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Ackermann DM, Hersch JK, Janda M, Bracken K, Turner RM, Bell KJL. Using the Behaviour Change Wheel to identify barriers and targeted strategies to improve adherence in randomised clinical trials: The example of MEL-SELF trial of patient-led surveillance for melanoma. Contemp Clin Trials 2024; 140:107513. [PMID: 38537902 DOI: 10.1016/j.cct.2024.107513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/06/2024] [Accepted: 03/24/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Adherence to self-management interventions is critical in both clinical settings and trials to ensure maximal effectiveness. This study reports how the Behaviour Change Wheel may be used to assess barriers to self-management behaviours and develop strategies to maximise adherence in a trial setting (the MEL-SELF trial of patient-led melanoma surveillance). METHODS The Behaviour Change Wheel was applied by (i) using the Capability, Opportunity, Motivation-Behaviour (COMB) model informed by empirical and review data to identify adherence barriers, (ii) mapping identified barriers to corresponding intervention functions, and (iii) identifying appropriate behaviour change techniques and developing potential solutions using the APEASE (Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects and safety, Equity) criteria. RESULTS The target adherence behaviour was defined as conducting a thorough skin self-examination and submitting images for teledermatology review. Key barriers identified included: non-engaged skin check partners, inadequate planning, time constraints, low self-efficacy, and technological difficulties. Participants' motivation was positively influenced by perceived health benefits and negatively impacted by emotional states such as anxiety and depression. We identified the following feasible interventions to support adherence: education, training, environmental restructuring, enablement, persuasion, and incentivisation. Proposed solutions included action planning, calendar scheduling, alternative dermatoscopes, optimised communication, educational resources in various formats to boost self-efficacy and motivation and optimised reminders (which will be evaluated in a Study Within A Trial (SWAT)). CONCLUSION The Behaviour Change Wheel may be used to improve adherence in clinical trials by identifying barriers to self-management behaviours and guiding development of targeted strategies.
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Affiliation(s)
- Deonna M Ackermann
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Australia.
| | - Jolyn K Hersch
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Australia
| | - Monika Janda
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Karen Bracken
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Australia
| | - Robin M Turner
- Biostatistics Centre, University of Otago, Dunedin, New Zealand
| | - Katy J L Bell
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Australia
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Drabarek D, Ackermann D, Medcalf E, Bell KJL. Acceptability of a Hypothetical Reduction in Routinely Scheduled Clinic Visits Among Patients With History of a Localized Melanoma (MEL-SELF): Pilot Randomized Clinical Trial. JMIR DERMATOLOGY 2023; 6:e45865. [PMID: 37632976 PMCID: PMC10335154 DOI: 10.2196/45865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/23/2023] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND After treatment for a localized melanoma, patients attend routinely scheduled clinics to monitor for new primary or recurrent melanoma. Patient-led surveillance (skin self-examination with patient-performed teledermoscopy) is an alternative model of follow-up that could replace some routinely scheduled visits. OBJECTIVE This study aims to assess the acceptability of a hypothetical reduction in routinely scheduled visits among participants of the Melanoma Self Surveillance (MEL-SELF) pilot randomized clinical trial of patient-led surveillance (intervention) versus usual care (control). METHODS Patients previously treated for localized melanoma in New South Wales who were participating in the MEL-SELF pilot randomized clinical trial were asked to respond to a web-based questionnaire at baseline and after 6 months on trial. We used mixed methods to analyze the data. The main outcome of interest was the acceptability of a hypothetical reduction in routinely scheduled visits for melanoma surveillance. RESULTS Of 100 randomized participants, 87 answered the questionnaire at baseline, 66 answered the questionnaire at 6 months, and 79 provided a free-text explanation at either time point. At 6 months, 33% (17/51) of the control group and 35% (17/49) of the intervention group indicated that a hypothetical reduction in routinely scheduled visits with all melanoma doctors was at least slightly acceptable (difference in proportions -1%, 95% CI -20% to 17%; P=.89). Participants suggested that prerequisites for a reduction in routinely scheduled visits would include that sufficient time had elapsed since the previous diagnosis without a new primary melanoma or recurrence, an unscheduled appointment could be made at short notice if the patient noticed something concerning, their melanoma doctor had suggested reducing their clinic visit frequency, and patients had confidence that patient-led surveillance was a safe and effective alternative. Participants suggested that a reduction in routinely scheduled visits would not be acceptable where they perceived a very high risk of new or recurrent melanoma, low self-efficacy in skin self-examination and in the use of technologies for the patient-led surveillance intervention, and where they had a preference for clinician-led surveillance. Some patients said that a partial reduction to once a year may be acceptable. CONCLUSIONS Some patients may be receptive to a reduction in routinely scheduled visits if they are assured that patient-led surveillance is safe and effective. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12616001716459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371865&isReview=true; ClinicalTrials.gov NCT03581188; https://clinicaltrials.gov/ct2/show/NCT03581188. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1001/jamadermatol.2021.4704.
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Affiliation(s)
- Dorothy Drabarek
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Deonna Ackermann
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ellie Medcalf
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Katy J L Bell
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Ackermann DM, Bracken K, Janda M, Turner RM, Hersch JK, Drabarek D, Bell KJL. Strategies to Improve Adherence to Skin Self-examination and Other Self-management Practices in People at High Risk of Melanoma: A Scoping Review of Randomized Clinical Trials. JAMA Dermatol 2023; 159:432-440. [PMID: 36857048 DOI: 10.1001/jamadermatol.2022.6478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Importance Adherence, both in research trials and in clinical practice, is crucial to the success of interventions. There is limited guidance on strategies to increase adherence and the measurement and reporting of adherence in trials of melanoma self-management practices. Objective This scoping review aimed to describe (1) strategies to improve adherence to self-management practices in randomized clinical trials of people at high risk of melanoma and (2) measurement and reporting of adherence data in these trials. Evidence Review Four databases, including MEDLINE, Embase, CENTRAL, and CINAHL, were searched from inception to July 2022. Eligible studies were randomized clinical trials of self-monitoring interventions for early detection of melanoma in people at increased risk due to personal history (eg, melanoma, transplant, dysplastic naevus syndrome), family history of melanoma, or as determined by a risk assessment tool or clinical judgment. Findings From 939 records screened, 18 eligible randomized clinical trials were identified, ranging in size from 40 to 724 participants, using a range of adherence strategies but with sparse evidence on effectiveness of the strategies. Strategies were classified as trial design (n = 15); social and economic support (n = 5); intervention design (n = 18); intervention and condition support (n = 10); and participant support (n = 18). No strategies were reported for supporting underserved groups (eg, people who are socioeconomically disadvantaged, have low health literacy, non-English speakers, or older adults) to adhere to self-monitoring practices, and few trials targeted provider (referring to both clinicians and researchers) adherence (n = 5). Behavioral support tools included reminders (n = 8), priority-setting guidance (n = 5), and clinician feedback (n = 5). Measurement of adherence was usually by participant report of skin self-examination practice with some recent trials of digital interventions also directly measuring adherence to the intervention through website or application analytic data. Reporting of adherence data was limited, and fewer than half of all reports mentioned adherence in their discussion. Conclusions and Relevance Using an adaptation of the World Health Organization framework for clinical adherence, this scoping review of randomized clinical trials identified key concepts as well as gaps in the way adherence is approached in design, conduct, and reporting of trials for skin self-examination and other self-management practices in people at high risk of melanoma. These findings may usefully guide future trials and clinical practice; evaluation of adherence strategies may be possible using a Study Within A Trial (SWAT) framework within host trials.
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Affiliation(s)
- Deonna M Ackermann
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Karen Bracken
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Monika Janda
- Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Robin M Turner
- Biostatistics Centre, University of Otago, Dunedin, New Zealand
| | - Jolyn K Hersch
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Dorothy Drabarek
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Katy J L Bell
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Williams JTW, Bell KJL, Morton RL, Dieng M. Exploring the Integration of Environmental Impacts in the Cost Analysis of the Pilot MEL-SELF Trial of Patient-Led Melanoma Surveillance. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:23-30. [PMID: 36195819 PMCID: PMC9834124 DOI: 10.1007/s40258-022-00765-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 06/16/2023]
Abstract
AIMS Human health is intrinsically linked with planetary health. But planetary resources are currently being degraded and this poses an existential threat to human health and the sustainability of our healthcare systems. The aims of this study were to (1) describe an approach to integrate environmental impacts in a cost analysis; and (2) demonstrate this approach by estimating select environmental impacts alongside traditional health system and other costs using the example of the pilot MEL-SELF randomised controlled trial of patient-led melanoma surveillance. METHODS Economic costs were calculated alongside a randomised trial using standard cost analysis methodology from a societal perspective. Environmental impacts were calculated using a type of carbon footprinting methodology called process-based life cycle analysis. This method considers three scopes of carbon emissions: Scope 1, which occur directly from the intervention; Scope 2, which occur indirectly from the intervention's energy use; and Scope 3, which occur indirectly because of the value chain of the intervention. In this study we only included emissions from patient transport to attend their melanoma clinic over the study period of 6 months. RESULTS The environmental impact per participant across allocated groups for patient transport to their melanoma clinic was estimated to be 10 kg carbon dioxide equivalent. Economic costs across the allocated groups indicated substantial health system costs, out-of-pocket costs, and productivity losses associated with melanoma surveillance. The largest cost contributor was health system costs, and the most expensive category of health system cost was hospital admission. CONCLUSION Calculating environmental impacts is worthwhile and feasible within a cost analysis framework. Further work is needed to address outstanding conceptual and practical issues so that a comprehensive assessment of environmental impacts can be considered alongside economic costs in health technology assessments.
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Affiliation(s)
- Jake T W Williams
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Camperdown, NSW, Australia.
| | - Katy J L Bell
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Camperdown, NSW, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Mbathio Dieng
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
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Drabarek D, Habgood E, Janda M, Hersch J, Ackermann D, Low D, Low C, Morton RL, Dieng M, Cust AE, Morgan A, Smith E, Bell KLJ. Experiences of Patient-Led Surveillance, Including Patient-Performed Teledermoscopy, in the MEL-SELF Pilot Randomized Controlled Trial: Qualitative Interview Study. JMIR DERMATOLOGY 2022; 5:e35916. [PMID: 37632893 PMCID: PMC10334928 DOI: 10.2196/35916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/05/2022] [Accepted: 04/18/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Current clinician-led melanoma surveillance models require frequent routinely scheduled clinic visits, with associated travel, cost, and time burden for patients. Patient-led surveillance is a new model of follow-up care that could reduce health care use such as clinic visits and medical procedures and their associated costs, increase access to care, and promote early diagnosis of a subsequent new melanoma after treatment of a primary melanoma. Understanding patient experiences may allow improvements in implementation. OBJECTIVE This study aims to explore patients' experiences and perceptions of patient-led surveillance during the 6 months of participation in the MEL-SELF pilot randomized controlled trial. Patient-led surveillance comprised regular skin self-examination, use of a mobile dermatoscope to image lesions of concern, and a smartphone app to track and send images to a teledermatologist for review, in addition to usual care. METHODS Semistructured interviews were conducted with patients previously treated for melanoma localized to the skin in New South Wales, Australia, who were randomized to the patient-led surveillance (intervention group) in the trial. Thematic analysis was used to analyze the data with reference to the technology acceptance model. RESULTS We interviewed 20 patients (n=8, 40% women and n=12, 60% men; median age 62 years). Patients who were more adherent experienced benefits such as increased awareness of their skin and improved skin self-examination practice, early detection of melanomas, and opportunities to be proactive in managing their clinical follow-up. Most participants experienced difficulty in obtaining clear images and technical problems with the app. These barriers were overcome or persevered by participants with previous experience with digital technology and with effective help from a skin check partner (such as a spouse, sibling, or friend). Having too many or too few moles decreased perceived usefulness. CONCLUSIONS Patients with melanoma are receptive to and experience benefits from patient-led surveillance using teledermoscopy. Increased provision of training and technical support to patients and their skin check partners may help to realize the full potential benefits of this new model of melanoma surveillance.
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Affiliation(s)
- Dorothy Drabarek
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Emily Habgood
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Monika Janda
- Centre for Health Services Research, University of Queensland, Brisbane, Australia
| | - Jolyn Hersch
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Deonna Ackermann
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Don Low
- Cancer Voices NSW, Sydney, Australia
| | | | - Rachael L Morton
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia
| | - Mbathio Dieng
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia
| | - Anne E Cust
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- The Daffodil Centre, The University of Sydney Cancer Council NSW, Sydney, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | - Adelaide Morgan
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Elloise Smith
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Katy L J Bell
- Sydney School of Public Health, University of Sydney, Sydney, Australia
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Medcalf E, Taylor A, Turner R, Espinoza D, Bell KJL. Can patient-led surveillance detect subsequent new primary or recurrent melanomas and reduce the need for routinely scheduled follow up? Statistical analysis plan for the MEL-SELF randomised controlled trial. Contemp Clin Trials 2022; 117:106761. [PMID: 35439647 DOI: 10.1016/j.cct.2022.106761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 03/31/2022] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The MEL-SELF trial is a randomised controlled trial of patient-led surveillance compared to clinician-led surveillance in people treated for localised cutaneous melanoma (stage 0, I, II). The primary trial aim is to determine if patient led-surveillance compared to clinician-led surveillance increases the proportion of participants who are diagnosed with a new primary or recurrent melanoma at a fast-tracked unscheduled clinic visit. The secondary outcomes include time to diagnosis of any skin cancer, psychosocial outcomes, acceptability, and resource use. OBJECTIVE The objective of this report is to outline and publish the pre-determined statistical analysis plan before the database lock and the start of analysis. METHODS/DESIGN The statistical analysis plan describes the overall analysis principles, including how participants will be included in each analysis, the presentation of the results, adjustments for covariates, the primary and secondary outcomes, and their respective analyses. In addition, we present the planned sensitivity and subgroup analyses. A separate analysis plan will be published for health economic outcomes. RESULTS The MEL-SELF statistical analysis plan has been designed to minimize bias in estimating effects of the intervention on primary and secondary outcomes. By pre-specifying analyses, we ensure the study's integrity and believability while enabling the reproducibility of the final analysis. CONCLUSION This detailed statistical analysis plan will help to ensure transparency of reporting of results from the MEL-SELF trial. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000176864. Registered 18 February 2021, https://www.anzctr.org.au/ACTRN12621000176864.aspx.
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Affiliation(s)
- Ellie Medcalf
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Aiya Taylor
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Robin Turner
- Biostatistics Centre, University of Otago, Dunedin, New Zealand
| | - David Espinoza
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia
| | - Katy J L Bell
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
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Win Myint TT, Selak V, Elwood M. The risk of subsequent invasive melanoma after a primary in situ or invasive melanoma in a high incidence country (New Zealand). SKIN HEALTH AND DISEASE 2022; 3:e116. [PMID: 37013115 PMCID: PMC10066759 DOI: 10.1002/ski2.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/07/2022]
Abstract
Background Patients with invasive melanoma are at increased risk of developing subsequent invasive melanoma, but the risks for those with primary in situ melanoma are unclear. Objectives To assess and compare the cumulative risk of subsequent invasive melanoma after primary invasive or in situ melanoma. To estimate the standardized incidence ratio (SIR) of subsequent invasive melanoma compared to population incidence in both cohorts. Methods Patients with a first diagnosis of melanoma (invasive or in situ) between 2001 and 2017 were identified from the New Zealand national cancer registry, and any subsequent invasive melanoma during follow-up to the end of 2017 identified. Cumulative risk of subsequent invasive melanoma was estimated by Kaplan-Meier analysis separately for primary invasive and in situ cohorts. Risk of subsequent invasive melanoma was assessed using Cox proportional hazard models. SIR was assessed, allowing for age, sex, ethnicity, year of diagnosis and follow up time. Results Among 33 284 primary invasive and 27 978 primary in situ melanoma patients, median follow up time was 5.5 and 5.7 years, respectively. A subsequent invasive melanoma developed in 1777 (5%) of the invasive and 1469 (5%) of the in situ cohort, with the same median interval (2.5 years) from initial to first subsequent lesion in both cohorts. The cumulative incidence of subsequent invasive melanoma at 5 years was similar in the two cohorts (invasive 4.2%, in situ 3.8%); the cumulative incidence increased linearly over time in both cohorts. The risk of subsequent invasive melanoma was marginally higher for primary invasive compared to in situ melanoma after adjustment for age, sex, ethnicity and body site of the initial lesion (hazard ratio 1.11, 95% CI 1.02-1.21). Compared to population incidence, the SIR of invasive melanoma was 4.6 (95% CI 4.3-4.9) for the primary invasive and 4 (95% CI 3.7-4.2) for the primary in situ melanoma cohorts. Conclusions The risk of subsequent invasive melanoma is similar whether patients present with in situ or invasive melanoma. Thus follow-up surveillance for new lesions should be similar, although patients with invasive melanoma require more surveillance for recurrence.
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Affiliation(s)
- Thu Thu Win Myint
- Department of Biostatistics and Epidemiology University of Auckland Auckland New Zealand
| | - Vanessa Selak
- Department of Biostatistics and Epidemiology University of Auckland Auckland New Zealand
| | - Mark Elwood
- Department of Biostatistics and Epidemiology University of Auckland Auckland New Zealand
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Ackermann DM, Dieng M, Medcalf E, Jenkins MC, van Kemenade CH, Janda M, Turner RM, Cust AE, Morton RL, Irwig L, Guitera P, Soyer HP, Mar V, Hersch JK, Low D, Low C, Saw RPM, Scolyer RA, Drabarek D, Espinoza D, Azzi A, Lilleyman AM, Smit AK, Murchie P, Thompson JF, Bell KJL. Assessing the Potential for Patient-led Surveillance After Treatment of Localized Melanoma (MEL-SELF): A Pilot Randomized Clinical Trial. JAMA Dermatol 2022; 158:33-42. [PMID: 34817543 PMCID: PMC8771298 DOI: 10.1001/jamadermatol.2021.4704] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/28/2021] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Patient-led surveillance is a promising new model of follow-up care following excision of localized melanoma. OBJECTIVE To determine whether patient-led surveillance in patients with prior localized primary cutaneous melanoma is as safe, feasible, and acceptable as clinician-led surveillance. DESIGN, SETTING, AND PARTICIPANTS This was a pilot for a randomized clinical trial at 2 specialist-led clinics in metropolitan Sydney, Australia, and a primary care skin cancer clinic managed by general practitioners in metropolitan Newcastle, Australia. The participants were 100 patients who had been treated for localized melanoma, owned a smartphone, had a partner to assist with skin self-examination (SSE), and had been routinely attending scheduled follow-up visits. The study was conducted from November 1, 2018, to January 17, 2020, with analysis performed from September 1, 2020, to November 15, 2020. INTERVENTION Participants were randomized (1:1) to 6 months of patient-led surveillance (the intervention comprised usual care plus reminders to perform SSE, patient-performed dermoscopy, teledermatologist assessment, and fast-tracked unscheduled clinic visits) or clinician-led surveillance (the control was usual care). MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of eligible and contacted patients who were randomized. Secondary outcomes included patient-reported outcomes (eg, SSE knowledge, attitudes, and practices, psychological outcomes, other health care use) and clinical outcomes (eg, clinic visits, skin surgeries, subsequent new primary or recurrent melanoma). RESULTS Of 326 patients who were eligible and contacted, 100 (31%) patients (mean [SD] age, 58.7 [12.0] years; 53 [53%] men) were randomized to patient-led (n = 49) or clinician-led (n = 51) surveillance. Data were available on patient-reported outcomes for 66 participants and on clinical outcomes for 100 participants. Compared with clinician-led surveillance, patient-led surveillance was associated with increased SSE frequency (odds ratio [OR], 3.5; 95% CI, 0.9 to 14.0) and thoroughness (OR, 2.2; 95% CI, 0.8 to 5.7), had no detectable adverse effect on psychological outcomes (fear of cancer recurrence subscale score; mean difference, -1.3; 95% CI, -3.1 to 0.5), and increased clinic visits (risk ratio [RR], 1.5; 95% CI, 1.1 to 2.1), skin lesion excisions (RR, 1.1; 95% CI, 0.6 to 2.0), and subsequent melanoma diagnoses and subsequent melanoma diagnoses (risk difference, 10%; 95% CI, -2% to 23%). New primary melanomas and 1 local recurrence were diagnosed in 8 (16%) of the participants in the intervention group, including 5 (10%) ahead of routinely scheduled visits; and in 3 (6%) of the participants in the control group, with none (0%) ahead of routinely scheduled visits (risk difference, 10%; 95% CI, 2% to 19%). CONCLUSIONS AND RELEVANCE This pilot of a randomized clinical trial found that patient-led surveillance after treatment of localized melanoma appears to be safe, feasible, and acceptable. Experiences from this pilot study have prompted improvements to the trial processes for the larger trial of the same intervention. TRIAL REGISTRATION http://anzctr.org.au Identifier: ACTRN12616001716459.
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Affiliation(s)
- Deonna M. Ackermann
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Mbathio Dieng
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Ellie Medcalf
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Marisa C. Jenkins
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Monika Janda
- Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Robin M. Turner
- Biostatistics Centre, University of Otago, Dunedin, Otago, New Zealand
| | - Anne E. Cust
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- The Daffodil Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachael L. Morton
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Les Irwig
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Pascale Guitera
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - H. Peter Soyer
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Australia
| | - Victoria Mar
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jolyn K. Hersch
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Donald Low
- Cancer Voices New South Wales, Sydney, New South Wales, Australia
| | - Cynthia Low
- Cancer Voices New South Wales, Sydney, New South Wales, Australia
| | - Robyn P. M. Saw
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard A. Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- New South Wales Health Pathology, Sydney, New South Wales, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Dorothy Drabarek
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David Espinoza
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Azzi
- Newcastle Skin Check, Newcastle, New South Wales, Australia
| | | | - Amelia K. Smit
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- The Daffodil Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter Murchie
- Academic Primary Care Research Group, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | - John F. Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Katy J. L. Bell
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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