Construct validity of the anglicised FACE-Q skin cancer module

OBJECTIVES

The FACE-Q Skin Cancer module is a patient-reported outcome measure (PROM) for facial skin cancer. It has been anglicised for the UK population and undergone psychometric testing using classical test theory. In this study, further evaluation of construct validity using Rasch measurement theory and hypothesis testing was performed.

METHODS

Patients were prospectively recruited to the Patient-Reported Outcome Measures In Skin Cancer Reconstruction (PROMISCR) study and asked to complete the anglicised FACE-Q Skin Cancer module. The scalability and unidimensionality of the data were assessed with a Mokken analysis prior to Rasch analysis. Response thresholds, targeting, fit statistics, local dependency, and internal consistency were examined for all items and subscales. Four a priori hypotheses were tested to evaluate the convergent and divergent validity. We additionally hypothesised that the median 'cancer worry' score would be lower in post-operative than pre-operative patients.

RESULTS

239 patients self-completed the questionnaire between August 2017 and May 2019. Of the ten subscales assessed, five showed relative fit to the Rasch model. Unidimensionality was present for all five subscales, with most demonstrating ordered item thresholds and appropriate fit statistics. Two items in the 'cancer worry' subscale had either disordered or very close response thresholds. Subscales of the FACE-Q Skin Cancer module demonstrated convergent and divergent validity with relevant Skin Cancer Index comparators (p < 0.001). Median 'cancer worry' was lower in post-operative patients (44 vs 39, p < 0.001).

CONCLUSION

The anglicised FACE-Q Skin Cancer module shows psychometric validity through hypothesis testing, and both classical and modern test theory.

Establishing the use of total body photography among U.K. dermatologists

Total body photography (TBP) is increasingly used to monitor skin lesions in individuals at high risk of melanoma. Two surveys of U.S. dermatologists demonstrated variable reasons for use and conflicting beliefs regarding TBP efficacy. Although TBP may reduce number-needed-to-biopsy when diagnosing melanoma, there is scarce evidence for TBP use in lower-risk populations and a lack of consensus on optimal TBP use. Thus, we undertook the first U.K. survey to assess TBP rationale, target populations, and protocols.

Embracing artificial intelligence- how can we make it inclusive and relevant for real world dermatological practice?

Artificial intelligence (AI) developments are rapidly advancing with algorithms capable of out-performing dermatologists in specific contrived challenges, but where prospective evaluation in real-world settings remain limited. Professional bodies have a role to encourage AI approaches to address clinical unmet needs, improve quality of care, and enhance patient experience without compromising safety. In 2019, the American Academy of Dermatology advocated principles of human-centred design for augmented intelligence innovations (1) emphasising the importance of synergy between dermatologist and the computer. More recently, the British Association of Dermatologists highlighted the weak current evidence-base supporting effectiveness of AI interventions in routine clinical practice and encouraged clinicians to independently evaluate the evidence prior to adoption (2).

POS1453 OVERLAPPING FEATURES OF RELAPSING POLYCHONDRITIS AND SWEET’S SYNDROME: COULD THIS BE VEXAS (VACUOLES, UBIQUITIN A1E MUTATION, X-LINKED, AUTOINFLAMMATORY, SOMATIC) SYNDROME?

Background:

An 83-year-old male presented to the infectious diseases team with intermittent fevers associated with tension headaches, malaise and fatigue for two years, with recent worsening. He had noted a progressive decline in his mobility over the past year following replacement of his right knee for osteoarthritis. His past medical history included atopic eczema, malaria and bilateral cataract extractions.

On examination, he had a widespread non-scaly annular urticated rash. He had persistently raised inflammatory markers (CRP 40mg/L, ESR 82mm/hour), normocytic anaemia (Hb 102 g/L, MCV 101.9 fL), lymphopenia (0.70 x10^9/L), fluctuating eosinophilia (0.88-1.25 x10^9/L) and a mildly elevated lactate dehydrogenase (243IU/L). A thorough work up for pyrexia of unknown origin showed no evidence of infection/ vasculitis/ immune pathology. The only positive finding was prior exposure to schistosomiasis, treated with a single dose of praziquantel. An echocardiogram and serial PET-CT scans were normal. Given the deterioration in mobility since the right knee replacement, an MRI knee was performed, and cobalt/ chromium levels to look for allergic responses to the prosthesis, but these tests did not reveal any findings of significance.

An initial haematology work-up did not identify an abnormality of concern (screening for a myeloproliferative neoplasm including BCR-ABL studies were negative and mast cell tryptase was not elevated). Due to a worsening skin rash, he was reviewed by dermatology where a skin biopsy showed features of superficial neutrophilic dermatosis which can be observed with Sweet’s syndrome. However, it was felt that this was an unlikely explanation for the persistent systemic symptoms. He proceeded to a bone marrow biopsy which showed reactive features including vacuolation of myeloid precursors with normal cytogenics.

During follow up appointments, the patient described new recurrent violaceous patches with episodes of inflammation of the pinna of the ear, suggesting a diagnosis of relapsing polychondritis and so the patient was started on high dose prednisolone (80mg per day [1mg per kg]) and referred for rheumatological assessment. He had an excellent response to prednisolone (fever, ear swelling and rash subsided). The overlapping features of relapsing polychondritis and Sweet’s syndrome in an elderly man suggested a diagnosis of VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory and somatic) syndrome. The prednisolone dose was rapidly reduced to 10mg per day and the patient was commenced on methotrexate, as a steroid-sparing agent. Further blood tests have been sent for genetic analysis for VEXAS syndrome but results are pending.

Objectives:

N/A

Methods:

N/A

Results:

N/A

Conclusion:

VEXAS syndrome is a newly identified genetically defined syndrome, described by Beck et al in October 2020 consisting of somatic mutations in the UBA1 gene, affecting bone marrow stem cells. In a study of 25 patients with this mutation, diagnostic/ classification criteria for relapsing polychondritis (n=15), Sweet’s syndrome (n=8), polyarteritis nodosa (n=3) or giant cell arteritis (n=1) were met and patients often had severe refractory disease with overlapping systemic inflammatory and haematologic features. Features of VEXAS include the presence of vacuoles in myeloid cells, somatic mutations in the UBA1 (ubiquitin-activating enzyme) gene, X-linkage (therefore only occurring in males), in older people with autoinflammatory syndromes. Although VEXAS syndrome is a relatively rare condition, it was a relevant consideration in this case.

References:

[1]Beck et al. Somatic Mutations in UBA1 and Severe Adult-Onset Autoinflammatory Disease. N Engl J Med 2020; 383:2628-2638. DOI: 10.1056/NEJMoa2026834

Disclosure of Interests:

None declared

Development of a core outcome set for cutaneous squamous cell carcinoma trials: identification of core domains and outcomes

BACKGROUND

The lack of uniformity in the outcomes reported in clinical studies of the treatment of cutaneous squamous cell carcinoma (cSCC) complicates efforts to compare treatment effectiveness across trials.

OBJECTIVES

To develop a core outcome set (COS), a minimum set of agreed-upon outcomes to be measured in all clinical trials of a given disease or outcome, for the treatment of cSCC.

METHODS

One hundred and nine outcomes were identified via a systematic literature review and interviews with 28 stakeholders. After consolidation of this long list, 55 candidate outcomes were rated by 19 physician and 10 patient stakeholders, in two rounds of Delphi exercises. Outcomes scored 'critically important' (score of 7, 8 or 9) by ≥ 70% of patients and ≥ 70% of physicians were provisionally included. At the consensus meeting, after discussion and voting of 44 international experts and patients, the provisional list was reduced to a final core set, for which consensus was achieved among all meeting participants.

RESULTS

A core set of seven outcomes was finalized at the consensus meeting: (i) serious or persistent adverse events, (ii) patient-reported quality of life, (iii) complete response, (iv) partial response, (v) recurrence-free survival, (vi) progression-free survival and (vii) disease-specific survival.

CONCLUSIONS

In order to increase the comparability of results across trials and to reduce selective reporting bias, cSCC researchers should consider reporting these core outcomes. Further work needs to be performed to identify the measures that should be reported for each of these outcomes.

A 10-year review of surgical management of dermatofibrosarcoma protuberans

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare skin cancer. Standard treatment in the UK is either wide local excision (WLE) or Mohs micrographic surgery (MMS). It is unclear which approach has the lower recurrence rate.

OBJECTIVES

We undertook a retrospective comparative review of surgical management of DFSP in the UK National Health Service in order to define (i) current surgical practice for primary and recurrent DFSP, (ii) local recurrence rates for primary DFSP and (iii) survival outcomes for DFSP.

METHODS

A retrospective clinical case-note review of patients with histologically confirmed DFSP (January 2004 to December 2013) who have undergone surgical treatment.

RESULTS

The surgical management of 483 primary and 64 recurrent DFSP in 11 plastic surgery and 15 dermatology departments was analysed. Almost 75% of primary DFSP (n = 362) were treated with WLE and 20% (n = 97) with MMS. For recurrent DFSP, 69% (n = 44) and 23% (n = 15) of patients underwent WLE and MMS, respectively. Recurrent primary DFSP occurred in six patients after WLE and none after MMS. The median follow-up time was 25·5 months (interquartile range 6·8-45·1) for new and 19·8 (IQR 4·5-44·5) for recurrent DFSP [Correction added on 1 Feb 2021, after first online publication: 4.8 years (interquartile range 3.5-5.8) was incorrect], with eight reported deaths during the follow-up analysis period (one confirmed to be DFSP related).

CONCLUSIONS

WLE was the most common surgical modality used to treat DFSP across the UK. The local recurrence rate was very low, occurring only after WLE. Although a prospective randomized controlled trial may provide more definitive outcomes, in the absence of a clearly superior surgical modality, treatment decisions should be based on patient preference, clinical expertise and cost.

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.

Cutaneous hyperpigmentation and familial gastrointestinal stromal tumour associated with KIT mutation

Gastrointestinal stromal tumours (GISTs) are mesenchymal tumours arising in the gastrointestinal tract. Early detection, before metastasis occurs, is important as complete surgical excision achieves cure. Approximately 85% of GISTs are associated with mutations in the KIT gene, and although the majority of GISTs are sporadic, familial GISTs have been identified. Several families with multiple GIST tumours have also been described with various cutaneous findings including hyperpigmentation, multiple lentigines, vitiligo and urticaria pigmentosa. We discuss a 6-year-old boy who presented with an unusual pattern of hyperpigmentation in association with a family history of GIST. A causative KIT mutation was identified in DNA from the pigmented skin and from the resected GIST, and the patient was referred to the Paediatric Gastroenterology department for GIST screening. The term 'GIST cutaneous hyperpigmentation disease' has been suggested previously for the association of familial GIST with cutaneous hyperpigmentation caused by a germline KIT mutation.

Patient preferences for topical treatment of actinic keratoses: a discrete-choice experiment

BACKGROUND

The treatment of actinic keratosis (AK) is a potentially effective strategy for the prevention of cutaneous squamous cell carcinoma (cSCC). However, the patient perspective on potential benefits of AK treatment in terms of skin cancer reduction has received little attention to date.

OBJECTIVES

(i) To investigate patient preferences for topical treatments for AK using a discrete-choice experiment (DCE); (ii) to evaluate patient willingness to trade between clinical benefit and medical burden.

METHODS

The DCE was conducted as part of a study to establish the feasibility of a phase III randomized controlled trial evaluating the prevention of cSCC using currently available topical interventions. Preferences were elicited by asking patients to make a series of choices between treatment alternatives with different hypothetical combinations of attribute levels. Willingness to trade between treatment attributes was estimated using a flexible-choice model that allows for the heterogeneity of patient preferences.

RESULTS

A total of 109 patients with AK completed the DCE. The majority of patients who expressed valid preferences were willing to accept some reduction in both prophylactic and cosmetic efficacy to reduce the burden of the treatment regimen, the severity of skin reaction and other adverse effects. Patients may reject treatment if the perceived therapeutic benefit is outweighed by the subjective burden of treatment.

CONCLUSIONS

Evidence of significant variation in the perceived utility of treatments across patients highlights the importance of taking individual patient preferences into account to improve AK treatment acceptability and adherence.

Do perioperative antibiotics reduce the risk of surgical-site infections following excision of ulcerated skin cancers? A Critically Appraised Topic

AIM

To review the efficacy of perioperative antibiotics in reducing the risk of surgical-site infections (SSIs) following excision of ulcerated skin cancers.

SETTING AND DESIGN

Study selection, data extraction and analysis were carried out independently by four authors. Only randomized controlled trials (RCTs) reported in the English language were included.

INCLUDED STUDIES

RCTs in the English language in which patients received perioperative topical, intralesional or oral antibiotics for dermatological surgery, including Mohs micrographic surgery in general practice, dermatology or plastic surgery departments, were included.

OUTCOME

The proportion of participants developing SSI following excision of skin lesions.

RESULTS

Thirteen RCTs were identified from our literature search of PubMed and Embase, which evaluated SSI following use of topical (n = 5), oral (n = 3), intramuscular (n = 2), intravenous (n = 1) and intralesional antibiotics (n = 2) in dermatological surgery. Two RCTs specifically investigated SSIs in ulcerated skin cancer excisions; one RCT investigated the SSI rate following surgical treatment specifically for ulcerated skin cancers in individuals randomized to topical antibiotics vs. oral cephalexin; and one RCT compared intravenous cefazolin with no antibiotic, demonstrating significant reduction in SSI rates for ulcerated tumours (P = 0·04).

CONCLUSIONS

The heterogeneity of the RCTs included in this study makes it difficult to make a direct comparison of the outcomes measured. High-quality evidence demonstrating a beneficial effect of the use of perioperative antibiotics to prevent SSI following excision of ulcerated skin cancers is lacking. In the absence of an evidence base, we propose that a well-designed multicentre RCT could evaluate the effect of perioperative antibiotics following excision of ulcerated tumours, and potentially reduce inappropriate antibiotic prescription.

Synchronous melanoma and renal carcinoma: a clinicopathological study of five cases

An increased frequency of renal carcinoma in men with melanoma has been reported in population based-studies. We report the clinicopathological findings of five cases of synchronous renal cell carcinoma (RCC), identified after routine radiological staging for cutaneous malignant melanoma (MM) between October 2006 and October 2008. The five patients (three men and two women, with a mean age of 62.4 years), presented with six melanomas of varying subtypes. The mean Breslow thickness was 1.87 mm. There was no family history of cancer in any of the cases. Routine radiological staging identified a mass arising from the left kidney in three cases and the right kidney in two cases. All patients underwent radical nephrectomy, and histology in each case confirmed RCC of the clear-cell subtype. Mean follow-up was 3 years. Although the simultaneous occurrence of RCC and MM may be coincidental, there are several plausible aetiological links. Further analysis of the synchronous occurrence of MM and renal cancer may provide therapeutic insights into these two important tumours.

Melanoma in organ transplant recipients: clinicopathological features and outcome in 100 cases

Organ transplant recipients have a higher incidence of melanoma compared to the general population but the prognosis of this potentially fatal skin cancer in this group of patients has not yet been established. To address this, we undertook a multicenter retrospective analysis to assess outcome for 100 melanomas (91 posttransplant and 9 pretransplant) in 95 individuals. Data were collected in 14 specialist transplant dermatology clinics across Europe belonging to the Skin Care in Organ Transplant Patients, Europe (SCOPE) Network, and compared with age, sex, tumor thickness and ulceration status-matched controls from the American Joint Committee on Cancer (AJCC) melanoma database. Outcome for posttransplant melanoma was similar to that of the general population for T1 and T2 tumors (< or = 2 mm thickness); but was significantly worse for T3 and T4 tumors (> 2 mm thickness); all nine individuals with a pretransplant melanoma survived without disease recurrence following organ transplantation. These data have implications for both cutaneous surveillance in organ transplant recipients and management of transplant-associated melanoma.

Audit of the management of genital herpes simplex infection

We evaluated the management of genital herpes simplex virus (HSV) infection at our clinic. Over six months, 135 patients with primary HSV and 97 patients with recurrent HSV attended. Sixty percent of patients presenting within five days of primary infection were treated with oral acyclovir. Only 53% of patients with primary HSV were given written/verbal information. Follow-up appointments were attended by 78%. Seventy-seven percent of patients with recurrent HSV had at least one viral isolate typed and 72% of patients experiencing episodes exceeding, annually, six were offered suppressive therapy. Our results demonstrate successful management of patients with HSV infections but recommendations are made to reach the standards set by BASSH. Furthermore, we illustrate that improved documentation would go a long way in validating the result.