definition of a suspicious lesion, the "gold-standard" determination of disease, and the number of true positive, false positive, true negative, and false negative test results. When possible, positive predictive values, likelihood ratios, sensitivity, and specificity were recorded.

DATA SYNTHESIS

No randomized or case-control studies have been done that demonstrate that routine screening for melanoma by primary care providers reduces morbidity or mortality. Basal cell carcinoma and squamous cell carcinoma are very common, but detection and treatment in the absence of formal screening are almost always curative. No controlled studies have shown that formal screening programs will improve this already high cure rate. While the efficacy of screening has not been established, the screening procedures themselves are noninvasive, and the follow-up test, skin biopsy, has low morbidity. Five studies from mass screening programs reported the accuracy of skin examination as a screening test. One of these, a prospective study, tracked patients with negative results to determine the number of patients with false-negative results. In this study, the sensitivity of screening for skin cancer was 94% and specificity was 98%. Several recent case-control studies confirm earlier evidence that risk of melanoma rises with the presence of atypical moles and/or many common moles. One well-done prospective study demonstrated that risk assessment by limited physical exam identified a relatively small (<10%) group of primary care patients for more thorough evaluation.

CONCLUSIONS

The quality of the evidence addressing the accuracy of routine screening by primary care providers for early detection of melanoma or nonmelanoma skin cancer ranged from poor to fair. We found no studies that assessed the effectiveness of periodic skin examination by a clinician in reducing melanoma mortality. Both self-assessment of risk factors or clinician examination can classify a small proportion of patients as at highest risk for melanoma. Skin cancer screening, perhaps using a risk-assessment technique to identify high-risk patients who are seeing a physician for other reasons, merits additional study as a strategy to address the excess burden of disease in older adults.

Patterns of detection in patients with cutaneous melanoma

BACKGROUND

Despite the importance of early detection in preventing mortality from melanoma, little is known regarding how patients with the disease come to diagnosis.

METHODS

The authors prospectively evaluated 471 newly diagnosed melanoma patients between 1995 and 1998. Patients completed a questionnaire that included 1) identification of the person who detected the lesion, 2) the anatomic location of the lesion, and 3) family history of melanoma. Logistic regression analysis was performed to examine the relation between detection patterns and lesion thickness, adjusting for age, gender, anatomic site of the primary lesion, and family history of melanoma.

RESULTS

The majority of patients detected their own melanoma (n = 270; 57%). Females were more likely to self-detect than males (69% vs. 47%; P < 0.0001). Physicians detected the melanoma in 16% of patients (n = 74), followed by "spouse" in 11% of patients (n = 51). Within this group, detection by wives was 7.5 times more common than detection by husbands (P < 0.0001). Logistic regression analysis revealed that physicians were 3.6 times more likely to detect thin lesions (</=0.75 mm) compared with nonphysician detectors (95% confidence interval [95% CI], 2.1, 6.5; P = 0.0001). In addition, patients who reported a family history of melanoma had a 2.7-fold increased likelihood of presenting with a thin lesion (95% CI, 1.6, 4.7; P = 0.0003).

CONCLUSIONS

Physician detection and a report of a family history of melanoma are associated with the presentation of patients with early melanoma, suggesting that awareness of the disease among physicians and the public is critical for preventing mortality from melanoma. Increasing melanoma awareness in males may be a particularly effective means of secondary prevention.