Correspondence between pigmented lesions identified by melanoma patients trained to perform partner-assisted skin self-examination and dermatological examination

The Level of Agreement between Self-Assessments and Examiner Assessments of Melanocytic Nevus Counts: Findings from an Evaluation of 4548 Double Assessments

Cutaneous melanoma (CM) is a candidate for screening programs because its prognosis is excellent when diagnosed at an early disease stage. Targeted screening of those at high risk for developing CM, a cost-effective alternative to population-wide screening, requires valid procedures to identify the high-risk group. Self-assessment of the number of nevi has been suggested as a component of such procedures, but its validity has not yet been established. We analyzed the level of agreement between self-assessments and examiner assessments of the number of melanocytic nevi in the area between the wrist and the shoulder of both arms based on 4548 study subjects in whom mutually blinded double counting of nevi was performed. Nevus counting followed the IARC protocol. Study subjects received written instructions, photographs, a mirror, and a "nevometer" to support self-assessment of nevi larger than 2 mm. Nevus counts were categorized based on the quintiles of the distribution into five levels, defining a nevus score. Cohen's weighted kappa coefficient (κ) was estimated to measure the level of agreement. In the total sample, the agreement between self-assessments and examiner assessments was moderate (weighted κ = 0.596). Self-assessed nevus counts were higher than those determined by trained examiners (mean difference: 3.33 nevi). The level of agreement was independent of sociodemographic and cutaneous factors; however, participants' eye color had a significant impact on the level of agreement. Our findings show that even with comprehensive guidance, only a moderate level of agreement between self-assessed and examiner-assessed nevus counts can be achieved. Self-assessed nevus information does not appear to be reliable enough to be used in individual risk assessment to target screening activities.

Melanoma Extension for Community Healthcare Outcomes: A Feasibility Study of Melanoma Screening Implementation in Primary Care Settings

Introduction

Melanoma incidence rates are rising faster than the rates of any other malignancy. As a major global public health concern, melanoma can be identified by a visual exam not requiring expensive invasive procedures. However, non-dermatologists lack specialized training and skills to identify high-risk patients and implement melanoma skin screenings during regular exams. Most patients from rural and underserved areas have inadequate access to specialty dermatologic care, which can potentially lead to later-stage melanomas and poor patient outcomes. The objective of this study was to identify facilitators and barriers to the implementation of risk surveys and melanoma skin screenings in primary care settings through live interactive education and the telementoring project - Melanoma ECHO (Extension for Community Healthcare Outcomes). 

Methods

This cross-sectional study was designed with theoretical concepts from dissemination and implementation research. Monthly Melanoma ECHO sessions were integrated into an ongoing Dermatology ECHO at the University of Missouri, Columbia, Missouri, USA, from April 2018 to February 2019. Ten primary care providers, medical doctors/doctors of osteopathic medicine (MDs/DOs), nurse practitioners (NPs), and physician assistants (PAs), from across Missouri participated. Eleven virtual monthly melanoma-related didactics and case-based discussions were provided to participants. Information regarding risk factors, risk surveys, and screening techniques was provided. Ongoing telementoring and guidance were also provided for de-identified real-life patient cases. The main outcomes and measures of the study were to identify the facilitators and barriers of risk survey and melanoma skin screenings in primary care settings and to quantify the number of high-risk patients identified by participating providers and the number of new melanomas detected by visual exams during the study period.

Results

The primary reason why six out of 10 providers reported participation in Melanoma ECHO was that implementing melanoma skin screenings in their practice was made easier as it increased their confidence. Nine providers reported increased knowledge, and eight cited professional networking as other facilitators. The main perceived barrier to melanoma skin screening was lack of administrative and nursing support, and six providers indicated that lack of time to incorporate skin exams was also a barrier. Combined, ten participants reported identifying 976 high-risk patients during the study period and detecting 36 new melanomas.

Discussion and conclusion

Our findings indicate that primary care providers may benefit from attending regularly scheduled and focused specialized telementoring sessions, such as Melanoma ECHO. Ongoing support from specialists may help providers practicing in rural and isolated areas with the successful integration of risk surveys and melanoma skin screenings in primary care settings. Further Melanoma ECHO sessions with a more diverse group of primary care providers are needed to better understand the generalizability of the results.

Remote skin self-examination training of melanoma survivors and their skin check partners: A randomized trial and comparison with in-person training

Background

Compared with other cancers, melanoma has the longest delays measured as the median time to patient presentation for care from symptom onset. Time to presentation for care is a key determinant of outcomes, including disease stage, prognosis, and treatment.

Methods

Melanoma survivors with localized disease and their skin check partners enrolled in two sequential randomized control trials of skin self‐examination (SSE) training. In Phase 1, the pair read a workbook in the office and had quarterly total body skin examinations with a study dermatologist. In Phase 2, materials were mailed to pairs, whose surveillance was with a community physician. SSE knowledge, performance (frequency and extent), and identification of concerning moles were compared between phases.

Results

Among 341 patients, 197 received the workbook and the others were controls. Knowledge in performing SSE was higher for the workbook relative to controls in both phases. The SSE frequency ranged from 2.38 to 5.97 times in 9 months. Patients randomized to the workbook in both phases performed significantly more SSE than controls at 9 months (P < .05). In both phases, trained survivors performed significantly more SSEs on the scalp than controls at 9 and 18 months (P < .05). Phase 1 survivors performed significantly more SSEs on the abdomen, buttocks, and soles of the feet than controls, but this did not occur in Phase 2. Finally, in both phases, survivors trained with the workbook resulted in greater detection of suspicious lesions and melanomas.

Conclusions

These findings justify the benefits of remote SSE training for patients as an adjunct to provider‐administered screening.

A Multimodal Skin Cancer Prevention Program for Heart Transplant Patients

Background:

Immunosuppressant medications are essential for long-term survival following transplantation but increase the risk of developing skin cancer. Prevention and early detection of skin cancer requires screening and sun protection behaviors that can be achieved with patient education.

Problem Statement:

Our method for educating post heart transplant patients regarding skin cancer was inconsistent and was not effective. The aim of this project was to develop and integrate a multimodal skin cancer education program to increase knowledge and protective behaviors for heart transplant recipients.

Methods:

Twenty-five post heart transplant patients who were scheduled to be seen for routine posttransplant care at a single-center transplant center between October 26, 2016, and November 15, 2016, took part in a multimodal skin cancer education program.

Results:

There was a significant increase in knowledge between pretest and posttest 1 ( P <.01) and pretest and posttest 2 ( P <.01). A significant increase in sun protective behavior was noted. The project noted that knowledge and behavior was retained, knowledge score posttest 1 to posttest 2 ( P = .085), all had seen a dermatologist or had an appointment scheduled, and self skin exam retention was noted between posttest 1 and posttest 2 ( P = .25).

Process Addressed:

The feasibility of and findings from this intervention have led the clinic team to implement this protocol as part of the standard care for all patients.

Conclusions:

These data suggests that a multimodal intensive skin cancer education program may be effective at increasing knowledge and protective behavior with heart transplant recipients.

Early Detection of New Melanomas by Patients With Melanoma and Their Partners Using a Structured Skin Self-examination Skills Training Intervention: A Randomized Clinical Trial

IMPORTANCE

More than 1 million patients with melanoma in the United States are at risk to develop a second primary melanoma. Early detection of melanoma improves survival. Patients with melanoma may be able to self-manage care with their skin-check partners ("partners") and alert the physician when a concerning lesion is identified, thus providing an important adjunct to yearly skin examinations by a physician.

OBJECTIVE

To evaluate the effect of a structured skin self-examination (SSE) intervention for patients with melanoma and their partners ("dyads") on SSE performance and the detection of new melanomas by the dyad or the physician.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial with 24-month follow-up assessments. Patients with stage 0 to IIB melanoma and their skin-check partners participated from June 6, 2011, to April 24, 2015.

INTERVENTIONS

Dyads of patients and their partners were randomly assigned to receive the skills training intervention or customary care (control group).

MAIN OUTCOMES AND MEASURES

The main outcome was frequency of SSE performance. The secondary outcome was detection of a new or recurrent melanoma by the dyad or physician. The tertiary outcome was the number of unscheduled physician appointments for concerning lesions.

RESULTS

The study cohort comprised 494 participants. The patient population was 51.2% (253 of 494) female and had a mean (SD) age of 55 (10) years. Patients in the intervention arms had significantly increased SSEs with their partners at 4, 12, and 24 months (P < .001 for all) compared with the control group (mean differences, 1.57 [95% CI, 1.29-1.85], 0.72 [95% CI, 0.39-1.06], and 0.94 [95% CI, 0.58-1.30], respectively). Patients in the intervention arms identified new melanomas more than those in the control group (χ21 = 28.77, P < .01 [n = 51 melanomas in situ] and χ21 = 6.43, P < .05 [n = 18 invasive melanomas]) and did not increase physician visits.

CONCLUSIONS AND RELEVANCE

Patients with melanoma and their partners reliably performed SSE after participating in a structured skills training program lasting approximately 30 minutes, with reinforcement every 4 months by the study dermatologist. Accurate SSE by those at risk to develop melanoma may enhance early detection and relieve some of the burden on health services to provide continuing follow-up to a growing population of eligible patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01432860.