Educational and Screening Campaigns to Reduce Deaths from Melanoma

A qualitative descriptive study of a novel nurse-led skin cancer screening model in rural Australia

Background

People residing in rural areas have higher rates of skin cancer and face barriers to accessing care. Models of skin cancer care addressing the specific needs of rural communities and overcoming specific challenges are required, but literature is scarce. This study aimed to describe the elements of a nurse-led skin cancer model in rural Victoria using qualitative methodology and programme logic to inform implementation and ongoing sustainability.

Methods

Qualitative descriptive design. Semi-structured interviews were conducted with key stakeholders involved in the skin cancer model, namely health service executive management, clinical staff, and administration staff. Interviews were audio-recorded and transcribed verbatim. Transcripts were thematically analysed independently by two researchers before themes were compared and refined. A programme logic model was developed to organise themes into contextual elements, inputs, activities and anticipated outcomes; it was also used as a visual tool to aid discussions with key stakeholders. Member checking of the logic model occurred to verify interpretation. This programme logic model will be refined throughout the implementation phase, and again after three years of service delivery.

Results

Eight stakeholders participated in interviews. Thematic analysis identified three major themes: the influence of the local rural context, the elements of the model, and “making it happen’. These major themes and accompanying sub-themes were mapped to the programme logic model by contextual elements (rural locale, health service access barriers, burden of disease), key inputs (promotion, human resources including appropriate nurse training and leadership) and ‘making it happen’ (governance including referral pathways, flexible and sustained funding, and partnerships). The anticipated outcomes identified include skin cancer care delivered locally, timely access, career development for nurses, and decreased skin cancer burden.

Conclusion

An initiative that is place-based and community driven in response to consumer demand addresses key system barriers to earlier detection of skin cancers. It is anticipated to result in flow-on reductions in skin cancer disease burden. Programme logic was useful to both describe the initiative and as a visual tool for discussions, with the potential to inform wider health service efforts to address system barriers and bottlenecks.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08411-6.

Development and preliminary validation of the physician support of skin self-examination scale

Skin self-examination (SSE) is a crucial preventive health behaviour in melanoma survivors, as it facilitates early detection. Physician endorsement of SSE is important for the initiation and maintenance of this behaviour. This study focussed on the preliminary validation of a new nine-item measure assessing physician support of SSE in melanoma patients. English and French versions of this measure were administered to 188 patients diagnosed with melanoma in the context of a longitudinal study investigating predictors and facilitators of SSE. Structural validity was investigated using exploratory factor analysis conducted in Mplus and convergent and divergent validity was assessed using bivariate correlations conducted in spss. Results suggest that the scale is a unidimensional and reliable measure of physician support for SSE. Given the uncertainty regarding the optimal frequency of SSE for at-risk individuals, we recommend that future psychometric evaluations of this scale consider tailoring items according to the most up-to-date research on SSE effectiveness.

The role of spatially-derived access-to-care characteristics in melanoma prevention and control in Los Angeles county

Among 10,068 incident cases of invasive melanoma, we examined the effects of patient characteristics and access-to-care on the risk of advanced melanoma. Access-to-care was defined in terms of census tract-level sociodemographics, health insurance, cost of dermatological services and appointment wait-times, clinic density and travel distance. Public health insurance and education level were the strongest predictors of advanced melanomas but were modified by race/ethnicity and poverty: Hispanic whites and high-poverty neighborhoods were worse off than non-Hispanic whites and low-poverty neighborhoods. Targeting high-risk, underserved Hispanics and high-poverty neighborhoods (easily identified from existing data) for early melanoma detection may be a cost-efficient strategy to reduce melanoma mortality.

Melanoma screening: A plan for improving early detection

Malignant melanoma ranks fifth in the number of new cases annually in the United States (US). Despite increasing incidence and lack of recent improvement in mortality, national melanoma screening guidelines are currently not in existence. Our purpose was to review the evidence regarding screening whole-body skin examinations for early detection and a possible mortality benefit for malignant melanoma. Data sources for our review were MEDLINE Complete, PubMed, Cochrane Library, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. Study selection included: epidemiologic data from the US and European cancer surveillance registries, population-based case-control screening trials, computer-simulated Markov model trials, and survey trials. Studies were limited to those published in the English language. Data was extracted using a dual extraction method. Data from studies have shown that the mortality of malignant melanoma is highly predicated on the tumor thickness at the time of diagnosis. Our data review is in support of the implementation of whole-body skin examinations, performed by primary care physicians, for the purpose of early detection of melanoma. A large national population-based, case-control, skin cancer screening trial in Germany has shown a reduction in melanoma-specific mortality. In conclusion, our review of the evidence supports physicians performed whole-body skin examination can lead to the detection of earlier stage melanomas as well as to a reduction in disease-specific mortality. We found a paucity of randomized trials to be a limitation of screening studies for many cancers, including melanoma. To improve screening rates and early detection of malignant melanoma, we propose making skin cancer education part of the curriculum in US primary care residency programs to become the genesis for widespread melanoma screening. Our study had no funding.

Epidemiology, risk factors, prevention, and early detection of melanoma

The incidence of melanoma has increased over the past several decades. Despite improved case mortality, overall deaths from melanoma have increased because of the large increase in incidence. Although we have a better understanding of the pathogenesis of melanoma and improved early diagnostic capabilities, the burden of disease and societal costs remain high. This article provides an update on the epidemiology of cutaneous melanoma worldwide and the common risk factors including heritable and modifiable risks, emphasizing the importance of education, early detection, and prevention in reducing the disease burden.

Deacetylated GM3 promotes uPAR-associated membrane molecular complex to activate p38 MAPK in metastatic melanoma

GM3, the simplest ganglioside, regulates cell proliferation, migration, and invasion by influencing cell signaling at the membrane level. Although the classic N-acetylated form of GM3 (NeuAcLacCer) is commonly expressed and has been well studied, deacetylated GM3 (NeuNH2LacCer, d-GM3) has been poorly investigated, despite its presence in metastatic tumors but not in noninvasive melanomas or benign nevi. We have recently found that d-GM3 stimulates cell migration and invasion by activating urokinase plasminogen activator receptor (uPAR) signaling to augment matrix metalloproteinase-2 (MMP-2) function. However, the mechanisms by which d-GM3/uPAR increase MMP-2 expression and activation are not clear. By modifying the expression of d-GM3 genetically and biochemically, we found that decreasing d-GM3 expression inhibits, whereas overexpressing d-GM3 stimulates, p38 mitogen-activated protein kinase (MAPK) activity to influence MMP-2 expression and activation. p38 MAPK (p38) activation requires the formation of a membrane complex that contains uPAR, caveolin-1, and integrin α5β1 in membrane lipid rafts. In addition, knocking down or inhibiting focal adhesion kinase (FAK), phosphoinositide 3-kinase (PI3K), or Src kinase significantly reduces d-GM3-induced p38 phosphorylation and activation. Taken together, these results suggest that d-GM3 enhances the metastatic phenotype by activating p38 signaling through uPAR/integrin signaling with FAK, PI3K, and Src kinase as intermediates. Elucidation of the mechanisms by which d-GM3, a newly discovered, potential biomarker of metastatic melanomas, promotes cell metastasis will help us to understand the function of d-GM3 in metastatic melanomas and may lead to novel GM3-based cancer therapies.

Barriers and facilitators of adherence to medical advice on skin self-examination during melanoma follow-up care

BACKGROUND

Melanoma is the fastest growing tumor of the skin, which disproportionately affects younger and middle-aged adults. As melanomas are visible, recognizable, and highly curable while in early stages, early diagnosis is one of the most effective measures to decrease melanoma-related mortality. Skin self-examination results in earlier detection and removal of the melanoma. Due to the elevated risk of survivors for developing subsequent melanomas, monthly self-exams are strongly recommended as part of follow-up care. Yet, only a minority of high-risk individuals practices systematic and regular self-exams. This can be improved through patient education. However, dermatological education is effective only in about 50% of the cases and little is known about those who do not respond. In the current literature, psychosocial variables like distress, coping with cancer, as well as partner and physician support are widely neglected in relation to the practice of skin self-examination, despite the fact that they have been shown to be essential for other health behaviors and for adherence to medical advice. Moreover, the current body of knowledge is compromised by the inconsistent conceptualization of SSE. The main objective of the current project is to examine psychosocial predictors of skin self-examination using on a rigorous and clinically sound methodology.

METHODS/DESIGN

The longitudinal, mixed-method study examines key psychosocial variables related to the acquisition and to the long-term maintenance of skin self-examination in 200 patients with melanoma. Practice of self-exam behaviors is assessed at 3 and 12 months after receiving an educational intervention designed based on best-practice standards. Examined predictors of skin self-exam behaviors include biological sex, perceived self-exam efficacy, distress, partner and physician support, and coping strategies. Qualitative analyses of semi-structured interviews will complement and enlighten the quantitative findings.

DISCUSSION

The identification of short and long-term predictors of skin self-examination and an increased understanding of barriers will allow health care professionals to better address patient difficulties in adhering to this life-saving health behavior. Furthermore, the findings will enable the development and evaluation of evidence-based, comprehensive intervention strategies. Ultimately, these findings could impact a wide range of outreach programs and secondary prevention initiatives for other populations with increased melanoma risk.

Melanoma thickness trends in the United States, 1988-2006

Over the past two decades, numerous efforts have been initiated to improve screening and early detection of melanoma both in the United States and worldwide. It is commonly believed that these efforts have contributed to the stabilization of melanoma mortality, and that the proportion of thick melanoma with unfavorable prognosis is on the decline. Data obtained from 17 population-based cancer registries of the Surveillance Epidemiology and End Result (SEER) program of the National Cancer Institute for 1988-2006 were used to examine trends in melanoma tumor thickness. For malignant melanoma cases with recorded thickness, the proportionate distribution among four thickness categories (<or=1, 1.01-2, 2.01-4, and >4 mm) remained relatively stable over the 19-year study period, however, for melanomas resulting in death, the proportion of thick tumors increased. The most substantial change occurred in the proportion of melanoma in situ, which nearly doubled from 1988 to 2006. Surveillance and early detection efforts in the United States have not resulted in a substantial reduction in the proportion of tumors with prognostically unfavorable thickness. Continued improvement and new methods of screening, especially among demographics with higher incidence of thick tumors, is necessary.