Melanoma incidence and patient compliance in a targeted melanoma screening intervention. One-year follow-up in a large French cohort of high-risk patients

Melanoma detection by skin self-examination targeting at-risk women: A randomized controlled trial with telemedicine support for concerning moles

Secondary melanoma prevention remains crucial to reduce morbidity and mortality for the 200,000 people in the United States estimated to develop melanoma in 2021. This 3-month randomized controlled trial of online skin self-examination (SSE) education among 1000 at-risk women who received care at Northwestern Medicine in Illinois sought to determine SSE initiation and monthly performance, SSE anxiety and confidence, and health care practitioner (HCP) visits for concerning moles. Positive responses to a personal history of sunburn, a personal or family history of skin cancer, and/or having 10 or more lifetime indoor tanning sessions identified and informed women of their increased risk of melanoma. At one month, 96.2% of women receiving SSE education (SSE women) initiated SSE compared to 48.1% in the active control arm (control) (p < 0.001). More control women sought HCP visits (n = 107) than SSE women (n = 39). Control women seen by HCPs identified benign lesions, especially seborrheic keratosis, more often than SSE women. More atypical nevi (SSE 38.5%, control 8.4%) and melanomas (SSE 25.6%, control 4.7%) were visually identified by SSE women seeing HPCs (p < 0.001). There was no significant difference in SSE anxiety between the control and SSE arms. Confidence increased significantly in the SSE arm whereas there was no change in the control group (p < 0.001). Women checked someone else for concerning moles [315/ 494 (63.8%) of SSE women]. Targeting at-risk women for SSE education may help reduce melanoma mortality, especially in rural communities where incidence and mortality are greater than in urban areas.

A systematic review and synthesis of qualitative and quantitative studies evaluating provider, patient, and health care system-related barriers to diagnostic skin cancer examinations

Melanoma-screening examinations support early diagnosis, yet there is a national shortage of dermatologists and most at-risk patients lack access to dermatologic care. Primary care physicians (PCPs) in the United States often bridge these access gaps, and thus, play a critical role in the early detection of melanoma. However, most PCPs do not offer skin examinations. We conducted a systematic review and searched Ovid MEDLINE, EMBASE, and the Cochrane Library from 1946 to July 2019 to identify barriers for skin screening by providers, patients, and health systems following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Of 650 abstracts initially identified, 111 publications were included for full-text review and 48 studies met the inclusion criteria. Lack of dermatologic training (89.4%), time constraints (70%), and competing comorbidities (51%) are the most common barriers reported by PCPs. Low perceived risk (69%), long delays in appointment (46%), and lack of knowledge about melanoma (34.8%) are most frequently reported patient barriers. Qualitative reported barriers for health system are lack of public awareness, social prejudice leading to tanning booth usage, public surveillance programs requiring intensive resources, and widespread ABCD evaluation causing delays in seeking medical attention for melanomas. Numerous barriers remain that prevent the implementation of skin screening practices in clinical practice. A multi-faceted combination of efforts is essential for the execution of acceptable and effective skin cancer-screening practices, thus, increasing early diagnosis and lowering mortality rates and burden of disease for melanoma.

Melanoma Epidemiology and Early Detection in Europe: Diversity and Disparities

Melanoma claims annually more than 20,000 lives in Europe and is an important public health burden through its continuously increasing incidence and with its high mortality, costs, and complexity of care in advanced stages. Epidemiological surveillance is indispensable for the research into its causes, new prognostic markers, and innovative therapies, as well as for the building of efficient cancer control plans. However, important differences in the sources and availability of accurate epidemiological data exist among European countries and regions, contributing to a heterogeneous picture with 20-fold differences in the reported national melanoma incidence rates, divergent mortality trends, and solid disparities in survival across the Continent. Countries in the eastern half of Europe report the lowest incidence rates, but high case fatality, persisting and increasing mortality, a higher proportion of thicker tumors and late diagnosis, and lower survival rates. They are the least well equipped with quality cancer registration and reporting, and they lag behind in efficient cancer control plans implementation. This review highlights the main differences in melanoma epidemiology across Europe, together with an insight into their underlying causes in the areas of melanoma registration, early diagnosis, and prevention. These differences should be acknowledged and understood by physicians, researchers, and all stakeholders involved in improving melanoma care and outcomes, as no one-size-fits-all solution can tackle the melanoma problem in Europe. Instead, there is a need for nuanced strategies, adapted to the heterogeneous national and regional contexts, that would build on European diversity to eliminate the outcome disparities.

Anxiety, locus of control and sociodemographic factors associated with adherence to an annual clinical skin monitoring: a cross-sectional survey among 1000 high-risk French patients involved in a pilot-targeted screening programme for melanoma

OBJECTIVE

The aim of the study was to assess whether adherence to annual clinical skin monitoring is dependent on patient sociodemographic characteristics or personality traits.

DESIGN

The study was a questionnaire survey.

SETTING AND PARTICIPANTS

Data were collected between February and April 2013 in a sample of 1000 patients at high risk of melanoma who participated in a pilot-targeted screening programme in western France.

OUTCOME MEASURES

Sociodemographic data, overall anxiety level (State-Trait Anxiety Inventory questionnaire), locus of control (Multidimensional Health Locus of Control scale) and levels of anxiety specifically associated with screening and melanoma were collected. Actual participation in the skin monitoring examination was reported by 78 general practitioner investigators.

STATISTICAL ANALYSIS

Statistical analysis was performed using R statistical software. Factors associated with non-adherence were identified by multivariate analysis.

RESULTS

Our analysis included 687 responses (526 adherent patients and 161 non-adherent patients). Non-adherence was higher in younger patients and in men (OR=0.63 (0.41-0.99)). Viewing health status as dependent on external persons (OR=0.90, 95% CI 0.83 to 0.97) or determined by chance (OR=0.89, 95% CI 0.80 to 0.98) and overall anxiety (OR=0.98, 95% CI 0.97 to 0.99) were also factors associated with non-adherence. In contrast, there was no link between anxiety specifically associated with the screening performed or melanoma and patient adherence to monitoring. Adherence was higher in married patients (OR=1.68 95% CI 1.08 to 2.60).

CONCLUSIONS

The results of this study suggest that sociodemographic and psychological characteristics should be considered when including patients at elevated risk of melanoma in a targeted screening programme.

TRIAL REGISTRATION NUMBER

NCT01610531; Post-results.

General practitioner management related to skin cancer prevention and screening during standard medical encounters: a French cross-sectional study based on the International Classification of Primary Care

OBJECTIVE

The aim of this study was to assess general practitioner (GP) management practices related to skin cancer prevention and screening during standard medical encounters.

SETTING

Data on medical encounters addressing skin cancer issues were obtained from a French database containing information from 17 019 standard primary care consultations.

PARTICIPANTS

Data were collected between December 2011 and April 2012 by 54 trainees who reported the regular practice of 128 GPs using the International Classification of Primary Care.

OUTCOME MEASURES

Reasons for encounters and the following care processes were recorded: counselling, clinical examinations and referral to a specialist. Medical encounters addressing skin cancer issues were compared with medical encounters that addressed other health problems using a multivariate analysis.

RESULTS

Only 0.7% of medical encounters addressed skin cancer issues. When patients did require management of a skin cancer-related issue, this was more likely initiated by the doctor than the patient (70.7% vs 29.3%; p<0.001). Compared with medical encounters addressing other health problems, encounters that addressed skin cancer problems required more tasks (3.7 vs 2.5; p<0.001) and lasted 1 min and 20 s longer (p=0.003). GPs were less involved in clinical examinations (67.5% vs 97.1%; p<0.001), both complete (7.3% vs 22.3%, p<0.001) and partial examinations (60.2% vs 74.9%), and were less involved in counselling (5.7% vs 16.9%; p<0.001). Patients presenting skin cancer issues were referred to a specialist more often than patients consulting for other health problems (39.0% vs 12.1%; p<0.001). GPs performed a biopsy in 6.7% of all skin cancer-related encounters.

CONCLUSIONS

This study demonstrates discrepancies between the high prevalence of skin cancer and the low rate of medical encounters addressing these issues in general practice. Our findings should be followed by qualitative interviews to better understand the observed practices in this field.

Inclusion of populations at risk of advanced melanoma in an opportunistic targeted screening project involving general practitioners

OBJECTIVE

The study objective was to measure the rates of inclusion of populations at risk of advanced melanoma in a pilot targeted screening project involving general practitioners.

DESIGN

This cross-sectional database study compared the inclusion rates of patients who signed inclusion in a targeted screening project with those of patients who did not, during a period in which both groups of patients consulted investigators.

SETTING

Data were extracted from the national healthcare insurance records in western France from 11 April to 30 October 2011.

PATIENTS

Patients, older than 18, considered for the data extraction had consulted one of the 78 participating GPs during the study period, and were affiliated with the national healthcare insurance.

MAIN OUTCOME MEASURES

Inclusion in the screening was the main outcome measure. Patients at risk of advanced melanoma were characterized by male gender, age over 50, low income, rural residence, farmer, and presence of chronic disease.

RESULTS

A total of 57,279 patients consulted GPs during the inclusion period and 2711 (4.73%) were included in the targeted screening. Populations at risk of advanced melanoma were less included: men (OR = 0.67; 95%CI [0.61-0.73]; p < 0.001), older than 50 (OR = 0.67; 95%CI [0.60-0.74]; p < 0.001), low income (OR = 0.65; 95%CI [0.55-0.77]; p < 0.001), farmer (OR = 0.23; 95%CI [0.17-0.30]; p < 0.001) and presence of a chronic disease (OR = 0.87; 95%CI [0.77-0.98]; p < 0.028).

CONCLUSION

This study demonstrated inequalities in the inclusion of patients in a melanoma screening. Patients at risk of advanced cancer were screened less often. Further studies should focus on GPs ability to identify and screen these patients. KEY POINTS Advanced melanoma is more frequently diagnosed in men, older patients and socioeconomically disadvantaged populations, which leads to survival inequalities. • Despite the involvement of general practitioners, the implementation of targeted melanoma screening did not avoid inclusion inequalities. • Men, older patients, patients suffering from chronic diseases, and low-income patients were less likely to benefit from screening. • The display of a conventional or an alarmist poster in the waiting room did not statistically reduce these inclusion inequalities.

Proposal for an annual skin examination by a general practitioner for patients at high risk for melanoma: a French cohort study

OBJECTIVE

To evaluate the efficacy of a targeted screening for melanoma in high-risk patients following the receipt of a mailed invitation to an annual skin examination by a general practitioner (GP).

METHODS

A prospective cohort study was conducted in a primary care setting in western France. A total of 3897 patients at elevated risk of melanoma (identified using the Self-Assessment of Melanoma Risk Score) consented to participate in a targeted melanoma screening project in 2011. One year later, the participants were invited by mail to consult their GP for an annual skin examination. Efficacy of the procedure was evaluated according to patient participation and the number of melanomas detected. The consultation dates and results were collected during the 12 months postreminder and were analysed using SAS. Analyses of whether participation decreased compared with that during the year of inclusion and whether populations at risk for thick melanoma showed reduced participation in the screening were performed.

RESULTS

Of the 3745 patients who received the mailed invitation, 61% underwent a skin examination. The participation of patients at risk for thick melanoma (any patient over 60 years of age and men over 50 years of age) was significantly greater than that of the patients in the other subgroups (72.4% vs 49.6%, p<0.001; and 66% vs 52.4%, p<0.001, respectively). The patients referred to the dermatologist after 1 year were more compliant compared with those referred during the first year (68.8% vs 59.1%, p=0.003). Six melanomas were detected within 1 year postreminder; therefore, the incidence of melanoma in the study population was 160/100 000.

CONCLUSIONS

This study confirms the benefits of developing a targeted screening strategy in primary care. In particular, after the annual reminder, patient participation and the diagnosis of melanoma remained high in the patients at elevated risk of thick melanomas.

TRIAL REGISTRATION NUMBER

NCT01610531.