Cost-effective Melanoma Screening

Primary care nurse's role and educational preparedness in skin cancer screening and early detection: A scoping review

AIM

To identify the available evidence regarding nursing roles in skin cancer screening and early detection and the reported education and training undertaken to do so.

DESIGN

Scoping review, reported in accordance with PRISMA-ScR.

DATA SOURCES

A database search of Medline, CINAHL, Scopus, Embase, Emcare and JBI was conducted in November 2021. A grey literature search was conducted in February 2022. Searches were updated in August 2023.

REVIEW METHODS

The data were extracted and synthesized into themes related to nursing roles and education.

RESULTS

Of the 2285 identified studies, 54 were included in the review. Nursing roles included screening and early detection, prevention and patient education or counselling. Except for specialized nurse practitioners, nurses working in primary clinical care mostly engage in skin cancer supportive/administrative roles rather than leading collaborators in screening and early detection. The education and training for nurses were identified around themes of didactic education, clinical experience, training in dermoscopy, performance and knowledge assessment and self-efficacy.

CONCLUSION

The roles and responsibilities of nurses working in skin cancer screening and early detection are highly variable, as are the reported training and education programmes. Little research has been conducted to explore this nursing role or the educational requirements needed for proficiency. With appropriate best practice education, it is within most primary care nurses' scope of practice to obtain competence in delivering opportunistic skin cancer screening.

IMPACT

While most nurse specialists in dermatology will be proficient in dermoscopy and skin cancer screening, nurses who work in general practice are often underutilized due to a lack of opportunity and a clear pathway to becoming proficient in dermoscopic skin cancer screening. Most nurses involved in skin cancer screening are employed in advanced roles, and only a few studies investigating educational interventions utilized dermoscopy among advanced nurses. With specific training, nurses can work within their full scope of practice and increase access to skin cancer screening and early detection.

REPORTING METHOD

Adhered to JBI Guidance for Conducting Systematic Scoping Reviews.

PROTOCOL REGISTRATION

Open Science Framework, https://doi.org/10.17605/OSF.IO/XUNE6 PATIENT OR PUBLIC CONTRIBUTION: N/A; a literature review.

Lesion-directed screening to optimize skin cancer detection in dermatology practice: an observational study

Background

Early detection of skin cancer is still a major challenge in dermatology practice today. While surveillance programs are offered to high‐risk patients, systematic total‐body examination (TBE) in the general population is not cost‐effective. In the past, we demonstrated that a lesion‐directed screening (LDS) in the general population delivered similar detection rates to TBE and was less time‐consuming.

Objectives

To study whether a lesion‐directed early‐access consultation can optimize skin cancer detection in dermatology practice.

Methods

In this observational study, we offered an early‐access consultation in patients contacting the dermatology department concerning 1 or 2 lesions of concern meeting predefined criteria.

Results

342 persons were seen at the dermatology department after triage by phone. Skin cancer detection rate was 13.2% (4.1% for melanoma). If advised/referred by a doctor skin cancer detection rate was 23.6% (9% for melanoma). With a history of skin cancer, detection rate was 24.3% (4.3% for melanoma). In patients with no referral and a negative history of skin cancer, detection rate was 7.7% (1.7% for melanoma), which is at least triple the rates reported by population‐based screening programs. In patients in whom the index lesion was benign, worry of having skin cancer had decreased significantly by the end of the consultation. Additional total‐body examination in these patients had low additional detection rate (0.5%) and a high number of unnecessary excisions (number needed to excise 13).

Conclusions

An early‐access dermatology consultation for LDS after triage by phone resulted in high overall skin cancer and melanoma detection rates. Our data indicate that performing TBE is especially useful if the index lesion is suspicious. In addition to surveillance programs in high‐risk patients, LDS may be a way to optimize skin cancer detection in the general population and use available time more efficiently in daily dermatology practice.

Assessment of Accuracy of an Artificial Intelligence Algorithm to Detect Melanoma in Images of Skin Lesions

Importance

A high proportion of suspicious pigmented skin lesions referred for investigation are benign. Techniques to improve the accuracy of melanoma diagnoses throughout the patient pathway are needed to reduce the pressure on secondary care and pathology services.

Objective

To determine the accuracy of an artificial intelligence algorithm in identifying melanoma in dermoscopic images of lesions taken with smartphone and digital single-lens reflex (DSLR) cameras.

Design, Setting, and Participants

This prospective, multicenter, single-arm, masked diagnostic trial took place in dermatology and plastic surgery clinics in 7 UK hospitals. Dermoscopic images of suspicious and control skin lesions from 514 patients with at least 1 suspicious pigmented skin lesion scheduled for biopsy were captured on 3 different cameras. Data were collected from January 2017 to July 2018. Clinicians and the Deep Ensemble for Recognition of Malignancy, a deterministic artificial intelligence algorithm trained to identify melanoma in dermoscopic images of pigmented skin lesions using deep learning techniques, assessed the likelihood of melanoma. Initial data analysis was conducted in September 2018; further analysis was conducted from February 2019 to August 2019.

Interventions

Clinician and algorithmic assessment of melanoma.

Main Outcomes and Measures

Area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity of the algorithmic and specialist assessment, determined using histopathology diagnosis as the criterion standard.

Results

The study population of 514 patients included 279 women (55.7%) and 484 white patients (96.8%), with a mean (SD) age of 52.1 (18.6) years. A total of 1550 images of skin lesions were included in the analysis (551 [35.6%] biopsied lesions; 999 [64.4%] control lesions); 286 images (18.6%) were used to train the algorithm, and a further 849 (54.8%) images were missing or unsuitable for analysis. Of the biopsied lesions that were assessed by the algorithm and specialists, 125 (22.7%) were diagnosed as melanoma. Of these, 77 (16.7%) were used for the primary analysis. The algorithm achieved an AUROC of 90.1% (95% CI, 86.3%-94.0%) for biopsied lesions and 95.8% (95% CI, 94.1%-97.6%) for all lesions using iPhone 6s images; an AUROC of 85.8% (95% CI, 81.0%-90.7%) for biopsied lesions and 93.8% (95% CI, 91.4%-96.2%) for all lesions using Galaxy S6 images; and an AUROC of 86.9% (95% CI, 80.8%-93.0%) for biopsied lesions and 91.8% (95% CI, 87.5%-96.1%) for all lesions using DSLR camera images. At 100% sensitivity, the algorithm achieved a specificity of 64.8% with iPhone 6s images. Specialists achieved an AUROC of 77.8% (95% CI, 72.5%-81.9%) and a specificity of 69.9%.

Conclusions and Relevance

In this study, the algorithm demonstrated an ability to identify melanoma from dermoscopic images of selected lesions with an accuracy similar to that of specialists.

Screening for reducing morbidity and mortality in malignant melanoma

BACKGROUND

Screening for malignant melanoma has the potential to reduce morbidity and mortality from the disease through earlier detection, as prognosis is closely associated with the thickness of the lesion at the time of diagnosis. However, there are also potential harms from screening people without skin lesion concerns, such as overdiagnosis of lesions that would never have caused symptoms if they had remained undetected. Overdiagnosis results in harm through unnecessary treatment and the psychosocial consequences of being labelled with a cancer diagnosis. For any type of screening, the benefits must outweigh the harms. Screening for malignant melanoma is currently practised in many countries, and the incidence of the disease is rising sharply, while mortality remains largely unchanged.

OBJECTIVES

To assess the effects on morbidity and mortality of screening for malignant melanoma in the general population.

SEARCH METHODS

We searched the following databases up to May 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registries, checked the reference lists of included and other relevant studies for further references to randomised controlled trials (RCTs), used citation tracking (Web of Science) for key articles, and asked trialists about additional studies and study reports.

SELECTION CRITERIA

RCTs, including cluster-randomised trials, of screening for malignant melanoma compared with no screening, regardless of screening modality or setting, in any type of population and in any age group where people were not suspected of having malignant melanoma. We excluded studies in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome) and studies performed exclusively in people with previous melanomas.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcomes of this review were total mortality, overdiagnosis of malignant melanoma, and quality of life/psychosocial consequences.

MAIN RESULTS

We included two studies with 64,391 participants. The first study was a randomised trial of an intervention developed to increase the rate of performance of thorough skin self-examination. The intervention group received instructional materials, including cues and aids, a 14-minute instruction video, and a brief counselling session, and at three weeks a brief follow-up telephone call from a health educator, aimed at increasing performance of thorough skin self-examination. The control group received a diet intervention with similar follow-up. The trial included 1356 people, who were recruited from 11 primary care practices in the US between 2000 and 2001. Participant mean age was 53.2 years and 41.7% were men. This study did not report on any of our primary outcomes or the following secondary outcomes: mortality specific to malignant melanoma, false-positive rates (skin biopsies/excisions with benign outcome), or false-negative rates (malignant melanomas diagnosed between screening rounds and up to one year after the last round). All participants were asked to complete follow-up telephone interviews at 2, 6, and 12 months after randomisation.The second study was a pilot study for a cluster-RCT of population-based screening for malignant melanoma in Australia. This pilot trial included 63,035 adults aged over 30 years. The three-year programme involved community education, an education and support component for medical practitioners, and the provision of free skin screening services. The mean age of people attending the skin screening clinics (which were held by primary care physicians in workplaces, community venues, and local hospitals, and included day and evening sessions) was 46.5 years, and 51.5% were men. The study included whole communities, targeting participants over 30 years of age, but information on age and gender of the whole study population was not reported. Study duration was three years (1998 to 2001), and outcomes were measured at the screening clinics during these three years. There was no further follow-up for any outcomes. The control group received no programme. The ensuing, planned cluster randomised trial in 560,000 adults was never carried out due to lack of funding. At the time of this review, there are no published or unpublished data on our prespecified outcomes available, and no results for mortality outcomes from the pilot study are to be expected.The risk of bias in these studies was high for performance bias (blinding study personnel and participants) and high or unclear for detection bias (blinding of outcome assessment). Risk of bias in the other domains was either unclear or low. We were unable to assess the certainty of the evidence for our primary outcomes as planned due to lack of data.

AUTHORS' CONCLUSIONS

Adult general population screening for malignant melanoma is not supported or refuted by current evidence from RCTs. It therefore does not fulfil accepted criteria for implementation of population screening programmes. This review did not investigate the effects of screening people with a history of malignant melanoma or in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome). To determine the benefits and harms of screening for malignant melanoma, a rigorously conducted randomised trial is needed, which assesses overall mortality, overdiagnosis, psychosocial consequences, and resource use.

A comparison of skin cancer screening and treatment costs at a Massachusetts cancer center, 2008 versus 2013

BACKGROUND

Temporal analyses of skin cancer costs are needed to examine how expenditure differences between diagnoses are changing.

OBJECTIVE

To tabulate the costs of skin cancer-related care (SCRC), including both screening and treatment, at an academic cancer center at 2 time points.

METHODS

Cost data (insurance and patient payments) at an academic cancer center from 2008 and 2013 were queried for International Classification of Diseases, Ninth Revision, codes pertaining to skin cancer. Screening costs were separated from treatment costs through associated Current Procedural Terminology codes.

RESULTS

The total annual cost of SCRC increased by 64%, the number of patients receiving SCRC increased by 45%, and the mean cost per patient treated increased by 13%. Screening accounted for 17% and 16% of total annual costs in 2008 and 2013, respectively. The mean cost per patient with melanoma increased by 84%, which was the largest increase among skin cancer diagnoses. In 2013, the few patients with melanoma who were treated with ipilimumab (n = 48 [4% of patients with melanoma]) accounted for 42% of melanoma treatment costs and 20% of SCRC costs.

LIMITATIONS

Prescription costs were unavailable.

CONCLUSIONS

Melanoma costs have increased as a result of the introduction of ipilimumab. Ongoing studies are needed to monitor the cost-effectiveness of SCRC at a national level.

Melanoma Perception in People of Color: A Targeted Educational Intervention

BACKGROUND

Although melanoma is more common in non-Hispanic Whites, ethnic minorities face a greater risk of melanoma-related mortality, which may be partially attributed to presentation at atypical sites and a lack of awareness.

OBJECTIVE

Our objective was to assess the effectiveness of a melanoma educational intervention targeted towards people of color.

DESIGN

Participants received one of two scripted melanoma educational interventions in the summer of 2015. They completed surveys before the intervention, immediately post-intervention, and 2 months post-intervention.

SETTING

Dermatology clinic at an academic hospital.

PARTICIPANTS

A consecutive sample of 100 participants who self-identified as African American, Asian, or Hispanic were recruited following their dermatology visit. In total, 70 participants completed the 2-month follow-up questionnaire.

INTERVENTION

The comparison intervention group received an educational intervention using a conventional pamphlet on the 'ABCDEs' (Asymmetry, Borders, Color, Diameter, Evolution) of melanoma. The targeted intervention group received a modified pamphlet that included a skin of color section, the nomenclature "melanoma skin cancer", and an image of an individual performing a skin self-examination with the help of a friend.

MAIN OUTCOMES AND MEASURES

Melanoma knowledge, perceived risk for developing melanoma, and skin self-examination practices were assessed through self-reported questionnaires.

RESULTS

Among the 100 participants, 78% self-identified as African American, 11% as Asian, and 11% as Hispanic. Both groups experienced a similar increase in melanoma knowledge that was retained at 2 months. Perceived personal risk for developing melanoma increased more in the targeted intervention group immediately post-intervention (p = 0.015), but this difference no longer existed between the groups at the 2-month follow-up. The targeted intervention group also demonstrated a greater increase in skin self-examinations (p = 0.048) and knowledge of warning signs to look for when examining the skin (p = 0.002) at the 2-month follow-up.

CONCLUSIONS AND RELEVANCE

The educational intervention targeted towards people of color resulted in increased skin self-examinations. Educational material that is relevant to ethnic minorities may better promote early detection and help to decrease the disparity in melanoma-related morality rates.

TRIAL REGISTRATION

Clinicaltrials.gov registration number NCT02437305.