Quality of life issues in nonmetastatic skin cancer

Quality of Life Before and After Radiation Therapy for Early-Stage Keratinocyte Carcinoma: A Longitudinal Analysis

PURPOSE

Little is known about patient-reported quality of life (QOL) before and after radiotherapy (RT) for early keratinocyte carcinoma (KC). The present study tested the hypothesis that QOL is hypothesized to deteriorate soon after RT, with subsequent improvement of a magnitude similar to other KC treatments.

METHODS AND MATERIALS

This observational study assessed prospectively collected longitudinal patient-reported QOL data at a single center. Patients undergoing external beam RT for early-stage (T0-2, <4 cm) KC that completed the Skindex-16 (S16) or Skin Cancer Index (SCI) before and at least once after RT were included. These indices include subscales of symptoms, emotions, and functioning for S16 and emotional, social, and appearance for SCI.

RESULTS

81 patients (median age 79 years) were treated for early KC, most being basal cell carcinomas (87%) on the face (80%) an average of 1.3 cm in diameter. Composite S16 scores and total SCI scores showed significant, clinically meaningful improvements at 3 months and 6 weeks after RT, respectively. QOL declined at 6 weeks after treatment on the S16 symptoms subscale. Concurrently, S16 and SCI emotional subscales significantly improved, and this trend persisted for 2+ years. Improvements in S16 functioning and SCI social and appearance QOL occurred after RT. The magnitude of improvement in QOL 3-12 months after RT was comparable to what has been previously reported after other types of KC treatments, like surgery.

CONCLUSIONS

QOL related to symptoms deteriorates during the first 6 weeks after RT for early KC, but it improves by 3 months. QOL related to emotions, functioning, social, and appearance all improve after RT. These changes in QOL are similar to those observed after other treatments of early KC.

Validation of the Turkish Version of the Skin Cancer Quality of Life Impact Tool (SCQOLIT): A Health-Related Quality of Life Questionnaire for Non-metastatic Melanoma and Non-melanoma Skin Cancer

Introduction: Skin cancer is the third most common type of cancer worldwide that has increased in incidence. Quality of life (QoL) instruments have been developed to measure the efficacy of treatments of  cancers. Objectives: The only validated tool that can be used in both nonmetastatic skin cancer types is the SCQOLIT. This study aimed to validate the Turkish version of the Skin Cancer Quality of Life Impact Tool (SCQOLIT).   Methods: A total of 141 patients diagnosed and treated for skin cancer within the previous 3 months were included.  The tool was translated into Turkish in accordance with International Translation Guidelines. The Dermatology Quality of Life Index that was used for external validation. Patient demographics were recorded. Results: Question 3 had a factor load of 0.372, indicating the inadequacy of this question in predicting QoL, a point that the original study did not mention. The SCQOLIT had external validity, convergent validity and internal consistency (Cronbach alpha=0.863), and test-repeat-test correlation coefficient was 0.824 (95% confidence interval; 0.644 – 0.918). Patients diagnosed with melanoma had poorer QoL scores. High-risk tumor characteristics in nonmelanoma skin cancer and stage of melanoma had no impact on QoL (p=0.235 for basal cell carcinoma, p=1.00 for squamous cell carcinoma, p=0.635 for melanoma).  Conclusions: The Turkish version of the SCQOLIT is validated. Age was shown to have a statistically significant negative correlation with QoL, while Fitzpatrick skin type, gender, risk classification, stage, history of skin cancer, family history of skin cancer and treatment modality had no effect on QoL. 

Mohs micrographic surgery versus wide local excision for eyelid melanoma: An analysis of a national database

BACKGROUND

Although eyelid melanomas represent less than 1% of eyelid neoplasms, they have the worst prognosis. Wide local excision (WLE) and Mohs micrographic surgery (MMS) are mainstay treatment options. We conducted a retrospective analysis to assess all-cause and cause-specific mortality rates in patients undergoing WLE or MMS for eyelid melanoma.

METHODS

A retrospective analysis of Surveillance, Epidemiology, and End Results (SEER) registry was performed for eyelid melanoma treated with WLE or MMS. Cases were limited to American Joint Committee on Cancer (AJCC) stage T1 primary malignancies.

RESULTS

A total of 45 cases of WLE were identified along with 48 cases of MMS for eyelid melanoma. There was no significant difference between subgroups in age group, sex, race, ethnicity, marital status at diagnosis, AJCC N stage, AJCC M stage, melanoma histology, chemotherapy use, and radiotherapy use. Among the cohort, all tumors were unilateral. Kaplan-Meier analysis with log-rank demonstrated no significant difference between MMS and WLE subgroups with regard to overall survival (P = 0.662) and cancer-specific survival (P = 0.494). Cox regression adjusting for variables with α<0.10 and found no significant difference in all-cause mortality (HR, 0.923; 95% CI 0.310-2.747; P = 0.885) or cancer-specific mortality (HR, 0.518; 95% CI 0.047-5.711; P = 0.591) when patients who underwent MMS were compared to those who underwent WLE.

CONCLUSION

While our study is limited by a small number of patients, our analysis demonstrated no significant difference in all-cause or cause-specific survival for patients with eyelid melanoma treated with MMS compared with WLE. In areas requiring preservation of tissue due to cosmetic or functional purposes, MMS is a reasonable surgical approach.

Patient Perception of the Diagnosis Announcement and its Impact on Quality of Life of Patients with Primary Melanoma or Basal Cell Carcinoma

An improved understanding of the impact of skin cancer on patients’ daily life may optimize disease management. This questionnaire survey of adult patients in real-world settings aimed to assess patient perception of the diagnosis announcement, and the impact of the diagnosis on the patients’ professional and personal life. Data from 355 patients with melanoma and 320 patients with basal cell carcinoma (BCC) were analysed. Melanoma significantly impacted the couple, and sexual relationships, as well as family and social life, and reduced the patient’s libido more significantly than did BCC (all p < 0.05). Melanoma and BCC significantly impacted the patients’ professional and personal lives. The word “cancer” used for a BCC announcement has a high anxiety-producing meaning for the patient. The announcement of each skin cancer should be made during a dedicated consultation, with more time devoted to the patient and with specific empathy, in order to improve reassurance of the patient. 

Quality of Life During Treatment for Cervicofacial Non-melanoma Skin Cancer

Non-melanoma skin cancer (NMSC), despite its low mortality, can impose a significant psychological burden on patients. The aim of the present study is to examine the evolution of the quality of life (QOL) in patients with cervicofacial NMSC during treatment. This prospective cohort study was conducted to a group of patients with cervicofacial NMSC, confirmed by skin biopsy. These patients completed the Skin Cancer Index questionnaire at the time of diagnosis and at 1 week, 1 month and 6 months after treatment began. Data for these patients' demographic characteristics and variables related to the type of tumour, the treatment received and the evolution of the condition were recorded. The study group was composed of 220 patients. At the time of diagnosis, the overall mean score for QOL was 54.1 (SD 21.9); for the social appearance component, it was 76.7 (SD 26.2), and for the emotional component, it was 23 (SD 25.1). Six months after treatment began, the overall mean score was 61 (SD19.1), that for social appearance, 85 (SD 20.6), and that for the emotional component, 27.4 (SD 26.6). All the differences were statistically significant (p < 0.05). The results obtained show that during the treatment period, it is at the time of diagnosis when patients with cervicofacial NMSC undergo the greatest deterioration in their QOL. In comparison with the findings obtained in previous studies, our population obtained lower overall scores in the questionnaires and less improvement during follow-up.

Health-Related Quality of Life of Patients with Recurrent or Metastatic Cutaneous Squamous Cell Carcinoma Treated with Pembrolizumab in KEYNOTE-629

INTRODUCTION

Pembrolizumab provided durable responses and acceptable safety in recurrent or metastatic (R/M) cutaneous squamous cell carcinoma (cSCC) in the KEYNOTE-629 study. In this elderly, fragile population with disfiguring tumours, preservation of health-related quality of life (HRQoL) is critical. Here, we present pre-specified exploratory HRQoL analyses from the first interim analysis of KEYNOTE-629.

METHODS

Patients with R/M cSCC not amenable to surgery or radiation therapy received pembrolizumab 200 mg every 3 weeks for ≤ 24 months. HRQoL end points included change from baseline to week 12 in European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) global health status (GHS)/QoL, functioning, symptom and European Quality of Life 5-Dimension 5-Level (EQ-5D-5L) scores and change from baseline through week 48 in EORTC QLQ-C30 GHS/QoL and physical functioning scores. Improvement (≥ 10-point increase post-baseline with confirmation) was assessed using the exact binomial method.

RESULTS

Analyses included 99 patients for EORTC QLQ-C30 and 100 for EQ-5D-5L. Compliance was > 80% at week 12. Mean scores were stable from baseline to week 12 for GHS/QoL (4.95 points; 95% confidence interval, -1.00 to 10.90) and physical functioning (-3.38 points; 95% confidence interval, -8.80 to 2.04). EORTC-QLQ-C30 functioning, symptom, and EQ-5D-5L scores remained stable at week 12. Post-baseline scores were improved in 29.3% of patients for GHS/QoL, 17.2% for physical functioning, and in a numerically higher proportion of responders versus non-responders (GHS/QoL, 55.6% versus 16.1%; physical functioning, 36.1% versus 7.1%).

CONCLUSIONS

In elderly patients with R/M cSCC, the clinical efficacy of pembrolizumab translates into a benefit validated by HRQoL preservation or improvement during treatment.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03284424.

Cancer worry after facial nonmelanoma skin cancer resection and reconstruction: A 1-year prospective study

OBJECTIVE

Nonmelanoma skin cancer (NMSC) is one of the most diagnosed cancers in the world, with the number of new occurrences rising every year. Most patients with facial skin cancer experience cancer-related worry. Yet, little is known about their worry during the period after cancer treatment. This study aimed to assess the long-term change of cancer worry after surgical treatment in patients with NMSC.

METHODS

Patients undergoing surgery for facial NMSC between December 2017 and March 2020 were asked to complete the FACE-Q Skin Cancer-Cancer Worry scale before (baseline), 3-month, and 1-year post-surgery.

RESULTS

A total of 151 patients completed the baseline and 3-month, and 99 (65.6%) the 1-year post-operative survey. A significant decrease in cancer worry score was seen between baseline and 3-month post-surgery (p < 0.001). No difference was found between the 3-month and 1-year post-surgery scores (p = 0.78). Less improvement in cancer worry was seen for patients who had one facial skin cancer in their medical history (p = 0.001) and patients who had a history of facial surgery (p < 0.001).

CONCLUSION

Post-surgery patients still experience cancer worry. Therefore, targeted counseling might be of value when coping with cancer-related concerns. Patients with a history of facial NMSC and patients with a history of facial surgery might benefit from additional counseling.

Assessing the Educational and Supportive Care Needs of Canadian Metastatic Melanoma Patients and Survivors Attending an Outpatient Clinic

The rapid development of metastatic melanoma treatment options has significantly improved overall survival, but paralleled patient educational and supportive care resources have fallen behind. Particularly, the need for grassroots programs targeting environments outside urban centers has grown. Accordingly, an environmental scan of the Durham region in Ontario, Canada, showed the lack of melanoma-specific resources for outpatients. The goal of this study was to identify the needs of metastatic melanoma patients and survivors attending a large outpatient clinic in Durham, and then develop a patient-reviewed intervention plan. Needs were assessed in 5 domains through a melanoma-specific supportive care needs assessment survey. Among 75 surveyed melanoma patients and survivors, high-level needs were identified in 3 domains: psychological, health system information, and melanoma-specific information. Furthermore, domain-specific needs were heightened in specific sociodemographic groups. Based on these survey results, a multifaceted intervention plan was developed to mitigate future needs. The intervention plan was patient-reviewed in focus groups prior to implementation, refining the developed intervention plan.

Comparison of the Skin Cancer Quality of Life Impact Tool and the Skin Cancer Index Questionnaire in Measurement of Health-Related Quality of Life and the Effect of Patient Education Brochures in Patients with Actinic Keratosis, Non-melanoma Skin Cancer, and Cutaneous Melanoma

Introduction

Few studies have evaluated patient-reported outcome measures and the effect of patient educational materials in German patients with skin cancer. We conducted a prospective study to measure the impact of treatment on health-related quality of life in German patients with skin cancer, identify variables that may contribute to changes in health-related quality of life, and evaluate the effect of providing additional information through a patient education brochure.

Methods

A total of 461 patients diagnosed with actinic keratosis, nonmetastatic nonmelanoma skin cancer, melanoma in situ, or nonmetastatic cutaneous melanoma treated between August 2018 and July 2020 were included. Ninety-seven patients were randomly selected to receive an additional patient education brochure (“Hautkrebs”). The patients completed a Skin Cancer Quality of Life Index Tool (n = 324) or a Skin Cancer Index Questionnaire (n = 137) 1 week after surgical treatment.

Results

Ninety-seven patients were provided an additional patient education brochure. We found statistical correlation between sociodemographic factors (young age and female gender) and the location of the skin cancer (head and face) and impairment of health-related quality of life in patients with skin cancer (p < 0.05). Moreover, we found that patients who were presented a brochure showed significantly higher awareness concerning direct sun exposure (p < 0.05).

Conclusion

Impaired health-related quality of life is correlated with a patient with skin cancer’s age, gender, and the location of the lesion. Physicians should consider these factors in clinical practice and advocate the use of patient education brochures as effective assets in preventing the reoccurrence of skin cancer.

Lifestyle behaviors and sun exposure among individuals diagnosed with skin cancer: a cross-sectional analysis of 2018 BRFSS data

PURPOSE

With the continued increase in skin cancer incidence rates, the population of skin cancer survivors continues to grow. Understanding skin cancer survivors' lifestyle behaviors, including ultraviolet radiation exposure, is important in reducing skin cancer recurrences and improving health outcomes. The objective of this study is to compare the differences in lifestyle behaviors among skin cancer survivors or individuals who currently have skin cancer versus individuals who have never had a skin cancer diagnosis.

METHODS

To investigate these lifestyle behaviors, we performed a cross-sectional analysis comparing lifestyle behaviors in persons diagnosed with skin cancer and those without a history of skin cancer among US citizens using publicly available data from the 2018 Behavior Risk Factor Surveillance System (BRFSS).

RESULTS

In total, there were 437,436 respondents. No significant difference existed between the two cohorts in sunburn frequency, use of sun protection, or indoor tanning; in fact, males were more likely to be afflicted with sunburns following diagnosis. Skin cancer survivors were less likely to be current smokers and sedentary. Female survivors were more likely to binge and heavily drink alcohol.

CONCLUSION

Our findings highlight important areas for reducing risk factors, which could reduce the recurrence of skin malignancies in skin cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Our study provides insight to lifestyle behaviors among skin cancer survivors. Being aware of these behaviors has the potential to reduce skin cancer recurrence.

Patient Experiences with Avelumab in Treatment-Naïve Metastatic Merkel Cell Carcinoma: Longitudinal Qualitative Interview Findings from JAVELIN Merkel 200, a Registrational Clinical Trial

BACKGROUND AND OBJECTIVE

Avelumab is approved for the treatment of metastatic Merkel cell carcinoma, a rare aggressive skin cancer with a poor prognosis. The aim of this qualitative study embedded in a clinical trial was to explore patient experiences while receiving avelumab.

METHODS

All treatment-naïve patients with metastatic Merkel cell carcinoma entering part B of the phase II, open-label, international, JAVELIN Merkel 200 trial (NCT02155647) were invited to participate in optional semi-structured phone interviews before avelumab administration (baseline) and at weeks 13 and 25. Interviews were conducted by trained professionals, audio-recorded, transcribed and analysed. Key concepts identified at baseline were assessed during follow-up interviews.

RESULTS

Twenty-nine patients completed the baseline interview; 19 had at least one follow-up interview. Baseline interviews described the patients' challenging journeys before being correctly diagnosed with Merkel cell carcinoma, the negative psychological burden of living with a symptomless disease and the hope for avelumab to be a successful therapy. During the trial, most patients reported an increased or continued sense of hope and willingness to fight metastatic Merkel cell carcinoma. Patients who self-reported disease improvement (n = 12) also reported stability or improvement in physical well-being and ability to do daily activities, having more energy, worrying less and being optimistic. Six patients who reported their condition as stable (n = 4) or worsened (n = 3) reported a worsening of physical well-being. Nine patients reported fatigue/tiredness on the day of and after receiving avelumab. Baseline and longitudinal experiences were similar across countries.

CONCLUSIONS

This study suggests that patients experience perceptible benefits in physical and psychological well-being following treatment success with first-line avelumab in metastatic Merkel cell carcinoma.

Effects of a brief multimodal online intervention on the intention to conduct sun protective behaviours through targeting illness representations about skin cancer: a randomized controlled trial

Objective: The incidence of skin cancer can be reduced by increasing sun protective behaviours. Based on the Common-Sense Model and the Intervention Mapping approach, a brief intervention targeting illness representations about skin cancer to increase the intention to conduct sun protective behaviours was developed and evaluated regarding its effectiveness.Design: A randomized pre-post control group design with 509 healthy participants (69% women, mean age 39 years).Main outcome measures: Changes in illness representations about skin cancer (emotional representations, illness coherence, and prevention control) and the intention to conduct sun protective behaviours, i.e. UV protection and sun avoidance.Results: ANCOVAs showed that the intervention increased illness coherence and perceived prevention control as well as the intention to conduct sun protective behaviours. Mediation analyses revealed that the increase in illness coherence and/or perceived prevention control partially mediated the effect of the intervention on the increase of the intention to use UV protection (indirect effects: .02*, .06*) and to avoid sun exposure (indirect effects: .01 ns, .04*).Conclusion: The intervention was successful in changing illness representations and thereby increasing the intention to conduct sun protective behaviours. The findings provide evidence for the usefulness of the Common-Sense Model in the context of illness prevention.

Regional Wait Times for Patients With Nonmelanoma Skin Cancer in Southwestern Ontario

Background

Nonmelanoma skin cancer (NMSC) affects many Canadians. Although morbidity and mortality are rare, the burden to patients and the health-care system is significant. This study aims to evaluate current plastic surgery wait times and care pathways for patients with NMSC in Southwestern Ontario.

Methods

A retrospective chart review of 225 patients treated in Ontario from 2015 to 2018 was conducted. Inclusion criteria included patients with an NMSC managed with surgical excision. Referral information was compared. Primary outcomes were wait times: from referral to consultation, referral to excision, and consultation to excision. Data were analyzed using Student t test with equal variance.

Results

One-hundred forty-three patients were included from the academic cohort and 82 from the community cohort. Referrals to academic and community surgeons included lesion location (90% and 97.6%, respectively), but less frequently included size (18% and 29.2%, respectively). Most referrals to academic surgeons included biopsy results (78.6%), as opposed to community referrals (25.6%). Patients in the academic cohort waited 15.3 ± 12.7 weeks from referral to consultation, and 15.7 ± 13 weeks from referral to excision. Patients from the community cohort waited significantly shorter periods of 4.9 ± 3.1 (P < .001) and 11.7 ± 9.9 weeks (P = .016), respectively. However, patients of the academic cohort waited 2.4 ± 7.1 weeks from consultation to excision, while patients in the community cohort waited 6.7 ± 9.6 weeks (P < .001). Rates of negative peripheral margins on pathology were similar between groups, at 89.5% of the academic cohort and 88.9% of the community cohort. Deep margins were positive 5.7% of the time at the academic sites and 6.2% of the time in the community.

Conclusions

Patients referred to academic centres waited significantly longer periods of time in several parameters compared to those referred to a community surgeon. However, academic surgeons often had expedited consultation-to-excision time frame. This study provides important data for future quality improvement initiatives in NMSC care.

Use of the Skin Cancer Quality of Life Impact Tool (SCQOLIT) - a feasibility study in non-melanoma skin cancer

BACKGROUND

Incidence of non-melanoma skin cancers (NMSCs) is increasing and can significantly impact on quality of life (QOL), yet there are few studies evaluating patient-reported outcome measures (PROMs) in NMSC populations. We undertook a prospective feasibility study to evaluate a skin cancer-specific PROM, the Skin Cancer Quality of Life Impact Tool (SCQOLIT), in patients with a new diagnosis of NMSC.

OBJECTIVES

(i) To establish acceptability of SCQOLIT in dermatology clinics, (ii) a descriptive analysis of SCQOLIT scores in NMSC.

METHODS

Patients with histologically confirmed NMSC completed SCQOLIT, EQ-5D and a transition item. Questionnaires were completed at baseline and 3 months for group 1 ('low-risk' NMSC) and group 2 ('high-risk' NMSC) with additional questionnaires at 6-9 months for group 2. Patients participated in structured interviews. Clinician experience was captured through staff evaluation forms and a focus group. Acceptability and psychometric properties of SCQOLIT were assessed.

RESULTS

Overall, 318 patients consented to participate. Mean SCQOLIT score at baseline was 5.33, with 2.6% of patients scoring ≥20. No ceiling effects were observed, whilst 13.9% scored 0. Validity was demonstrated against EQ-5D. Cronbach's alpha 0.84 demonstrated internal consistency. Thirteen patients were interviewed and thought SCQOLIT was comprehensive, captured impact on health-related QOL and helped express their needs to clinicians. Most clinicians found SCQOLIT 'very useful' or 'useful to some extent' in facilitating discussions.

CONCLUSIONS

This feasibility study demonstrates that SCQOLIT is acceptable to patients and staff in dermatology skin cancer clinics. The psychometric properties of SCQOLIT confirm its utility in NMSC populations.

Quality of life measurement in skin cancer patients: literature review and position paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes, Melanoma and Non-Melanoma Skin Cancer

The European Academy of Dermatology and Venereology (EADV) Task Forces (TFs) on Quality of Life (QoL) and Patient Oriented Outcomes, Melanoma and Non-Melanoma Skin Cancer (NMSC) present a review of the literature and position statement on health-related (HR) QoL assessment in skin cancer patients. A literature search was carried out to identify publications since 1980 that included information about the impact of SC on QoL. Generic, dermatology-specific, cancer-specific, SC-specific, facial SC-specific, NMSC-specific, basal cell carcinoma-specific and melanoma-specific QoL questionnaires have been used to assess HRQoL in SC patients. HRQoL was assessed in the context of creation and validation of the HRQoL instruments, clinical trials, comparison of QoL in SC and other cancers, other diseases or controls, HRQoL assessment after treatment, comorbidities, behaviour modification, predictors of QoL and survival, supportive care needs, coping strategies and fear of cancer recurrence. The most widely used instruments for HRQoL assessment in SC patients are the European Organisation for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30), the Functional Assessment of Cancer Therapy-Melanoma (FACT-M), Skin Cancer Index (SCI), Short Form 36 Item Health Survey (SF-36) and the Dermatology Life Quality Index (DLQI). The TFs recommend the use of the cancer-specific EORTC QLQ-C30, especially in late stages of disease, and the melanoma-specific FACT-M and SC-specific SCI questionnaires. These instruments have been well validated and used in several studies. Other HRQoL instruments, also with good basic validation, are not currently recommended because the experience of their use is too limited. Dermatology-specific HRQoL instruments can be used to assess the impact of skin-related problems in SC. The TFs encourage further studies to validate HRQoL instruments for use in different stages of SC, in order to allow more detailed practical recommendations on HRQoL assessment in SC.

Basal cell carcinoma: Contemporary approaches to diagnosis, treatment, and prevention

As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education series provides a comprehensive and contemporary review of basal cell carcinoma. The second article in this series will present both the current standard of care and newly developed approaches to diagnosis, treatment, and prevention of this disease.

Patient-reported outcome measures for facial skin cancer: a systematic review and evaluation of the quality of their measurement properties

BACKGROUND

Skin cancer is the commonest malignancy worldwide, often occurring on the face. Both the condition and treatment can lead to scarring and facial disfigurement, affecting a patient's health-related quality of life (HRQoL), which can be measured using patient-reported outcome measures (PROMs).

OBJECTIVES

This systematic review identifies PROMs for facial skin cancer and appraises their methodological quality and psychometric properties using up-to-date methods.

METHODS

MEDLINE, Embase, PsycINFO, Cochrane and CINAHL were searched systematically in accordance with PRISMA guidelines, identifying all PROMs designed for or validated in facial skin cancer. Methodological quality and evidence of psychometric properties were assessed using the COnsensus-based Standards for the Selection of Health Measurement INstruments (COSMIN) checklist and criteria proposed by Terwee and colleagues. A best-evidence synthesis and assessment of instrument focus on post-resection reconstruction was also performed.

RESULTS

We included 24 studies on 11 PROMs. Methodological quality and psychometric evidence was variable, with the Patient Outcome of Surgery - Head/Neck (POS-H/N), Skin Cancer Index (SCI), Skin Cancer Quality of Life Impact Tool (SCQOLIT) and Essers and colleagues demonstrating the greatest level of validation. None scored well in their relevance to post-skin cancer reconstruction of the face.

CONCLUSIONS

This systematic review critically appraises PROMs for facial skin cancer using internationally accepted criteria. The identified PROMs demonstrate a variation in the quality of validation performed, with a need to improve this across all PROMs in the field. Only through improving the quality of available PROMs and their focus on the post-treatment aesthetic and functional outcome will we be able to truly appreciate the concerns of our patients and improve the management of facial skin cancer.

Health Outcome Studies in Skin Cancer Surgery

As cutaneous cancers are the most common malignancies affecting US citizens, they represent a significant public health problem and health care cost burden. There are a variety of treatment options available to manage cutaneous malignancies, but limited data are available regarding outcomes, including quality of life, recurrence, and mortality. Here, we examine outcomes of skin cancer surgery as they relate to sociodemographic data and treatment factors.

FACE-Q Skin Cancer Module for measuring patient-reported outcomes following facial skin cancer surgery

BACKGROUND

The patient's perspective of their facial scar after skin cancer surgery influences perception of care and quality of life (QoL). Appearance satisfaction after surgery is also an important but often overlooked treatment outcome.

OBJECTIVES

To report the psychometric validation of the FACE-Q Skin Cancer Module consisting of five scales, measuring appearance satisfaction (Satisfaction with Facial Appearance, Appraisal of Scars), QoL (Cancer Worry, Appearance-related Psychosocial Distress) and the patient experience (Satisfaction with Information: Appearance).

METHODS

Participants underwent Mohs surgery for facial basal or squamous cell carcinoma or excision of early facial melanoma. Cohort 1 received a set of scales before and after surgery. Cohort 2 received the scales on two occasions in the postoperative period for test-retest reliability. Rasch measurement theory was used to select (item-reduce) the most clinically meaningful items for the scales. Reliability, validity, floor and ceiling effects and responsiveness were also analysed.

RESULTS

Of 334 patients, 209 (response rate 62·6%) were included. Rasch analysis reduced the total scale items from 77 to 41. All items had ordered thresholds and good psychometric fit. Reliability was high (Person separation index and Cronbach's α ≥ 0·90) and scales measuring similar constructs were correlated. High floor and ceiling effects were seen for the scales. The Cancer Worry scale demonstrated responsiveness (P = 0·004).

CONCLUSIONS

The FACE-Q Skin Cancer Module meet the requirements of the Rasch model providing linearized measurement. Discriminating between patients with minimal appearance or worry impairment may be a limitation. The scales can be used for larger validation studies, clinical practice and research.

Patient quality of life fluctuates before and after Mohs micrographic surgery: A longitudinal assessment of the patient experience

BACKGROUND

Changes in patient perceptions of quality of life (QOL) after Mohs micrographic surgery (MMS) may benefit from different counseling or treatment.

OBJECTIVE

To measure QOL before and after MMS and to identify risk factors associated with impaired QOL.

METHODS

Prospective observational study of 727 patients with skin cancer who self-reported QOL via the Skin Cancer Index immediately before and at 1 to 2 weeks and 3 months after MMS.

RESULTS

QOL fluctuated after MMS. At 1 to 2 weeks after surgery, overall QOL remained unchanged compared with before MMS. Patients reported reduced anxiety about skin cancer but had increased distress about social interactions and physical appearance. At 3 months after surgery, patients reported an overall improvement in QOL compared with before MMS (P = .0007). Age younger than 65 years (P = .0001), female sex (P = .0001), and tobacco use (P = .03) were associated with lower QOL scores at all assessment points.

LIMITATIONS

Single-site observational study. Significant loss to follow-up at both time points after MMS.

CONCLUSION

Patients with skin cancer had persistent concerns about social interactions and physical appearance 1 to 2 weeks after MMS, but all aspects of their QOL improved by 3 months after surgery. Patients who underwent MMS that were younger than 65 years, were female, or smoked were at increased risk for longitudinally impaired QOL.

Skin Cancer Epidemics in the Elderly as An Emerging Issue in Geriatric Oncology

Skin cancer is a worldwide, emerging clinical need in the elderly white population, with a steady increase in incidence rates, morbidity and related medical costs. Skin cancer is a heterogeneous group of cancers comprising cutaneous melanoma and non-melanoma skin cancers (NMSC), which predominantly affect elderly patients, aged older than 65 years. Melanoma has distinct clinical presentations in the elderly patient and represents a challenging question in terms of clinical management. NMSC includes the basal cell carcinoma and cutaneous squamous cell carcinoma and presents a wide disease spectrum in the elderly population, ranging from low-risk to high-risk tumours, advanced and inoperable disease. Treatment decisions for NMSC are preferentially based on tumour characteristics, patient’s chronological age and physician’s preferences and operational settings. Several treatment options are available for NMSC, from surgery to non-invasive/medical therapies, but patient-based factors, such as geriatric comorbidities and patient’s life expectancy, do not frequently modulate treatment goals. In melanoma, age-related variations in clinical management are significant and may frequently lead to under-treatment, limiting access to advanced surgical and medical treatments. Clinical decision-making in the care of elderly skin cancer patient should ideally implement a geriatric assessment, prioritizing patient-based factors and efficiently differentiating fit from frail cancer patients. Current clinical practice guidelines for NMSC and melanoma only partially address geriatric aspects of cancer care, such as frailty, limited life-expectancy, geriatric comorbidities and treatment compliance. We review the recent evidence on the scope and problem of skin cancer in the elderly population as well as age-related variations in its clinical management, highlighting the potential role of a geriatric approach in optimizing dermato-oncological care.

Indoor tanning promotions on social media in six US cities #UVTanning #tanning

There is no research investigating indoor tanning advertising on social media. We assessed the use of social media to promote indoor tanning. We subscribed to social media platforms in six US cities and content-analyzed promotional messages received. We captured 662 messages on Twitter and Facebook, through salon emails, and in daily deal coupons. Salon postings were most frequent on Twitter and Facebook, with an average of 2-3 postings per week. National chains posted more frequently than local businesses. Forty percent of messages were devoid of tanning content and included photos, jokes, or popular references. Thirty percent mentioned price reductions, and 28 % referenced an upcoming holiday. Sunless tanning (17 %) was promoted more often than ultraviolet tanning (9 %). Tanning salons actively use social media as a strategy for maintaining relationships with customers and offer pricing deals that promote loyalty and high-frequency tanning.

Cost-Effectiveness Analysis of a Skin Awareness Intervention for Early Detection of Skin Cancer Targeting Men Older Than 50 Years

OBJECTIVES

To assess the cost-effectiveness of an educational intervention encouraging self-skin examinations for early detection of skin cancers among men older than 50 years.

METHODS

A lifetime Markov model was constructed to combine data from the Skin Awareness Trial and other published sources. The model incorporated a health system perspective and the cost and health outcomes for melanoma, squamous and basal cell carcinomas, and benign skin lesions. Key model outcomes included Australian costs (2015), quality-adjusted life-years (QALYs), life-years, and counts of skin cancers. Univariate and probabilistic sensitivity analyses were undertaken to address parameter uncertainty.

RESULTS

The mean cost of the intervention was A$5,298 compared with A$4,684 for usual care, whereas mean QALYs were 7.58 for the intervention group and 7.77 for the usual care group. The intervention was thus inferior to usual care. When only survival gain is considered, the model predicted the intervention would cost A$1,059 per life-year saved. The likelihood that the intervention was cost-effective up to A$50,000 per QALY gained was 43.9%. The model was stable to most data estimates; nevertheless, it relies on the specificity of clinical diagnosis of skin cancers and is subject to limited health utility data for people with skin lesions.

CONCLUSIONS

Although the intervention improved skin checking behaviors and encouraged men to seek medical advice about suspicious lesions, the overall costs and effects from also detecting more squamous and basal cell carcinomas and benign lesions outweighed the positive health gains from detecting more thin melanomas.

Barriers to Seeking Help for Skin Cancer Detection in Rural Australia

This study explores rural South Australians’ barriers to help-seeking for skin cancer detection. A total of 201 randomly selected rural adults (18–94 years, 66% female) were presented with a skin-cancer-related scenario via telephone and were asked the extent to which various barriers would impede their help-seeking, based on an amended version of the Barriers to Help-Seeking Scale. Older (≥63 years) and less educated participants endorsed barriers more strongly than their younger, more educated counterparts in the following domains; “Concrete barriers and distrust of caregivers”, “Emotional control”, “Minimising problem and Normalisation”, “Need for control and self-reliance” (every domain other than “Privacy”). Socioeconomic disadvantage, gender, and farmer status did not predict stronger overall barriers, but some gender and occupation-related differences were detected at the item level. Farmers were also more likely to endorse the “Minimising problem and normalization” domain than their non-farmer working rural counterparts. Widely endorsed barriers included the tendency to minimise the problem, a desire to remain in control/not be influenced by others, reluctance to show emotion or complain, and having concerns about privacy or waiting times.

Patient experiences and outcomes following facial skin cancer surgery: A qualitative study

Early melanoma and non-melanoma skin cancer of the facial area are primarily treated with surgery. Little is known about the outcomes of treatment for facial skin cancer patients. The objective of the study was to identify concerns about aesthetics, procedures and health from the patients' perspective after facial skin surgery. Semi-structured in-depth interviews were conducted with 15 participants. Line-by-line coding was used to establish categories and develop themes. We identified five major themes on the impact of skin cancer surgery: appearance-related concerns; psychological (e.g., fear of new cancers or recurrence); social (e.g. impact on social activities and interaction); physical (e.g. pain and swelling) concerns and satisfaction with the experience of care (e.g., satisfaction with surgeon). The priority of participants was the removal of the facial skin cancer, as this reduced their overall worry. The aesthetic outcome was secondary but important, as it had important implications on the participants' social and psychological functioning. The participants' experience with the care provided by the surgeon and staff also contributed to their satisfaction with their treatment. This conceptual framework provides the basis for the development of a new patient-reported outcome instrument.

Cross-cultural development of a quality-of-life measure for patients with melanoma: phase 3 testing of an EORTC Melanoma Module

Melanoma is an increasingly common skin cancer worldwide. Recent treatment advances have provided patients and healthcare professionals (HCPs) with choices where quality of life (QoL) and toxicity are important considerations. A melanoma-specific QoL questionnaire is being developed in a cross-cultural setting using a four phase process developed by the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Group. In phase 1, a literature search identified a list of pertinent QoL issues; this was shown to HCPs and patients in eight countries and rated for importance and relevance. Questions were constructed for the highest-rated issues (phase 2) and piloted in another patient sample (phase 3). Using EORTC Quality of Life Group criteria and sequential use of factor and Rasch analysis, scales were hypothesized for field testing (phase 4). Seven QoL domains (disease symptoms, treatment issues, financial issues, access/quality of information, satisfaction with care, psychosocial issues and support), comprising 73 QoL issues, were rated by 46 HCPs and 78 patients. Fifty-six issues were rephrased as questions and piloted with 132 patients. A 38-item questionnaire (QLQ-MEL38) is available for field testing in conjunction with the EORTC QLQ-C30. This study has shown that melanoma patients have important QoL issues that have been incorporated into a new cross-culturally validated instrument. Future testing of this EORTC module is planned and will be an important step forward in providing reliable QoL data to aid future decision-making in the management and clinical trials of this complex group of patients.

A Qualitative Comparison of Symptoms and Impact of Varying Stages of Basal Cell Carcinoma

INTRODUCTION

Basal cell carcinoma (BCC) is the most common form of skin cancer; however, few data are available relating to patients' perspectives and experiences of this disease. This study explored the spectrum of BCC symptoms and their impact by disease stage to determine how BCC affects the overall health-related quality of life (HRQL) of patients.

METHODS

This study comprised a cross-sectional, qualitative approach involving telephone interviews with patients with BCC who had been divided into two groups: group 1 (G1), patients with stage 1, non-advanced BCC (and of superficial or nodular histology); and group 2 (G2), patients with locally advanced or metastatic BCC. Patients were recruited from three clinical sites in the USA based on a separate qualitative interview study (I4J-MC-HHBB [1.3]) over a 10-month period. Techniques in qualitative methodology were used by applying 'open-ended' questions and probing techniques intended to elicit patients' own description of their experiences with BCC. Telephone interviews lasted between 60 and 90 mins.

RESULTS

Thirty-four interviews were conducted (G1: N = 13; G2: N = 21). The majority of patients were aged either 55-64 years (32%, N = 11) or 76+ years (32%, N = 11) and were primarily male (82%, N = 28); most (75%, N = 24) patients were actively receiving BCC treatment. Both groups reported similar symptoms, with the most common being red lesions or open sores that failed to heal (41%, N = 14) and cancer-related stress (41%, N = 14). G2 reported more frequent and severe HRQL impact as a result of their cancer condition because most were affected in their daily activities (76%, N = 16) or emotional well-being (71%, N = 15). Cosmetic and functional impacts were relevant and important aspects of HRQL for both patient groups (G1: 31%, N = 4; G2: 48%, N = 10).

CONCLUSIONS

Patients with non-advanced or locally advanced and metastatic BCC experience disease-related symptoms that affect their HRQL, activities of daily living, emotional well-being, and social and/or leisure activities. Qualitative descriptions of patient experiences can help healthcare providers and caregivers better understand the impact of BCC from the patient perspective.

FUNDING

Eli Lilly and Company.

Importance of physical appearance in patients with skin cancer

BACKGROUND

Physical appearance influences nearly every aspect of human life-impacting how people are judged and subsequently treated by others.

OBJECTIVE

To summarize the literature that addresses the psychosocial impact of facial scarring, with a particular emphasis on scarring after skin cancer treatment.

MATERIALS AND METHODS

A comprehensive PubMed search was conducted to find articles related to scarring and appearance in the contexts of cutaneous oncology and surgical reconstruction. References from retrieved articles were also considered for review.

RESULTS

Scars, especially on the head and neck, change physical appearance and can negatively impact psychosocial functioning. Medical professionals may underestimate the importance of physical appearance for patients with skin cancer. Validated patient-reported outcome (PRO) tools may prove better than objective scar ratings to identify patients who may experience psychosocial impairment from scarring.

CONCLUSION

Scarring after skin cancer surgery can profoundly affect psychosocial functioning. Perioperative use of validated PRO tools can help to identify patients with scar concerns. Heightened awareness of patients' psychosocial status will allow practitioners to offer appropriate counseling or support.

Coping with melanoma-related worry: a qualitative study of the experiences and support needs of patients with malignant melanoma

AIMS AND OBJECTIVES

To explore the patients' experience of having malignant melanoma, their related support needs and the processes that lead to these needs being met.

BACKGROUND

The number of patients attending surveillance clinics after a diagnosis of malignant melanoma is increasing. In the UK specialist nurses provide support to patients, but little evidence exists about the nature of patients' support needs or their experience of having melanoma. Melanoma has often been researched within general cancer studies, yet the support needs of melanoma patients may be different from those of patients with other skin cancers or tumour types.

DESIGN

A Grounded Theory Approach was used to guide sampling, data collection and analysis.

METHODS

In-depth interviews were conducted with eleven patients who where purposively sampled. Transcripts were read several times, coded and categorised using the constant comparative method. Emergent categories were discussed with participants.

RESULTS

Three emergent categories related to a core category of melanoma-related worry which formed a substantive theory about the strategies patients use to control this. Participants reported needing to have their concerns believed by others prior to and after diagnosis. They discussed discerning whom to share their concerns with depending upon who they felt would not perceive assisting them as being burdensome. They also sought ways to reassure themselves.

CONCLUSIONS

Patients need to have their fear and worries acknowledged by others. This includes nurses, healthcare professionals and family members. Patients will also use self-examination and the absence of symptoms to reassure themselves.

RELEVANCE TO CLINICAL PRACTICE

Nurses play key roles throughout the patient's care; therefore they need to be sensitive to the fact that patients may consider them a primary source of support. When teaching self-examination it is important that nurses discuss that this may ease worry and aid coping.

A Spanish version of the Skin Cancer Index: a questionnaire for measuring quality of life in patients with cervicofacial nonmelanoma skin cancer

INTRODUCTION

The Skin Cancer Index (SCI) is the first specific patient-reported outcome measure for patients with cervicofacial nonmelanoma skin cancer. To date, only the original English version has been published.

OBJECTIVES

To develop a Spanish version of the SCI that is semantically and linguistically equivalent to the original, and to evaluate its measurement properties in this different cultural environment.

MATERIAL AND METHODS

A cross-sectional study was conducted of the cultural adaptation and empirical validation of the questionnaire, analysing the psychometric properties of the new index at different stages.

RESULTS

Of 440 patients recruited to the study, 431 (95%) completed the Spanish version of the SCI questionnaire, in a mean time of 6·3 min (SD 2·9). Factor analysis of the scale revealed commonality and loading values of < 0·5 for three of the 15 items. The remaining 12 items converged into two components: appearance/social aspects (seven items) and emotional aspects (five items). Both domains presented a high level of internal consistency, with Cronbach's alpha values above 0·8. The convergent-discriminant validity analysis produced correlations higher than 0·3 for the mental component of the Short Form Health Survey-12v2 Health Questionnaire (correlation coefficient 0·39) and the Dermatology Quality of Life Index (correlation coefficient -0·30). In the test-retest, nine of the 12 items produced a weighted kappa value exceeding 0·4, and for the remaining three items, the absolute agreement percentage exceeded 60%.

CONCLUSIONS

The Spanish version of the SCI quality of life scale has been satisfactorily adapted and validated for use in Spanish-speaking countries and populations.

Nonmelanoma skin cancer: disease-specific quality-of-life concerns and distress

PURPOSE/OBJECTIVES

To provide a better understanding of the disease-specific quality-of-life (QOL) concerns of patients with nonmelanoma skin cancer (NMSC).

DESIGN

Cross-sectional.

SETTING

Skin cancer clinic of Jewish General Hospital in Montreal, Quebec, Canada.

SAMPLE

56 patients with basal cell carcinoma and/or squamous cell carcinoma.

METHODS

Descriptive and inferential statistics applied to quantitative self-report data.

MAIN RESEARCH VARIABLES

Importance of appearance, psychological distress, and QOL.

FINDINGS

The most prevalent concerns included worries about tumor recurrence, as well as the potential size and conspicuousness of the scar. Skin cancer-specific QOL concerns significantly predicted distress manifested through anxious and depressive symptomology. In addition, the social concerns related to the disease were the most significant predictor of distress.

CONCLUSIONS

The findings of this study provide healthcare professionals with a broad picture of the most prevalent NMSC-specific concerns, as well as the concerns that are of particular importance for different subgroups of patients.

IMPLICATIONS FOR NURSING

Nurses are in a position to provide pivotal psychosocial and informational support to patients, so they need to be aware of the often-overlooked psychosocial effects of NMSC to address these issues and provide optimal care.

Experience of gratitude, awe and beauty in life among patients with multiple sclerosis and psychiatric disorders

Background

Feelings of gratitude and awe facilitate perceptions and cognitions that go beyond the focus of illness and include positive aspects of one’s personal and interpersonal reality, even in the face of disease. We intended to measure feelings of gratitude, awe, and experiences of beauty in life among patients with multiple sclerosis and psychiatric disorders, particularly with respect to their engagement in specific spiritual/religious practices and their life satisfaction.

Methods

We conducted a cross-sectional survey with standardized questionnaires to measure engagement in various spiritual practices (SpREUK-P) and their relation to experiences of Gratitude, Awe and Beauty in Life and life satisfaction (BMLSS-10). In total, 461 individuals (41 ± 13 years; 68% women) with multiple sclerosis (46%) and depressive (22%) or other psychiatric disorders (32%) participated.

Results

Among participants, 23% never, 43% rarely, 24% often, and 10% frequently experienced Gratitude. In contrast, 41% never, 37% rarely, 17% often, and 6% frequently experienced Awe. Beauty in Life was never experienced by 8% of the sample, and 28% rarely, 46% often, and 18% frequently experienced it. Gratitude (F = 9.2; p = .003) and Beauty in Life (F = 6.0; p = .015) were experienced significantly more often by women than men. However, the experience of Awe did not differ between women and men (F = 2.2; n.s.). In contrast to our hypothesis, Gratitude/Awe cannot explain any relevant variance in patients’ life satisfaction (R² = .04). Regression analyses (R² = .42) revealed that Gratitude/Awe can be predicted best by a person’s engagement in religious practices, followed by other forms of spiritual practices and life satisfaction. Female gender was a weak predictor and underlying disease showed no effect.

Conclusions

Gratitude/Awe could be regarded as a life orientation towards noticing and appreciating the positive in life - despite the symptoms of disease. Positive spirituality/religiosity seems to be a source of gratitude and appreciation in life, whereas patients with neither spiritual nor religious sentiments (R-S-) seem to have a lower awareness for these feelings.