Examining the views and practices of participants in a melanoma self-surveillance trial reveals some interesting findings.
“I know what I have to do, but I don’t know if I have the strength to do it.” – Kylo Ren
Rising melanoma numbers can partially be explained by increased awareness and/or surveillance of potential skin cancers from both a clinician- or patient-perspective, resulting in earlier detection.
Clinician- and patient-led screening has their own advantages and disadvantages.
“There is no comparative evidence that more frequent scheduled clinic visits, compared with less frequent or no scheduled clinic visits, increases detection of new primary or recurrent melanoma, or improves patient survival. Routinely scheduled visits may result in psychosocial harms for patients and increased health care utilisation and costs,” Australian researchers wrote in JAMA Dermatology.
“Patient-led surveillance in an alternative model of follow-up care where patients take a greater role in self-managing their melanoma risk through regular skin self-examination (SSE). This model draws on evidence that many melanomas are self- or partner-detected prior to a routinely scheduled visit, and that interventions using smartphone or digital applications may improve SSE practice.
“[But] in theory, performing SSE too frequently could decrease its effectiveness by making it more difficult to distinguish the signal (suspicious long-term changes in lesions) from the noise (short-term random variations). Too frequent SSE could also increase the fear of cancer recurrence (FCR) or anxiety, which may lead to increased health care resource use.”
But does patient-led surveillance actually result in more melanomas being diagnosed at fast-tracked or unscheduled clinic visits compared to regularly scheduled visits and clinician-led surveillance?
This is the question the Melanoma Self Surveillance (MEL-SELF) randomised trial is trying to answer.
And while waiting for follow-up data to be collected, the MEL-SELF research team have described some of the characteristics and SSE practices of the people taking part in the study.
Researchers recruited 504 adult patients who had previously receive treatment for early-stage melanoma (i.e., American Joint Committee of Cancer’s Cancer Staging Manual stages 0, I, or II) from dermatology or skin cancer clinics across New South Wales, Queensland or Victoria.
Participants were randomised to either patient-led surveillance (n = 251), which involved using a mobile dermatoscope, a smartphone and a teledermatology app to conduct regular SSEs, or clinician-led surveillance (n = 253).
The teledermatologist could arrange fast-track clinic visits for people in the patient-led surveillance group if they felt the SSE findings warranted further examination.
Related
Although 94% of participants in each group acknowledged it is important to check for skin cancer even when no symptoms are present, pre-study SSE practices ranged from once a year (17% and 15% respectively) through to weekly (11% and 8%).
However, around one in five participants indicated they had not performed an SSE in the past 12 months (21% and 20%). On a more positive note, around three quarters of participants reported they looked for moles, lumps or bumps that were new or looked different to other spots or moles during their most recent skin check (74% and 73%).
The patient- and clinician-led screening groups had similar average FCR scores, as measured by the Fear of Cancer Recurrence Inventory severity subscale (mean [SD] 14.7 [5.7] and 14.6 [5.5]), and an equal proportion of patients with a clinically meaningful FCR (i.e., a score ≥16, 46% in each group).
Men were less likely to have clinically significant FCR compared to women (odds ratio [95% confidence interval] 0.56 [0.39-0.81]), as were older people compared to younger people (10-year increase in age 0.64 [0.54-0.75]).
People with higher depression, anxiety and stress scores as per the Depression, Anxiety and Stress Scale-21 were also more likely to have higher FCR compared to people with lower scores on these measures (1.12 [1.07-1.17], 1.16 [1.10-1.24] and 1.12 [1.08-1.15] per 1-unit increase in each score).
“People with higher perceived lifetime absolute or comparative risk of a subsequent melanoma were also more likely to have clinically significant FCR,” the researchers wrote.
“Notably, there was no association between calculated risk of subsequent melanoma and FCR (1.00 [0.99-1.01])”.
Given the findings, the researchers suggested that a patient-centred approach where an individual’s potential risk of future skin cancer was discussed using best practices in risk communication and uncertainty could help in reducing FCR.
“For example, using plain language, absolute rather than relative risk measures, and icon arrays (where icons are displayed in a grid to visually convey an individual’s risk of developing a melanoma) can be effective in communicating risk in ways that patients understand,” they said.
“The use of psychological or psychoeducational interventions has also demonstrated effectiveness in reducing FCR severity. Such interventions may help reduce the increased healthcare resource use that is associated with high FCR.
“Previous research on self-surveillance interventions has shown that such interventions can lead to improvements in depression, anxiety and stress as well as less worry about melanoma recurrence, although this evidence is limited.”
