Teledermatology for diagnosing skin cancer in adults

Training Family Medicine Residents in Dermoscopy Using an e-Learning Course: Pilot Interventional Study

BACKGROUND

Skin cancers are the most common group of cancers diagnosed worldwide. Aging and sun exposure increase their risk. The decline in the number of dermatologists is pushing the issue of dermatological screening back onto family doctors. Dermoscopy is an easy-to-use tool that increases the sensitivity of melanoma diagnosis by 60% to 90%, but its use is limited due to lack of training. The characteristics of "ideal" dermoscopy training have yet to be established. We created a Moodle (Moodle HQ)-based e-learning course to train family medicine residents in dermoscopy.

OBJECTIVE

This study aimed to evaluate the evolution of dermoscopy knowledge among family doctors immediately and 1 and 3 months after e-learning training.

METHODS

We conducted a prospective interventional study between April and November 2020 to evaluate an educational program intended for family medicine residents at the University of Montpellier-Nîmes, France. They were asked to complete an e-learning course consisting of 2 modules, with an assessment quiz repeated at 1 (M1) and 3 months (M3). The course was based on a 2-step algorithm, a method of dermoscopic analysis of pigmented skin lesions that is internationally accepted. The objectives of modules 1 and 2 were to differentiate melanocytic lesions from nonmelanocytic lesions and to precisely identify skin lesions by looking for dermoscopic morphological criteria specific to each lesion. Each module consisted of 15 questions with immediate feedback after each question.

RESULTS

In total, 134 residents were included, and 66.4% (n=89) and 47% (n=63) of trainees fully participated in the evaluation of module 1 and module 2, respectively. This study showed a significant score improvement 3 months after the training course in 92.1% (n=82) of participants for module 1 and 87.3% (n=55) of participants for module 2 (P<.001). The majority of the participants expressed satisfaction (n=48, 90.6%) with the training course, and 96.3% (n=51) planned to use a dermatoscope in their future practice. Regarding final scores, the only variable that was statistically significant was the resident's initial scores (P=.003) for module 1. No measured variable was found to be associated with retention (midtraining or final evaluation) for module 2. Residents who had completed at least 1 dermatology rotation during medical school had significantly higher initial scores in module 1 at M0 (P=.03). Residents who reported having completed at least 1 dermatology rotation during their family medicine training had a statistically significant higher score at M1 for module 1 and M3 for module 2 (P=.01 and P=.001).

CONCLUSIONS

The integration of an e-learning training course in dermoscopy into the curriculum of FM residents results in a significant improvement in their diagnosis skills and meets their expectations. Developing a program combining an e-learning course and face-to-face training for residents is likely to result in more frequent and effective dermoscopy use by family doctors.

From diagnosis to intervention: a review of telemedicine's role in skin cancer care

Skin cancer treatment is a core aspect of dermatology that relies on accurate diagnosis and timely interventions. Teledermatology has emerged as a valuable asset across various stages of skin cancer care including triage, diagnosis, management, and surgical consultation. With the integration of traditional dermoscopy and store-and-forward technology, teledermatology facilitates the swift sharing of high-resolution images of suspicious skin lesions with consulting dermatologists all-over. Both live video conference and store-and-forward formats have played a pivotal role in bridging the care access gap between geographically isolated patients and dermatology providers. Notably, teledermatology demonstrates diagnostic accuracy rates that are often comparable to those achieved through traditional face-to-face consultations, underscoring its robust clinical utility. Technological advancements like artificial intelligence and reflectance confocal microscopy continue to enhance image quality and hold potential for increasing the diagnostic accuracy of virtual dermatologic care. While teledermatology serves as a valuable clinical tool for all patient populations including pediatric patients, it is not intended to fully replace in-person procedures like Mohs surgery and other necessary interventions. Nevertheless, its role in facilitating the evaluation of skin malignancies is gaining recognition within the dermatologic community and fostering high approval rates from patients due to its practicality and ability to provide timely access to specialized care.

Cutaneous melanoma in older patients

BACKGROUND

In industrialized countries, the aging population is steadily rising. The incidence of cutaneous malignant melanoma (CMM) is highest in old people. This study focuses on the clinicopathological profile of CMM and indicators of diagnostic-therapeutic performance in older patients.

METHODS

This retrospective population-based cohort study included 1,368 incident CMM, as recorded in 2017 by the Regional Veneto Cancer Registry (Northeast Italy). Older subjects were defined as ≥ 80, old as 65-79, and adults as < 65 years of age. The strength of association between pairs of variables was tested by Cramer's-V. Using age groups as the dependent variable, ordered logistic regression was fitted using the clinicopathological CMM profiles as covariates. In each of the three age-groups, the indicators of clinical performance were computed using the Clopper-Pearson exact method.

RESULTS

Compared to patients aged younger than 80 years (1,187), CMM in older patients (181; 13.2%) featured different CMM topography, a higher prevalence of ulcers (43.3% versus 12.7%; p < 0.001), a higher Breslow index (p < 0.001), a lower prevalence of tumor-infiltrating lymphocytes (64.4% versus 76.5%, p < 0.01), and a more advanced pTNM stage at clinical presentation (p < 0.001). Elderly patients with a positive sentinel-lymph node less frequently underwent sentinel- lymph node biopsy and lymphadenectomy (60.0% versus 94.2%, and 44.4% versus 85.5%, respectively; p < 0.001).

CONCLUSIONS

In older CMM patients, the clinicopathological presentation of CMM shows a distinctive profile. The present results provide critical information to optimize secondary prevention strategies and refine diagnostic-therapeutic procedures tailored to older patients.

Emerging Trends in Teledermatology Research: A Scientometric Analysis from 2002 to 2021

Background: With advances in technology, teledermatology (TD) research has increased. However, an updated comprehensive quantitative analysis of TD research, especially one that identifies emerging trends of TD research in the coronavirus disease 2019 (COVID-19) era, is lacking. Objective: To conduct a scientometric analysis of TD research documents between 2002 and 2021 and explore the emerging trends. Methods: CiteSpace was used to perform scientometric analysis and yielded visualized network maps with corresponding metric values. Emerging trends were identified mainly through burst detection of keywords/terms, co-cited reference clustering analysis, and structural variability analysis (SVA). Results: A total of 932 documents, containing 27,958 cited references were identified from 2002 to 2021. Most TD research was published in journals from the "Dermatology" and "Health Care Sciences & Services" categories. American, Australian, and European researchers contributed the most research and formed close collaborations. Keywords/terms with strong burst values to date were "primary care," "historical perspective," "emerging technique," "improve access," "mobile teledermoscopy (TDS)," "access," "skin cancer," "telehealth," "recent finding," "artificial intelligence (AI)," "dermatological care," and "dermatological condition." Co-cited reference clustering analysis showed that the recently active cluster labels included "COVID-19 pandemic," "skin cancer," "deep neural network," and "underserved population." The SVA identified two reviews (Tognetti et al. and Mckoy et al.) that may be highly cited in the future. Conclusion: During and after the COVID-19 era, emerging trends in research on TD (especially mobile TDS) may be related to skin cancer and AI as well as further exploration of primary care in underserved areas.

A country-wide teledermatoscopy service in Estonia shows results comparable to those in experimental settings in management plan development and diagnostic accuracy: A retrospective database study

Background

Teledermatoscopy accuracy has been examined in experimental settings and is recommended for primary care despite lacking real-world implementation evidence. A teledermatoscopy service has been provided in Estonia since 2013, where lesions are evaluated based on the patient's or general practitioner's suggestion.

Objective

The management plan and diagnostic accuracy of a real-world store-and-forward teledermatoscopy service for melanoma diagnosis were evaluated.

Methods

A retrospective study analyzed 4748 cases from 3403 patients using the service between October 16, 2017 and August 30, 2019 by matching country-wide databases. Management plan accuracy was calculated as the percentage of melanoma found that was managed correctly. Diagnostic accuracy parameters were sensitivity, specificity, and positive and negative predictive values.

Results

Management plan accuracy for melanoma detection was 95.5% (95% CI, 77.2-99.9). Diagnostic accuracy showed a sensitivity of 90.48% (95% CI, 69.62-98.83) and a specificity of 92.57% (95% CI, 91.79-93.31).

Limitations

Matching the lesions was limited to SNOMED CT location standard precision. Diagnostic accuracy was calculated based on a combination of diagnosis and management plan data.

Conclusion

Teledermatoscopy for detecting and managing melanoma in real-world clinical practice displays results comparable with those in experimental setting studies.

Smart e-Skin Cancer Care in Europe During and after the Covid-19 Pandemic: a Multidisciplinary Expert Consensus

INTRODUCTION

Melanoma is the deadliest of all the skin cancers and its incidence is increasing every year in Europe. Patients with melanoma often present late to the specialist and treatment is delayed for many reasons (delay in patient consultation, misdiagnosis by general practitioners, and/or limited access to dermatologists). Beyond this, there are significant inequalities in skin cancer between population groups within the same country and between countries across Europe. The emergence of the COVID-19 pandemic only aggravated these health deficiencies.

OBJECTIVES

The aim was to create an expert opinion about the challenges in skin cancer management in Europe during the post COVID-19 acute pandemic and to identify and discuss the implementation of new technologies (including e-health and artificial intelligence defined as "Smart Skin Cancer Care") to overcome them.

METHODS

For this purpose, an ad-hoc questionnaire with items addressing topics of skin cancer care was developed, answered independently and discussed by a multidisciplinary European panel of experts comprising dermatologists, dermato-oncologists, patient advocacy representatives, digital health technology experts, and health technology assessment experts.

RESULTS

After all panel of experts discussions, a multidisciplinary expert opinion was created.

CONCLUSIONS

As a conclusion, the access to dermatologists is difficult and will be aggravated in the near future. This fact, together with important differences in Skin Cancer Care in Europe, suggest the need of a new approach to skin health, prevention and disease management paradigm (focused on integration of new technologies) to minimize the impact of skin cancer and to ensure optimal quality and equity.

Teledermatology for Enhancing Skin Cancer Diagnosis and Management: Retrospective Chart Review

BACKGROUND

Skin cancer rates are at all-time highs, but the shortage of dermatologists compels patients to seek medical advice from general practitioners. A new referral pathway called the Suspected Skin Cancer (SSC) service was established to provide general practitioners in Waikato, New Zealand, with rapid diagnosis and treatment advice for lesions suspicious for skin cancer.

OBJECTIVE

The aim of this study was to assess the quantity, quality, and characteristics of referrals to the SSC teledermatology service during its first 6 months.

METHODS

A retrospective chart review of all referrals sent to the SSC teledermatology service during the first 6 months of its operation was conducted. Time to advice, diagnoses, diagnostic discordance, adherence to advice, and time to treatment were recorded. Diagnostic discordance between general practitioners, dermatologists, and pathologists was calculated.

RESULTS

The SSC service received 340 referrals for 402 lesions. Dermatologists diagnosed 256 (63.7%) of these lesions as benign; 56 (13.9%) were histologically confirmed as malignant, including 19 (4.7%) melanomas. The overall discordance between referrer and dermatologist on specific and broad (ie, benign or malignant) diagnoses for 402 lesions was 47% and 26% (κ=0.58, SD 0.07), respectively; 44% and 26% (κ=0.61, SD 0.15) between referrer and pathologist; and 18% and 12% (κ=0.82, SD 0.12) between dermatologist and pathologist. The mean time between referral submission and receiving advice was 1.02 days. The average time to action (eg, excision) was 64.8 days.

CONCLUSIONS

An electronic referral system can be an effective form of teledermatology for providing prompt diagnosis and management advice for benign and malignant skin lesions.

Store-and-Forward Teledermatology for Assessing Skin Cancer in 2023: Literature Review

BACKGROUND

The role of teledermatology for skin lesion assessment has been a recent development, particularly, since the COVID-19 pandemic has impacted the ability to assess patients in person. The growing number of studies relating to this area reflects the evolving interest.

OBJECTIVE

This literature review aims to analyze the available research on store-and-forward teledermatology for skin lesion assessment.

METHODS

MEDLINE was searched for papers from January 2010 to November 2021. Papers were searched for assessment of time management, effectiveness, and image quality.

RESULTS

The reported effectiveness of store-and-forward teledermatology for skin lesion assessment produces heterogeneous results likely due to significant procedure variations. Most studies show high accuracy and diagnostic concordance of teledermatology compared to in-person dermatologist assessment and histopathology. This is improved through the use of teledermoscopy. Most literature shows that teledermatology reduces time to advice and definitive treatment compared to outpatient clinic assessment.

CONCLUSIONS

Overall, teledermatology offers a comparable standard of effectiveness to in-person assessment. It can save significant time in expediting advice and management. Image quality and inclusion of dermoscopy have a considerable bearing on the overall effectiveness.

The Dermatologic Care Needs of a Rural Community in South Florida

For patients in rural areas, primary care is often their only access to healthcare services, and skin concerns are among the most common diseases seen in these settings. This study aims to investigate the most common skin conditions, management trends and patterns of referral to dermatology in a rural and underserved community in South Florida. A retrospective chart review was conducted using medical records from the C.L. Brumback Primary Care Clinic in Belle Glade, FL. The most common skin conditions were fungal infections, unspecified dermatitis, pruritus, skin cancer concern, alopecia, and autoimmune skin disorders. The most frequent management strategy was medication prescription followed by specialist referral. Of the 21 percent of patients referred to a specialist, 55 percent of these were to dermatology. The most common diagnoses referred to dermatology were atopic dermatitis and alopecia. Only 20 percent of these patients reported attending their follow-up appointment, and the average distance to referral was 21 miles. Belle Glade is unique in its need for and access to dermatologic care. The lack of access to specialists in rural communities is a public health issue that more studies and outreach initiatives should address.

Synchronous Home-Based Telemedicine for Primary Care: A Review

Synchronous home-based telemedicine for primary care experienced growth during the coronavirus disease 2019 pandemic. A review was conducted on the evidence reporting on the feasibility of synchronous telemedicine implementation within primary care, barriers and facilitators to implementation and use, patient characteristics associated with use or nonuse, and quality and cost/revenue-related outcomes. Initial database searches yielded 1,527 articles, of which 22 studies fulfilled the inclusion criteria. Synchronous telemedicine was considered appropriate for visits not requiring a physical examination. Benefits included decreased travel and wait times, and improved access to care. For certain services, visit quality was comparable to in-person care, and patient and provider satisfaction was high. Facilitators included proper technology, training, and reimbursement policies that created payment parity between telemedicine and in-person care. Barriers included technological issues, such as low technical literacy and poor internet connectivity among certain patient populations, and communication barriers for patients requiring translators or additional resources to communicate.

Impact of the COVID-19 Pandemic on Melanoma Diagnosis in Romania-Data from Two University Centers

The COVID-19 pandemic affected the healthcare system in our country and led non-COVID patients to postpone medical visits that were not urgent. The purpose of this study was to investigate the impact of the first year of the COVID-19 pandemic on the trends in melanoma diagnosis and to compare the pathological characteristics of melanoma patients before and during the pandemic. The number of primary cutaneous melanomas diagnosed each month between 1 March 2019 and 29 February 2020 (pre-COVID-19) and between 1 March 2020 and 28 February 2021 (COVID-19) in the North-Western Region of Romania (Cluj and Bihor counties) was determined. The pathological characteristics of melanomas diagnosed in the two intervals were compared. The number of melanoma diagnoses substantially decreased during the pandemic, with 66 (-19.3%) fewer cutaneous melanomas being diagnosed in the first year of the pandemic when compared with the previous year. The tumor thickness and mitotic rate were significantly higher in cases found during the COVID-19 pandemic. Our study suggests that COVID-19 has delayed diagnosis in patients with melanoma, leading to the detection of thicker melanomas that may increase morbidity and mortality. Further studies are needed to determine the consequences of this delay on outcomes.

Digital Health at Enterprise Scale: An Evaluation Framework for Selecting Patient Facing Software in a Digital First Health System (Preprint)

The digital transformation of our health care system will require not only digitization of existing tools but also a redesign of our care delivery system and collaboration with digital partners. Traditional patient journeys are reactive to symptom presentation and delayed by health care system-centric scheduling, leading to poor experience and avoidable adverse outcomes. Patient journeys will be reimagined to a digital health pathway that seamlessly integrates various care experiences from telemedicine, remote monitoring, to in-person clinic visits. Through centering the care delivery around the patients, they can have more delightful experiences and enjoy the quality of standardized condition pathways and outcomes. To design and implement digital health pathways at scale, enterprise health care systems need to develop capabilities and partnerships in human-centered design, operational workflow, clinical content management, communication channels and mechanisms, reporting and analytics, standards-based integration, security and data management, and scalability. Using a human-centered design methodology, care pathways will be built upon an understanding of the unmet needs of the patients to have a more enjoyable experience of care with improved clinical outcomes. To power this digital care pathway, enterprises will choose to build or partner for clinical content management to operationalize up-to-date, best-in-class pathways. With this clinical engine, this digital solution will engage with patients through multimodal communication modalities, including written, audio, photo, or video, throughout the patient journey. Leadership teams will review reporting and analytics functions to track that the digital care pathways will be iterated to improve patient experience, clinical metrics, and operational efficiency. On the backend, standards-based integration will allow this system to be built in conjunction with the electronic medical record and other data systems to provide safe and efficient use of the digital care solution. For protecting patient information and compliance, a security and data management strategy is critical to derisking breeches and preserving privacy. Finally, a framework of technical scalability will allow digital care pathways to proliferate throughout the enterprise and support the entire patient population. This framework empowers enterprise health care systems to avoid collecting a fragmented series of one-off solutions but develop a sustainable concerted roadmap to the future of proactive intelligent patient care.

Partnering with a senior living community to optimise teledermatology via full body skin screening during the COVID-19 pandemic: A pilot programme

BACKGROUND

Elderly patients in senior communities faced high barriers to care during the COVID-19 pandemic, including increased vulnerability to COVID-19, long quarantines for clinic visits, and difficulties with telemedicine adoption.

OBJECTIVE

To pilot a new model of dermatologic care to overcome barriers for senior living communities during the COVID-19 pandemic and assess patient satisfaction.

METHODS

From 16 November 2020 to 9 July 2021, this quality improvement programme combined in-residence full body imaging with real-time outlier lesion identification and virtual teledermatology. Residents from the Sequoias Portola Valley Senior Living Retirement Community (Portola Valley, California) voluntarily enroled in the Stanford Skin Scan Programme. Non-physician clinical staff with a recent negative COVID-19 test travelled on-site to obtain in-residence full body photographs using a mobile app-based system on an iPad called SkinIO that leverages deep learning to analyse patient images and suggest suspicious, outlier lesions for dermoscopic photos. A single dermatologist reviewed photographs with the patient and provided recommendations via a video visit. Objective measures included follow-up course and number of skin cancers detected. Subjective findings were obtained through patient experience surveys.

RESULTS

Twenty-seven individuals participated, three skin cancers were identified, with 11 individuals scheduled for a follow up in-person visit and four individuals starting home treatment. Overall, 88% of patients were satisfied with the Skin Scan programme, with 77% likely to recommend the programme to others. 92% of patients agreed that the Skin Scan photographs were representative of their skin. In the context of the COVID-19 pandemic, 100% of patients felt the process was safer or comparable to an in-person visit. Despite overall appreciation for the programme, 31% of patients reported that they would prefer to see dermatologist in-person after the pandemic.

CONCLUSIONS

This programme offers a framework for how a hybrid skin scan programme may provide high utility for individuals with barriers to accessing in-person clinics.

Management of the Two-Week Wait Pathway for Skin Cancer Patients, before and during the Pandemic: Is Virtual Consultation an Option?

Background: Although telemedicine emerged more than 100 years ago, the recent pandemic underlined the role of remote assessment of different diseases. The diagnoses of cutaneous conditions, especially malignant lesions, have placed significant stress on the fast-track pathway for general practitioners (GPs), dermatologists, and plastic surgeons. The aim of the study was to compare (pre- and during the pandemic) the ability of professionals to face the challenge. Methods: The study was composed of 1943 consecutive patients (mean age 61.9 ± 18.3, 53.8% female) assessed by GPs, face-to-face (988 patients, 50.8%, between October 2019 and March 2020) and by virtual (video/photo) visits (955 patients, 49.2%, between March 2020 and October 2020) for skin lesions, and referred to secondary care via the two-week wait pathway for suspected skin malignancy. Results: The two groups had similar primary skin malignancies identification rates (24.3% vs. 22.1%, p = 0.25). The virtual visits identified squamous cell carcinoma (SCC) better than face-to-face consultations (p = 0.04), but identified basal cell carcinoma less-well (BCC, p = 0.02), whereas malignant melanoma (MM) was equally identified in the two groups (p = 0.13). There was no difference in the median breach time (days) of the two-week wait pathway (12, IQR = 6 vs. 12, IQR = 5, p = 0.16) in the two groups. Virtual assessments (by GPs) of skin lesions suspected of malignancy, and referred via the two-week wait pathway, increased the probability of diagnosing SCC by 42.9% (p = 0.03), while for malignant melanomas, face-to-face and virtual consultations were alike (p = 0.12). Conclusions: The equivalent outcomes in the management of skin cancers (SCC, MM) via the two-week pathway through virtual consultations and face-to-face appointments underline the role of telemedicine as a reliable alternative to face-to-face assessments.

Teledermatology to reduce face-to-face appointments in general practice during the COVID-19 pandemic: a quality improvement project

Teledermatology is an important subspecialty of telemedicine that continues to evolve with advances in telecommunication and mobile phone technology. A 19-week primary care quality improvement project collected baseline data and tested three change ideas, using the Model for Improvement method, with primary and secondary aims: to increase the weekly percentage of remote dermatological consultations with supporting images that were successfully concluded remotely to greater than 80% and to reduce the weekly percentage of dermatological face-to-face consultations to less than 50%. We hypothesised that by improving the quality of patient images and the confidence of reception staff in triaging skin complaints, there would be a decrease in the weekly number of face-to-face dermatological appointments, thereby decreasing the risk of COVID-19 transmission within the practice and community. Two change ideas focused on supporting patients to improve image quality by introducing ‘4 Key Instructions’ and a patient information leaflet (PIL). The third focused on increasing reception staff confidence in triaging skin complaints by introducing a triage pathway guidance tool. A total of 253 dermatological consultations were analysed: 170 of these were telephone consultations with 308 supporting images. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to an increase in completed remote consultation. Our primary outcome measure was achieved. Our secondary outcome measure suggested that in the absence of high-quality images, it might not be possible to reduce dermatological face-to-face consultations much below 50% in primary care. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to the increase in remote consultation. The implications of these findings for the theory of change are discussed.

Effects of COVID-19 Lockdown on Melanoma Diagnosis in Switzerland: Increased Tumor Thickness in Elderly Females and Shift towards Stage IV Melanoma during Lockdown

At the early stages of the COVID-19 outbreak in 2020, Switzerland was among the countries with the highest number of SARS-CoV2-infections per capita in the world. Lockdowns had a remarkable impact on primary care access and resulted in postponed cancer screenings. The aim of this study was to investigate the effects of the COVID-19 lockdown on the diagnosis of melanomas and stage of melanomas at diagnosis. In this retrospective, exploratory cohort study, 1240 patients with a new diagnosis of melanoma were analyzed at five tertiary care hospitals in German-speaking Switzerland over a period of two years and three months. We compared the pre-lockdown (01/FEB/19-15/MAR/20, n = 655) with the lockdown (16/MAR/20-22/JUN/20, n = 148) and post-lockdown period (23/JUN/20-30/APR/21, n = 437) by evaluating patients' demographics and prognostic features using Breslow thickness, ulceration, subtype, and stages. We observed a short-term, two-week rise in melanoma diagnoses after the major lift of social lockdown restrictions. The difference of mean Breslow thicknesses was significantly greater in older females during the lockdown compared to the pre-lockdown (1.9 ± 1.3 mm, p = 0.03) and post-lockdown period (1.9 ± 1.3 mm, p = 0.048). Thickness increase was driven by nodular melanomas (2.9 ± 1.3 mm, p = 0.0021; resp. 2.6 ± 1.3 mm, p = 0.008). A proportional rise of advanced melanomas was observed during lockdown (p = 0.047). The findings provide clinically relevant insights into lockdown-related gender- and age-dependent effects on melanoma diagnosis. Our data highlight a stable course in new melanomas with a lower-than-expected increase in the post-lockdown period. The lockdown period led to a greater thickness in elderly women driven by nodular melanomas and a proportional shift towards stage IV melanoma. We intend to raise awareness for individual cancer care in future pandemic management strategies.

Differences in Thickness-Specific Incidence and Factors Associated With Cutaneous Melanoma in the US From 2010 to 2018

Importance

The recent incidence of cutaneous melanoma of different thicknesses in the US is not well described.

Objective

To evaluate recent patterns in the incidence of melanoma by tumor thickness and examine associations of sex, race and ethnicity, and socioeconomic status with melanoma thickness-specific incidence.

Design, Setting, and Participants

This population-based cohort study analyzed data for 187 487 patients with a new diagnosis of invasive cutaneous melanoma from the Surveillance, Epidemiology, and End Results Registry from January 1, 2010, to December 31, 2018. The study was conducted from May 27 to December 29, 2021. Data were analyzed from June 21 to October 24, 2021.

Main Outcomes and Measures

Age-adjusted incidence rates of melanoma were calculated by tumor thickness (categorized by Breslow thickness) and annual percentage change (APC) in incidence rates. Analyses were stratified by sex and race and ethnicity. The associations with socioeconomic status were evaluated in 134 359 patients diagnosed with melanoma from 2010 to 2016.

Results

This study included 187 487 patients with a median (IQR) age of 62 (52-72) years and 58.4% men. Melanoma incidence was higher in men compared with women across all tumor thickness groups. Individuals in lower socioeconomic status quintiles and members of minority groups were more likely to be diagnosed with thicker (T4) tumors (20.7% [169 of 816] among non-Hispanic Black patients, 11.2% [674 of 6042] among Hispanic patients, and 6.3% [10 774 of 170 155] among non-Hispanic White patients). Between 2010 and 2018, there was no significant increase in incidence of cutaneous melanoma across the full population (APC, 0.39%; 95% CI, -0.40% to 1.18%). The incidence of the thickest melanomas (T4, >4.0 mm) increased between 2010 and 2018, with an APC of 3.32% (95% CI, 2.06%-4.60%) overall, 2.50% (95% CI, 1.27%-3.73%) in men, and 4.64% (95% CI, 2.56%-6.75%) in women.

Conclusions and Relevance

In this population-based cohort study, the incidence of the thickest cutaneous melanoma tumors increased from 2010 to 2018, in contrast with the incidence patterns for thinner melanomas. The findings suggest potential stabilization of overall melanoma incidence rates in the US after nearly a century of continuous increase in incidence. Patients with low socioeconomic status and Hispanic patients were more likely to be diagnosed with thick melanoma. The continued rise in incidence of thick melanoma is unlikely to be attributable to overdiagnosis given the stability of thin melanoma rates.

Emergency Use and Efficacy of an Asynchronous Teledermatology System as a Novel Tool for Early Diagnosis of Skin Cancer during the First Wave of COVID-19 Pandemic

Background: After the outbreak of the corona virus disease-19 (COVID-19) pandemic, teledermatology was implemented in the Hungarian public healthcare system for the first time. Our objective was to assess aggregated diagnostic agreements and to determine the effectiveness of an asynchronous teledermatology system for skin cancer screening. Methods: This retrospective single-center study included cases submitted for teledermatology consultation during the first wave of the COVID-19 pandemic. Follow-up of the patients was performed to collect the results of any subsequent personal examination. Results: 749 patients with 779 lesions were involved. 15 malignant melanomas (9.9%), 78 basal cell carcinomas (51.3%), 21 squamous cell carcinomas (13.8%), 7 other malignancies (4.6%) and 31 actinic keratoses (20.4%) were confirmed. 87 malignancies were diagnosed in the high-urgency group (42.2%), 49 malignancies in the moderate-urgency group (21.6%) and 16 malignancies in the low-urgency group (4.6%) (p < 0.0001). Agreement of malignancies was substantial for primary (86.3%; κ = 0.647) and aggregated diagnoses (85.3%; κ = 0.644). Agreement of total lesions was also substantial for primary (81.2%; κ = 0.769) and aggregated diagnoses (87.9%; κ = 0.754). Conclusions: Our findings showed that asynchronous teledermatology using a mobile phone application served as an accurate skin cancer screening system during the first wave of the COVID-19 pandemic.

Teledermatologie: Fluch oder Segen?

Teledermatologische Dienste haben sich insbesondere während der COVID-19-Pandemie als Alternative zu „Echt“visiten verbreitet. Der Mangel an Dermatologen und die Möglichkeit einer präzisen Diagnose auch bei unterversorgten Regionen macht diese Alternative für alle Beteiligten besonders attraktiv. Trotzdem ist der Bedarf an Schulungen des Personals und der Anwender hoch. Ebenfalls können Implementierungs-, Instandhaltungs- und Wartungskosten der notwendigen Ausrüstung und die Heterogenität der unterschiedlichen Anbieter nachteilig für Patient und Arzt sein. In diesem Artikel werden wesentliche Vorteile und Nachteile der Teledermatologie zusammengefasst.

Melanoma Management during the COVID-19 Pandemic Emergency: A Literature Review and Single-Center Experience

Simple Summary

COVID-19 is a highly contagious infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In March 2020, the World Health Organization (WHO) declared that COVID-19 had become a pandemic; since then, several elective clinical and surgical activities have been postponed to reduce the risk of nosocomial infection. This has influenced the diagnosis and management of many diseases, including melanoma. The aim of our literature review was to evaluate whether the management of melanoma has been changed by the outbreak of COVID-19, and if so, what the consequences of these changes are. The main topics in this literature review are the screening of suspicious lesions, diagnosis of primary melanoma, and the management of early-stage and advanced melanomas in the COVID-19 era. We also reported the experience of our dermatological clinic in Turin, one of the most affected areas in Italy.

Abstract

Background: The current COVID-19 pandemic has influenced the modus operandi of all fields of medicine, significantly impacting patients with oncological diseases and multiple comorbidities. Thus, in recent months, the establishment of melanoma management during the emergency has become a major area of interest. In addition to original articles, case reports and specific guidelines for the period have been developed. Purpose: This article aims to evaluate whether melanoma management has been changed by the outbreak of COVID-19, and if so, what the consequences are. We summarized the main issues concerning the screening of suspicious lesions, the diagnosis of primary melanoma, and the management of early-stage and advanced melanomas during the pandemic. Additionally, we report on the experience of our dermatological clinic in northern Italy. Methods: We performed a literature review evaluating articles on melanomas and COVID-19 published in the last two years on PubMed, as well as considering publications by major healthcare organizations. Concerning oncological practice in our center, we collected data on surgical and therapeutic procedures in patients with a melanoma performed during the first months of the pandemic. Conclusions: During the emergency period, the evaluation of suspicious skin lesions was ensured as much as possible. However, the reduced level of access to medical care led to a documented delay in the diagnosis of new melanomas. When detected, the management of early-stage and advanced melanomas was fully guaranteed, whereas the follow-up visits of disease-free patients have been postponed or replaced with a teleconsultation when possible.

Remote Skin Cancer Diagnosis: Adding Images to Electronic Referrals Is More Efficient Than Wait-Listing for a Nurse-Led Imaging Clinic

Simple Summary

Skin cancer is a significant cause of death and disability, particularly in New Zealand. Expert diagnosis reduces unnecessary excision of benign lesions, reduces patient anxiety, and allows early identification of skin cancer, particularly of melanoma. The study assessed an electronic referral pathway for teledermatology—diagnosing skin lesions remotely using a standardised template with regional, close-up, and dermoscopic images—and compared this to scheduled nurse-led teledermoscopy clinics. A dermatology opinion was reached more rapidly with comparable efficacy when referrals include good quality images, compared to nurse-led imaging clinics.

Abstract

We undertook a retrospective comparison of two teledermatology pathways that provide diagnostic and management advice for suspected skin cancers, to evaluate the time from referral to diagnosis and its concordance with histology. Primary Care doctors could refer patients to either the Virtual Lesion Clinic (VLC), a nurse-led community teledermoscopy clinic or, more recently, to the Suspected Skin Cancer (SSC) pathway, which requires them to attach regional, close-up, and dermoscopic images. The primary objective of this study was to determine the comparative time course between the SSC pathway and VLC. Secondary objectives included comparative diagnostic concordance, skin lesion classification, and evaluation of missed skin lesions during subsequent follow-up. VLC referrals from July to December 2016 and 2020 were compared to SSC referrals from July to December 2020. 408 patients with 682 lesions in the VLC cohort were compared with 480 patients with 548 lesions from the 2020 SSC cohort, matched for age, sex, and ethnicity, including histology where available. Median time (SD) from referral to receipt of teledermatology advice was four (2.8) days and 50 (43.0) days for the SSC and VLC cohorts, respectively (p < 0.001). Diagnostic concordance between teledermatologist and histopathologist for benign versus malignant lesions was 70% for 114 lesions in the SSC cohort, comparable to the VLC cohort (71% of 122 lesions). Referrals from primary care, where skin lesions were imaged with variable devices and quality resulted in faster specialist advice with similar diagnostic performance compared to high-quality imaging at nurse-led specialist dermoscopy clinics.

Consumer Preference and Willingness to Pay for Direct-to-Consumer Mobile Teledermoscopy Services in Australia

OBJECTIVE

To investigate consumer preference and willingness to pay for mobile teledermoscopy services in Australia.

METHODS

Consumers who were taking part in a randomised controlled trial comparing mobile teledermoscopy and skin self-examination were asked to complete a survey which incorporated a discrete choice experiment (DCE) and a contingent valuation question. Responses were used to determine their willingness to pay for mobile teledermoscopy services in Australia and their overall service preferences.

RESULTS

The 199 consumers who responded were 71% female and had a mean age of 42 years (range, 18-73). The DCE results showed that consumers prefer a trained medical professional to be involved in their skin cancer screening. Consumers were willing to pay AUD 41 to change from a general practitioner reviewing their lesions in-person to having a dermatologist reviewing the teledermoscopy images. Additionally, they were willing to pay for services that had shorter waiting times, that reduced the time away from their usual activities, and that have higher accuracy and lower likelihood of unnecessary excision of a skin lesion. When asked directly about their willingness to pay for a teledermoscopy service using a contingent valuation question, the majority (73%) of consumers selected the lowest two value brackets of AUD 1-20 or AUD 21-40.

CONCLUSION

Consumers are willing to pay out of pocket to access services with attributes such as a dermatologist review, improved accuracy, and fewer excisions.

Teledermatology in 2020: past, present and future perspectives

Born in 1995, teledermatology (TD) turns 25 years old today. Since then, TD evolved according to patients and physicians needs. The present review aimed to summarize all the efforts and experiences carried out in the field of TD and its subspecialties, the evolution and the future perspectives. A literature search was conducted in PubMed and Google Scholar. The state of the art of the "tele-dermo research" included TD and clinical trials, TD/TDS web platforms, TDS and artificial intelligence studies. Finally, the future perspective of TD/TDS in the era of social distancing was discussed. Using TD in specific situations adds several benefits including time-effectiveness of intervention and reduction in the waiting time for the first visit, reduced travel-costs, reduced sanitary costs, equalization of access from patient to specialistic consult. The communication technologies devices currently available can adequately support the growing needs of tele-assistance. A main limit is the current lack of a common clear European regulation for practicing TD, encompassing privacy issues and data management. The pandemic lockdown of 2020 has highlighted the importance of performing TD for all those patient, elderly and/or fragile, where the alternative would be no care at all. Many efforts are needed to develop efficient workflows and TD programs to facilitate the interplay among the different TD actors, along with practice guidelines or position statements.

The role of teleconsultation in the management of suspected skin malignancy in plastic surgery during COVID-19 outbreak: A single centre experience

The COVID-19 pandemic has had a profound impact on the provision of skin cancer treatment in the UK. To preserve the service, the department transformed the outpatient skin cancer clinic into teleclinic service. This study examines the safety and efficacy of a teleclinic consultation, in comparison to a face-to-face consultation. We assessed efficacy in terms of accuracy of the clinical diagnosis in comparison to the histopathological result and whether treatment was designated the appropriate clinical priority/urgency. A total of 120 lesions in 98 patients were assessed, 55 patients in the face-to-face clinic cohort, and 43 patients in the teleclinic cohort. Diagnostic accuracy was better in face-to-face clinic compared to teleclinic; 85.0% and 63.6% respectively (χ² (1, N = 120) = 7.35, p = 0.0067). The accuracy of listing patients on the correct pathway was slightly higher for teleclinic patients. Of the teleclinic patients listed through the urgent pathway, 45.7% justified their urgent status, compared with 37.5% of those listed urgent in face-to-face clinic (p = 0.67). For those listed as routine, 100% of teleclinic patients were listed appropriately whereas the accuracy was 96.8% for the face-to-face clinic counterpart. In conclusion, despite teleclinic having slightly reduced diagnostic accuracy, teleclinics show comparable accuracy in listing patients to urgent or routine skin cancer pathways. It offers convenience to patients in addition to reducing time to treatment and cost effectiveness. The lessons learned in the pandemic can be applied to the post-COVID healthcare environment.

Teledermatology Addressing Disparities in Health Care Access: a Review

Purpose of Review

Dermatologists have been at the forefront of researching telemedicine to expand access to care. The current COVID-19 pandemic has prompted even greater expansion and implementation of teledermatology. This review discusses the research examining the potential impact of teledermatology addressing disparities in care.

Recent Findings

Teledermatology appears to increase access to dermatology given expanded means to deliver care. Specifically, recent studies have found increased access among Medicaid-insured, resource-poor urban and rural, and elderly populations. Teledermatology implementation also facilitates education among providers at different levels of training. Still, as some patients have inconsistent access to the required technology, increased reliance on telemedicine may also potentially increase disparities for some populations.

Summary

Teledermatology may serve to reduce disparities in health care access in many underserved and marginalized communities. Future research should continue to study implementation, especially given the expansion during the COVID-19 pandemic. Ultimately, teledermatology may play an important role in ensuring equitable care access for all.

Impact of rurality on melanoma diagnosis in Utah

Aim

To analyze trends in Utah melanoma diagnosis and study the impact of rurality.

Patients & methods

State-wide melanoma incidence was calculated using Surveillance, Epidemiology, and End Results data (2005-2013). A subset of 5199 patients treated in an integrated healthcare system was further stratified for urban or rural residence.

Results

Early-stage tumors accounted for most of the increase in melanoma incidence over time. Age-adjusted melanoma incidence rate was higher in rural counties (46.7 vs 39.4). Anatomic site and stage did not differ between rural and urban patients. Rural patients were more commonly diagnosed by a local primary care provider.

Conclusion

Rurality had an impact on melanoma diagnosis in the specialty and location of the diagnosing provider.

Factors Contributing to Diagnostic Discordance Between Store-and-Forward Teledermatology Consultations and In-Person Visits: Case Series

BACKGROUND

Use of asynchronous store-and-forward (SAF) teledermatology can improve access to timely and cost-effective dermatologic care and has increased during the COVID-19 pandemic. Previous research has found high diagnostic concordance rates between SAF teledermatology and face-to-face clinical diagnosis, but to our knowledge, none have used specific cases to illustrate factors contributing to diagnostic discordance.

OBJECTIVE

To identify and illustrate characteristics that may have contributed to diagnostic discordance between store-and-forward teledermatology and in-person clinical diagnosis in a series of patients.

METHODS

We identified 7 cases of diagnostic discordance between teledermatology and in-person visits where the favored diagnosis of the in-person dermatologist was not included in the differential diagnosis formulated by the teledermatologist. Cases were identified from a previously published retrospective chart review of 340 SAF teledermatology consultations, which was previously performed at an academic community health care system in the greater Boston area, Massachusetts, from January 1, 2014, through December 31, 2017. Of 99 patients who completed an in-person dermatology appointment after their teledermatology consultation, 7 had diagnostic disagreement between the teledermatologist and in-person dermatologist where the diagnosis in the in-person consultation was not included in the differential diagnosis in the original teledermatology consult. These 7 cases were examined by 2 author reviewers to identify factors that may have contributed to diagnostic discordance.

RESULTS

Factors contributing to diagnostic discordance between SAF teledermatology consultations and in-person visits included poor image quality, inadequate history or diagnostic workup, inability to evaluate textural characteristics, diagnostic uncertainty due to atypical presentations, and evolution in appearance of skin conditions over time.

CONCLUSIONS

We identified multiple factors that contributed to diagnostic discordance. Recognition and mitigation of these factors, when possible, may help to improve diagnostic accuracy and reduce the likelihood of misdiagnosis. Continuing education of referring providers and implementation of standardized guidelines for referrals may also be helpful in reducing the risk of misdiagnosis due to inherent limitations of teledermatology services.

Suitability of Video Consultations During the COVID-19 Pandemic Lockdown: Cross-sectional Survey Among Norwegian General Practitioners

Background

The COVID-19 pandemic imposed an acute, sharp rise in the use of video consultations (VCs) by general practitioners (GPs) in Norway.

Objective

This study aims to document GPs’ experiences with the large-scale uptake of VCs in the natural experiment context of the pandemic.

Methods

A nationwide, cross-sectional online survey was conducted among Norwegian GPs during the pandemic lockdown (April 14-May 3, 2020). Each respondent was asked to evaluate up to 10 VCs. Basic demographic characteristics of the GPs and their practices were collected. The associations between GPs’ perceived suitability of the VCs, the nature of the patients’ main problems, prior knowledge of the patients (relational continuity), and follow-up of previously presented problems (episodic continuity) were explored using descriptive statistics, diagrams, and chi-square tests.

Results

In total, 1237 GPs (26% of the target group) responded to the survey. Among these, 1000 GPs offered VCs, and 855 GPs evaluated a total of 3484 VCs. Most GPs who offered VCs (1000/1237; 81%) had no experience with VCs before the pandemic. Overall, 51% (1766/3476) of the evaluated VCs were considered to have similar or even better suitability to assess the main reason for contact, compared to face-to-face consultations. In the presence of relational continuity, VCs were considered equal to or better than face-to-face consultations in 57% (1011/1785) of cases, as opposed to 32% (87/274) when the patient was unknown. The suitability rate for follow-up consultations (episodic continuity) was 61% (1165/1919), compared to 35% (544/1556) for new patient problems. Suitability varied considerably across clinical contact reasons. VCs were found most suitable for anxiety and life stress, depression, and administrative purposes, as well as for longstanding or complex problems that normally require multiple follow-up consultations. The GPs estimate that they will conduct about 20% of their consultations by video in a future, nonpandemic setting.

Conclusions

Our study of VCs performed in general practice during the pandemic lockdown indicates a clear future role for VCs in nonpandemic settings. The strong and consistent association between continuity of care and GPs’ perceptions of the suitability of VCs is a new and important finding with considerable relevance for future primary health care planning.

Treating Melanoma in Situ During a Pandemic with Telemedicine and a Combination of Imiquimod, 5-Fluorouracil, and Tretinoin

The recent coronavirus disease 2019 (COVID-19) pandemic has created a quandary for the physician in terms of evaluating and treating cutaneous skin cancers, particularly melanomas. At the onset of the pandemic, many planned medical and surgical visits for skin cancers were postponed. Physicians and patients have had to balance the risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with that of worsening morbidity and mortality due to delays in skin cancer treatments. We present a male patient who had two melanoma-in-situs (MISs) that were treated during the COVID-19 pandemic with a combination of topical imiquimod 5% cream, 5-fluorouracil 2% solution, and tretinoin 0.1% cream. The successful treatments occurred without in-person visits and with the aid of telemedicine. Although surgery is the standard for the treatment of melanoma in situ, this case demonstrates an effective viable treatment modality for MIS during a pandemic situation.

Evaluation of Diagnostic Tests

As technology advances, diagnostic tests continue to improve and each year, we are presented with new alternatives to standard procedures. Given the plethora of diagnostic alternatives, diagnostic tests must be evaluated to determine their place in the diagnostic armamentarium. The first step involves determining the accuracy of the test, including the sensitivity and specificity, positive and negative predictive values, likelihood ratios for positive and negative tests, and receiver operating characteristic (ROC) curves. The role of the test in a diagnostic pathway has then to be determined, following which the effect on patient outcome should be examined.

Identification of Incidental Skin Cancers Among Adults Referred to Dermatologists for Suspicious Skin Lesions

IMPORTANCE

The incidence of skin cancer is increasing and evaluation of the utility of total body skin examination (TBSE) in detecting incidental skin cancers is warranted.

OBJECTIVES

To evaluate the proportion and rate of incidental skin cancer detection in urgent skin cancer clinics and investigate the rate of incidental skin cancer detection in 2 groups based on the degree of clinical suspicion of the index lesion for malignancy.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter retrospective cohort study with a case note review of consecutive secondary care consultations was conducted using data from 2 urgent suspected skin cancer screening clinics in UK National Health Service trusts. The study was performed from January 1, 2015, to March 31, 2016, and data analysis was performed from October 14, 2018, to February 1, 2019. Patients included those presenting with a skin lesion suspicious of malignancy who were referred to the urgent suspected skin cancer clinic (N = 5944) over 15 months. Patients who accepted and received a TBSE were subsequently included in the analysis.

MAIN OUTCOMES AND MEASURES

The proportion and rate of incidental skin cancer detection through TBSE and whether a clinically suspicious (malignant) index lesion was associated with a higher chance of having a malignant incidental lesion.

RESULTS

Of the 5944 patients referred to the clinic, 4726 individuals (79.5%) were evaluated. In the cohort included in the analyses, the median age was 57 years (interquartile range, 39-73 years); 2567 patients (54.3%) were women. A total of 1117 skin cancers were identified; of these, 242 lesions (21.7%) were detected incidentally through TBSE, including 197 of 570 (34.6%) basal cell carcinomas, 16 of 250 (6.4%) squamous cell carcinomas, and 25 of 215 (11.6%) melanomas. The detection rate of incidental malignant lesions was 5.1 lesions per 100 patients examined (5.1%; 95% CI, 4.5%-5.8%). There was a higher detection rate of histologically confirmed incidental malignant lesions in individuals with clinically suspicious index lesions requiring biopsy (10.9%; 95% CI, 9.5%-12.5%) compared with those presenting with clinically benign index lesions (2.0%; 95% CI, 1.6%-2.5%) (P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this study support the use of TBSE for urgent skin cancer referrals, highlighting the potential harms of solitary lesion assessment in a subgroup. Individuals presenting with a clinically suspicious index lesion requiring biopsy are most likely to benefit from TBSE and should be counseled regarding the benefit.

Part II: Accuracy of Teledermatology in Skin Neoplasms

Teledermatology has been proving to be of great help for delivering healthcare, especially now, during the SARS-CoV-2 pandemic. It is crucial to assess how accurate this method can be for evaluating different dermatoses. Such knowledge can contribute to the dermatologists' decision of whether to adhere to teledermatology or not. Our objective was to determine the accuracy of teledermatology in the 10 most frequent skin neoplasms in our population, comparing telediagnosis to histopathological report and in-person dermatologists' diagnosis. A retrospective cohort study was conducted in São Paulo, Brazil, where a store-and-forward teledermatology project was implemented under primary-care attention to triage surgical, more complex, or severe dermatoses. A total of 30,976 patients presenting 55,012 lesions took part in the project. Thirteen teledermatologists who participated in the project had three options to refer the patients: send them directly to biopsy, to the in-person dermatologist, or back to the general physician with the most probable diagnosis and management. In the groups referred to the in-person dermatologist and biopsy, we looked for the 10 most frequent International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10) of skin neoplasms, which resulted in 289 histopathologic reports and 803 in-person dermatologists' diagnosis. We were able to compare the ICD-10 codes filled by teledermatologists, in-person dermatologists, and from histopathological reports. The proportion of complete, partial, and no agreement rates between the in-person dermatologist's, histopathologic report, and the teledermatologist's diagnosis was assessed. We also calculated Cohen's kappa, for complete and complete plus partial agreement. The mean complete agreement rate comparing telediagnosis to histopathological report was 54% (157/289; kappa = 0.087), being the highest for malign lesions; to in-person dermatologists was 61% (487/803; kappa = 0.213), highest for benign lesions. When accuracy of telediagnosis for either malign or benign lesions was evaluated, the agreement rate with histopathology was 70% (kappa = 0.529) and with in-person dermatologist, 81% (kappa = 0.582). This study supports that teledermatology for skin neoplasms has moderate accuracy. This result reassures that it can be a proper option for patient care, especially when the goal is to differentiate benign from malign lesions.

Part I: Accuracy of Teledermatology in Inflammatory Dermatoses

Teledermatology is assuming a progressively greater role as a healthcare delivery method, especially now, during this pandemic time. It is important to know how accurate this tool is for different skin diseases. Most of the studies have focused on skin neoplasms or general dermatology. Studies based on a large number of inflammatory dermatoses have not yet been performed. Such knowledge can help dermatologists to decide whether endorsing this method or not. Our objective was to determine the accuracy of teledermatology in inflammatory dermatoses in a robust number of cases. A retrospective cohort study was conducted in São Paulo, Brazil, from July 2017–18, where a store-and-forward Teledermatology project was implemented under primary-care attention to triage surgical, more complex, or severe dermatoses. A total of 30,976 patients presenting 55,012 lesions took part in the project. Thirteen participating teledermatologists had three options to refer the patients: directly to biopsy, to the in-person dermatologist or back to the general physician with most probable diagnosis and management. In the group referred to the in-person dermatologist, we looked for the 20 most frequent International Classification of Diseases and Related Health Problems- 10th revision (ICD-10) of inflammatory dermatoses, which resulted in 739 patients and 739 lesions. As patients had been triaged by teledermatology previously, we were able to compare ICD-10 codes filled both by teledermatogists and by in-person dermatologists. The proportion of complete, partial, and no agreement rates between the in-person dermatologist's and the teledermatologist's diagnoses was used for accuracy. We also calculated Cohen's kappa, a statistical measure of inter-rater agreement, for complete agreement. The mean complete agreement rate for all twenty dermatoses was 78% (31–100%) and kappa = 0.743; partial agreement 8%; and no agreement 14%, presenting variability according to the disease. Our study showed that teledermatology for inflammatory dermatoses has a high accuracy. This result reassures that it can be a proper option for patient care.

Teledermatology: current indications and considerations for future use

Telemedicine is one of the most consequential technologies in modern healthcare. In certain situations, it allows for the delivery of care with high quality and minimal difficulty. This is particularly true in dermatology, in which many dermatological conditions can be treated remotely. The burden on dermatology patients has been greatly reduced for certain pathologies due to telemedicine. Health care providers also achieve improved job satisfaction following the convenience of meeting their patients. This paper details select dermatological conditions, and subsequently divides them into those treatable by telemedicine appointments, and those requiring face to face appointments.

Telemedicine as the New Outpatient Clinic Gone Digital: Position Paper From the Pandemic Health System REsilience PROGRAM (REPROGRAM) International Consortium (Part 2)

Technology has acted as a great enabler of patient continuity through remote consultation, ongoing monitoring, and patient education using telephone and videoconferencing in the coronavirus disease 2019 (COVID-19) era. The devastating impact of COVID-19 is bound to prevail beyond its current reign. The vulnerable sections of our community, including the elderly, those from lower socioeconomic backgrounds, those with multiple comorbidities, and immunocompromised patients, endure a relatively higher burden of a pandemic such as COVID-19. The rapid adoption of different technologies across countries, driven by the need to provide continued medical care in the era of social distancing, has catalyzed the penetration of telemedicine. Limiting the exposure of patients, healthcare workers, and systems is critical in controlling the viral spread. Telemedicine offers an opportunity to improve health systems delivery, access, and efficiency. This article critically examines the current telemedicine landscape and challenges in its adoption, toward remote/tele-delivery of care, across various medical specialties. The current consortium provides a roadmap and/or framework, along with recommendations, for telemedicine uptake and implementation in clinical practice during and beyond COVID-19.

Remote assessment in sport and exercise medicine (SEM): a narrative review and teleSEM solutions for and beyond the COVID-19 pandemic

Background

The COVID-19 pandemic forces sport and exercise medicine (SEM) physicians to think differently about the clinical care of patients. Many rapidly implement eHealth and telemedicine solutions specific to SEM without guidance on how best to provide these services.

Aim

The aim of this paper is to present some guiding principles on how to plan for and perform an SEM consultation remotely (teleSEM) based on a narrative review of the literature. A secondary aim is to develop a generic teleSEM injury template.

Results

eHealth and telemedicine are essential solutions to effective remote patient care, also in SEM. This paper provides guidance for wise planning and delivery of teleSEM. It is crucial for SEM physicians, technology providers and organisations to codesign teleSEM services, ideally involving athletes, coaches and other clinicians involved in the clinical care of athletes, and to gradually implement these services with appropriate support and education.

Conclusion

teleSEM provides solutions for remote athlete clinical care during and after the COVID-19 pandemic. We define two new terms—eSEM and teleSEM and discuss guiding principles on how to plan for and perform SEM consultations remotely (teleSEM). We provide an example of a generic teleSEM injury assessment guide.

Consumer Preferences for Skin Cancer Screening Using Mobile Teledermoscopy: A Qualitative Study

BACKGROUND

Mobile teledermoscopy is a rapidly advancing technology that promotes early detection and management of skin cancers. Whilst the use of teledermoscopy has proven to be effective and has a role in the detection of skin cancers, patients' attitudes towards the multiple ways in which this technology can be utilised has not been explored.

METHODS

Data were obtained from a large randomised controlled trial comparing mobile teledermoscopy-enhanced skin self-examinations (SSEs) with naked-eye SSE. A semi-structured interview guide was developed by the investigators with questions focusing on people's previous skin screening behaviours and 2 of the major pathways which can be utilised in mobile teledermoscopy: (i) direct-to-consumer and (ii) doctor-to-doctor. All interviews were tape-recorded and transcribed verbatim. Thematic analysis was undertaken by 2 independent researchers.

RESULTS

Twenty-eight participants were interviewed. Eighty-six percent of participants (n = 24/28) had previously had a clinical skin examination. Only 18% of participants (n = 5/28) visited the same doctor for each clinical skin examination. Five main themes were identified in the interviews that affected how people felt about the integration of mobile teledermoscopy into skin screening pathways: history of clinical skin examinations, continuity of the doctor-patient relationship, convenience of the direct-to-consumer teledermoscopy, expedited review enhancing the doctor-to-doctor setting and mobile teledermoscopy as a partner-assisted task.

CONCLUSIONS

Overall mobile teledermoscopy was viewed positively for both direct-to-consumer and doctor-to-doctor interaction. Continuity of care in the doctor-patient relationship was not found to be a priority for clinical skin examination with most participants visiting several doctors throughout their clinical skin examination history.

Recognising Skin Cancer in Primary Care

Skin cancer, including melanoma, basal cell carcinoma and cutaneous squamous cell carcinoma, has one of the highest global incidences of any form of cancer. In 2016 more than 16,000 people were diagnosed with melanoma in the UK. Over the last decade the incidence of melanoma has increased by 50% in the UK, and about one in ten melanomas are diagnosed at a late stage. Among the keratinocyte carcinomas (previously known as non-melanoma skin cancers), basal cell carcinoma is the most common cancer amongst Caucasian populations. The main risk factor for all skin cancer is exposure to ultraviolet radiation-more than 80% are considered preventable. Primary care clinicians have a vital role to play in detecting and managing patients with skin lesions suspected to be skin cancer, as timely diagnosis and treatment can improve patient outcomes, particularly for melanoma. However, detecting skin cancer can be challenging, as common non-malignant skin lesions such as seborrhoeic keratoses share features with less common skin cancers. Given that more than 80% of skin cancers are attributed to ultraviolet (UV) exposure, primary care clinicians can also play an important role in skin cancer prevention. This article is one of a series discussing cancer prevention and detection in primary care. Here we focus on the most common types of skin cancer: melanoma, squamous cell carcinoma and basal cell carcinoma. We describe the main risk factors and prevention advice. We summarise key guidance on the symptoms and signs of skin cancers and their management, including their initial assessment and referral. In addition, we review emerging technologies and diagnostic aids which may become available for use in primary care in the near future, to aid the triage of suspicious skin lesions.

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.

Poor agreement between the automated risk assessment of a smartphone application for skin cancer detection and the rating by dermatologists

Background

Several smartphone applications (app) with an automated risk assessment claim to be able to detect skin cancer at an early stage. Various studies that have evaluated these apps showed mainly poor performance. However, all studies were done in patients and lesions were mainly selected by a specialist.

Objectives

To investigate the performance of the automated risk assessment of an app by comparing its assessment to that of a dermatologist in lesions selected by the participants.

Methods

Participants of a National Skin Cancer Day were enrolled in a multicentre study. Skin lesions indicated by the participants were analysed by the automated risk assessment of the app prior to blinded rating by the dermatologist. The ratings of the automated risk assessment were compared to the assessment and diagnosis of the dermatologist. Due to the setting of the Skin Cancer Day, lesions were not verified by histopathology.

Results

We included 125 participants (199 lesions). The app was not able to analyse 90 cases (45%) of which nine BCC, four atypical naevi and one lentigo maligna. Thirty lesions (67%) with a high and 21 with a medium risk (70%) rating by the app were diagnosed as benign naevi or seborrhoeic keratoses. The interobserver agreement between the ratings of the automated risk assessment and the dermatologist was poor (weighted kappa = 0.02; 95% CI −0.08‐0.12; P = 0.74).

Conclusions

The rating of the automated risk assessment was poor. Further investigations about the diagnostic accuracy in real‐life situations are needed to provide consumers with reliable information about this healthcare application.

Reflectance confocal microscopy 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. Early detection and treatment is key to improving survival; however, anxiety around missing early cases needs to be balanced against appropriate levels of referral and excision of benign lesions. Used in conjunction with clinical or dermoscopic suspicion of malignancy, or both, reflectance confocal microscopy (RCM) may reduce unnecessary excisions without missing melanoma cases.

OBJECTIVES

To determine the diagnostic accuracy of reflectance confocal microscopy for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults with any lesion suspicious for melanoma and lesions that are difficult to diagnose, and to compare its accuracy with that of dermoscopy.

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; and seven other databases. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Studies of any design that evaluated RCM alone, or RCM in comparison to dermoscopy, in adults with lesions suspicious for melanoma or atypical intraepidermal melanocytic variants, 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 threshold were missing. We estimated summary sensitivities and specificities per algorithm and threshold using the bivariate hierarchical model. To compare RCM with dermoscopy, we grouped studies by population (defined by difficulty of lesion diagnosis) and combined data 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 specificity at the point on the SROC curve with 90% sensitivity as this value lies within the estimates for the majority of analyses. We investigated the impact of using a purposely developed RCM algorithm and in-person test interpretation.

MAIN RESULTS

The search identified 18 publications reporting on 19 study cohorts with 2838 lesions (including 658 with melanoma), which provided 67 datasets for RCM and seven for dermoscopy. Studies were generally at high or unclear risk of bias across almost all domains and of high or unclear concern regarding applicability of the evidence. Selective participant recruitment, lack of blinding of the reference test to the RCM result, and differential verification were particularly problematic. Studies may not be representative of populations eligible for RCM, and test interpretation was often undertaken remotely from the patient and blinded to clinical information.Meta-analysis found RCM to be more accurate than dermoscopy in studies of participants with any lesion suspicious for melanoma and in participants with lesions that were more difficult to diagnose (equivocal lesion populations). Assuming a fixed sensitivity of 90% for both tests, specificities were 82% for RCM and 42% for dermoscopy for any lesion suspicious for melanoma (9 RCM datasets; 1452 lesions and 370 melanomas). For a hypothetical population of 1000 lesions at the median observed melanoma prevalence of 30%, this equated to a reduction in unnecessary excisions with RCM of 280 compared to dermoscopy, with 30 melanomas missed by both tests. For studies in equivocal lesions, specificities of 86% would be observed for RCM and 49% for dermoscopy (7 RCM datasets; 1177 lesions and 180 melanomas). At the median observed melanoma prevalence of 20%, this reduced unnecessary excisions by 296 with RCM compared with dermoscopy, with 20 melanomas missed by both tests. Across all populations, algorithms and thresholds assessed, the sensitivity and specificity of the Pellacani RCM score at a threshold of three or greater were estimated at 92% (95% confidence interval (CI) 87 to 95) for RCM and 72% (95% CI 62 to 81) for dermoscopy.

AUTHORS' CONCLUSIONS

RCM may have a potential role in clinical practice, particularly for the assessment of lesions that are difficult to diagnose using visual inspection and dermoscopy alone, where the evidence suggests that RCM may be both more sensitive and specific in comparison to dermoscopy. Given the paucity of data to allow comparison with dermoscopy, the results presented require further confirmation in prospective studies comparing RCM with dermoscopy in a real-world setting in a representative population.

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.

Exfoliative cytology for diagnosing basal cell carcinoma and other skin cancers in adults

BACKGROUND

Early accurate detection of all skin cancer types is essential to guide appropriate management, reduce morbidity and improve survival. Basal cell carcinoma (BCC) is usually localised to the skin but has potential to infiltrate and damage surrounding tissue, while cutaneous squamous cell carcinoma (cSCC) and melanoma have a much higher potential to metastasise and ultimately lead to death. Exfoliative cytology is a non-invasive test that uses the Tzanck smear technique to identify disease by examining the structure of cells obtained from scraped samples. This simple procedure is a less invasive diagnostic test than a skin biopsy, and for BCC it has the potential to provide an immediate diagnosis that avoids an additional clinic visit to receive skin biopsy results. This may benefit patients scheduled for either Mohs micrographic surgery or non-surgical treatments such as radiotherapy. A cytology scrape can never give the same information as a skin biopsy, however, so it is important to better understand in which skin cancer situations it may be helpful.

OBJECTIVES

To determine the diagnostic accuracy of exfoliative cytology for detecting basal cell carcinoma (BCC) in adults, and to compare its accuracy with that of standard diagnostic practice (visual inspection with or without dermoscopy). Secondary objectives were: to determine the diagnostic accuracy of exfoliative cytology for detecting cSCC, invasive melanoma and atypical intraepidermal melanocytic variants, and any other skin cancer; and for each of these secondary conditions to compare the accuracy of exfoliative cytology with visual inspection with or without dermoscopy in direct test comparisons; and to determine the effect of observer experience.

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 also studied the reference lists of published systematic review articles.

SELECTION CRITERIA

Studies evaluating exfoliative cytology in adults with lesions suspicious for BCC, cSCC or melanoma, compared with a reference standard of histological confirmation.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). Where possible we estimated summary sensitivities and specificities using the bivariate hierarchical model.

MAIN RESULTS

We synthesised the results of nine studies contributing a total of 1655 lesions to our analysis, including 1120 BCCs (14 datasets), 41 cSCCs (amongst 401 lesions in 2 datasets), and 10 melanomas (amongst 200 lesions in 1 dataset). Three of these datasets (one each for BCC, melanoma and any malignant condition) were derived from one study that also performed a direct comparison with dermoscopy. Studies were of moderate to poor quality, providing inadequate descriptions of participant selection, thresholds used to make cytological and histological diagnoses, and blinding. Reporting of participants' prior referral pathways was particularly poor, as were descriptions of the cytodiagnostic criteria used to make diagnoses. No studies evaluated the use of exfoliative cytology as a primary diagnostic test for detecting BCC or other skin cancers in lesions suspicious for skin cancer. Pooled data from seven studies using standard cytomorphological criteria (but various stain methods) to detect BCC in participants with a high clinical suspicion of BCC estimated the sensitivity and specificity of exfoliative cytology as 97.5% (95% CI 94.5% to 98.9%) and 90.1% (95% CI 81.1% to 95.1%). respectively. When applied to a hypothetical population of 1000 clinically suspected BCC lesions with a median observed BCC prevalence of 86%, exfoliative cytology would miss 21 BCCs and would lead to 14 false positive diagnoses of BCC. No false positive cases were histologically confirmed to be melanoma. Insufficient data are available to make summary statements regarding the accuracy of exfoliative cytology to detect melanoma or cSCC, or its accuracy compared to dermoscopy.

AUTHORS' CONCLUSIONS

The utility of exfoliative cytology for the primary diagnosis of skin cancer is unknown, as all included studies focused on the use of this technique for confirming strongly suspected clinical diagnoses. For the confirmation of BCC in lesions with a high clinical suspicion, there is evidence of high sensitivity and specificity. Since decisions to treat low-risk BCCs are unlikely in practice to require diagnostic confirmation given that clinical suspicion is already high, exfoliative cytology might be most useful for cases of BCC where the treatments being contemplated require a tissue diagnosis (e.g. radiotherapy). The small number of included studies, poor reporting and varying methodological quality prevent us from drawing strong conclusions to guide clinical practice. Despite insufficient data on the use of cytology for cSCC or melanoma, it is unlikely that cytology would be useful in these scenarios since preservation of the architecture of the whole lesion that would be available from a biopsy provides crucial diagnostic information. Given the paucity of good quality data, appropriately designed prospective comparative studies may be required to evaluate both the diagnostic value of exfoliative cytology by comparison to dermoscopy, and its confirmatory value in adequately reported populations with a high probability of BCC scheduled for further treatment requiring a tissue diagnosis.

Computer-assisted diagnosis techniques (dermoscopy and spectroscopy-based) for diagnosing skin cancer in adults

BACKGROUND

Early accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and cutaneous squamous cell carcinoma (cSCC) are high-risk skin cancers which have the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC) is usually localised with potential to infiltrate and damage surrounding tissue. Anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Computer-assisted diagnosis (CAD) systems use artificial intelligence to analyse lesion data and arrive at a diagnosis of skin cancer. When used in unreferred settings ('primary care'), CAD may assist general practitioners (GPs) or other clinicians to more appropriately triage high-risk lesions to secondary care. Used alongside clinical and dermoscopic suspicion of malignancy, CAD may reduce unnecessary excisions without missing melanoma cases.

OBJECTIVES

To determine the accuracy of CAD systems for diagnosing cutaneous invasive melanoma and atypical intraepidermal melanocytic variants, BCC or cSCC in adults, and to compare its accuracy with that of dermoscopy.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials (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 CAD alone, or in comparison with dermoscopy, in adults with lesions suspicious for melanoma or BCC or cSCC, and 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 threshold were missing. We estimated summary sensitivities and specificities separately by type of CAD system, using the bivariate hierarchical model. We compared CAD with dermoscopy using (a) all available CAD data (indirect comparisons), and (b) studies providing paired data for both tests (direct comparisons). We tested the contribution of human decision-making to the accuracy of CAD diagnoses in a sensitivity analysis by removing studies that gave CAD results to clinicians to guide diagnostic decision-making.

MAIN RESULTS

We included 42 studies, 24 evaluating digital dermoscopy-based CAD systems (Derm-CAD) in 23 study cohorts with 9602 lesions (1220 melanomas, at least 83 BCCs, 9 cSCCs), providing 32 datasets for Derm-CAD and seven for dermoscopy. Eighteen studies evaluated spectroscopy-based CAD (Spectro-CAD) in 16 study cohorts with 6336 lesions (934 melanomas, 163 BCC, 49 cSCCs), providing 32 datasets for Spectro-CAD and six for dermoscopy. These consisted of 15 studies using multispectral imaging (MSI), two studies using electrical impedance spectroscopy (EIS) and one study using diffuse-reflectance spectroscopy. Studies were incompletely reported and at unclear to high risk of bias across all domains. Included studies inadequately address the review question, due to an abundance of low-quality studies, poor reporting, and recruitment of highly selected groups of participants.Across all CAD systems, we found considerable variation in the hardware and software technologies used, the types of classification algorithm employed, methods used to train the algorithms, and which lesion morphological features were extracted and analysed across all CAD systems, and even between studies evaluating CAD systems. Meta-analysis found CAD systems had high sensitivity for correct identification of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in highly selected populations, but with low and very variable specificity, particularly for Spectro-CAD systems. Pooled data from 22 studies estimated the sensitivity of Derm-CAD for the detection of melanoma as 90.1% (95% confidence interval (CI) 84.0% to 94.0%) and specificity as 74.3% (95% CI 63.6% to 82.7%). Pooled data from eight studies estimated the sensitivity of multispectral imaging CAD (MSI-CAD) as 92.9% (95% CI 83.7% to 97.1%) and specificity as 43.6% (95% CI 24.8% to 64.5%). When applied to a hypothetical population of 1000 lesions at the mean observed melanoma prevalence of 20%, Derm-CAD would miss 20 melanomas and would lead to 206 false-positive results for melanoma. MSI-CAD would miss 14 melanomas and would lead to 451 false diagnoses for melanoma. Preliminary findings suggest CAD systems are at least as sensitive as assessment of dermoscopic images for the diagnosis of invasive melanoma and atypical intraepidermal melanocytic variants. We are unable to make summary statements about the use of CAD in unreferred populations, or its accuracy in detecting keratinocyte cancers, or its use in any setting as a diagnostic aid, because of the paucity of studies.

AUTHORS' CONCLUSIONS

In highly selected patient populations all CAD types demonstrate high sensitivity, and could prove useful as a back-up for specialist diagnosis to assist in minimising the risk of missing melanomas. However, the evidence base is currently too poor to understand whether CAD system outputs translate to different clinical decision-making in practice. Insufficient data are available on the use of CAD in community settings, or for the detection of keratinocyte cancers. The evidence base for individual systems is too limited to draw conclusions on which might be preferred for practice. Prospective comparative studies are required that evaluate the use of already evaluated CAD systems as diagnostic aids, by comparison to face-to-face dermoscopy, and in participant populations that are representative of those in which the test would be used in practice.