The different psychological profiles of subjects attending melanoma screening campaigns and those delaying diagnosis: an aid for designing preventive campaigns?

ARTICLE

Auteur(s) : Matilde Forghieri¹, Caterina Longo², Gian Maria Galeazzi³, Marco Rigatelli¹, Stefania Seidenari², Giovanni Pellacani²

¹Department of Neuroscience TCR, Section of Psychiatry, University of Modena and Reggio Emilia
²Department of Dermatology, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124 Modena, Italy
³Newham Rehabilitation and Recovery Team, East London NHS Foundation Trust

accepté le 8 Ao�t 2010

Melanoma (MM) incidence is increasing worldwide with different trends for Caucasian populations in respect to darker skinned groups [1]. Early diagnosis represents the key issue for secondary MM prevention, aiming to improve MM prognosis by identifying thin MMs, since no therapy has been proven to be effective in advanced stages [2]. Many efforts have been made to promote screening campaigns offering free access examinations for pigmented lesion and health education. Since the year 2000, skin cancer screening campaigns (Euromelanoma Day) have been organized in Europe. The efficacy of these campaigns in reaching high risk individuals and detecting a significant number of skin tumours is still matter of debate. Although screening campaigns in Belgium seemed effective in detecting early stage MMs in a large number of patients, results in other European countries showed very low rates of detection and a high number of worried healthy attendees [3-5]. Recently, results in screening campaigns in Greece, from 2000 to 2004, showed that the population accessing screening campaigns was predominantly represented by young women with few pigmented lesions, while only a small fraction belonged to the group more frequently presenting with thicker MMs, such as elderly men. This may explain the low reported MM detection rate per year (0.35%) [6]. These data highlight the need to better design MM detection campaigns in order to attract older age groups and people at high risk of developing a MM [3, 4].

Patient delay in seeking medical attention for MM, defined as the time from the patient's first awareness of a symptom or sign, to the first consultation with the physician, is directly related to a higher morbidity and mortality rate [7] and constitutes one of the main challenges in designing prevention campaign strategies. Delay factors in MM detection are both doctor and patient related. Doctor related factors, connected to the diagnostic ability of recognizing a malignant lesion, seem to account for only a small part of the total delay [8-10]. Patient delay is related both to sociodemographic features, such as male gender, older age, poorer educational level, living in a rural area, unemployment [11-13] and psychological elements, such as levels of awareness and sensitization to this kind of malignant lesion [14, 15], a tendency to minimise the seriousness of the condition [16] and a hypothesized psychological personality profile, defined by passive, bland, appeasing and helpless traits [17].

No conclusive study exploring the psychological aspects of patients presenting cancer delay using standardized and validated psychometric instruments is currently available. The purpose of our study was to compare sociodemographic variables and psychological profiles, in terms of personality traits and attitude toward illness, emerging from 5 validated psychometric tests of people accessing a skin cancer preventive campaign, with those of a group of patients newly diagnosed with MM, in usual clinical practice. We tested the hypothesis that the psychological profile of subjects attending the MM screening day would differ from that patients diagnosed with MM following the usual clinical pathways, and, also, that there would be differences among patients with late vs early MM diagnosis. We believe that this exploration could lead to insights as to how to more effectively target preventive campaigns.

Materials and methods

The study population consisted of two groups:

• – MM patient group was formed of 50 newly diagnosed MM patients consecutively referred from 01/05/06 to 1/11/06 to the Dermatology Department of the University of Modena and Reggio Emilia. 42 patients completed the questionnaire before diagnosis communication;
• – the MM screening group was made up of the first 50 patients accessing the EUROMELANOMA Day prevention campaign (EMD) held at the Dermatology Department of the University of Modena and Reggio Emilia. 46 patients returned the questionnaire. No patient was diagnosed with MM as a result of the screening. Sociodemographic data concerning age, sex, living area (urban/rural), educational level (elementary and middle school/high school and university), living situation (alone/with partner) were collected for both groups. Each subject completed the following self-administered psychometric standardized instruments in their validated Italian version:
• – the Harm Avoidance subscales of the Temperament and Character Inventory (TCI) [18], a 36 item subscale exploring individual propensity to avoid risky and unpleasant events, which yields a total score and four subscale scores: fearful, pessimistic, shy and fatigable;
• – the Ways of Coping Scale (WCS) [19], a 36 item scale assessing thoughts and actions used to cope with stressful encounters of everyday living which gives the following subscale scores: planned problem solving, seeking social support, escape-avoidance and their respective ratios;
• – the Multidimensional Health Locus of Control Scale Form B (MHLC) [20], an 18 item scale used to assess the perception of health control and structured into three dimensions: internality, powerful others and chance;
• – the Illness Behaviour Questionnaire (IBQ) [21-23] a 62 item questionnaire exploring dysfunctional reactions towards disease clustered into seven dimensions: general hypochondriasis, disease conviction, somatic perception, affective inhibition, affective disturbance, denial, irritability;
• – the scale developed by Meechan et al. [24] to measure emotional response to cancer symptom discovery, consisting of 4 items evaluating individual illness reaction in term of being afraid, anxious, distressed and scared.

The MM population was evaluated for clinical measurable characteristics of MM, such as body site, clinical ABCD and diameter. For each case, Breslow's thickness was reported. Since patient-related MM delay is influenced by characteristics of the melanoma and of the individual, we identified within the whole MM patients two subgroups: one group of patients able to recognize difficult to spot MM (good-detectors, GD) and another, including those diagnosed with advanced clearly visible cancers (bad-detectors, BD). GD were, for the aims of this study, those diagnosed with: thin MMs (Breslow's thickness < 1 mm), with a small size (< 1 cm) with only one out of four ABCD criteria present, and with lesions located on not easily explorable body sites (scalp, back, buttocks, and posterior thighs). On the contrary, BD were defined by: MMs thicker than 1 mm, larger than 1 cm, showing at least two or more ABCD criteria and arising on a visible location (anterior body site and upper limbs). 32 of the 42 MM patients matched histo-clinical criteria and could be included in the two sub-groups (GD and BD), whereas it was not possible to attribute 10 cases to one of the two sub-groups.

The study obtained approval by the Modena and Reggio Emilia University Ethical Review Board and was conducted according to the last version of the Declaration of Helsinki.

Descriptive statistics were used to describe sociodemographic characteristics of the population and psychometric instruments scores. The Mann-Whitney U Test and Pearson Chi Square test were used to compare the MM population and its two subgroups with EMD patients and to compare psychometric scores between GD and BD populations.

Results

Psychometric scale and subscale scores of the four groups are described in table 2.

None of the TCI Harm Avoidance scale scores differed among groups, except for the Fearful domain, which was significantly higher in BD versus GD (p < .05). WCS scores did not significantly differ among groups. Powerful Others scale of the MHLC was statistically higher (p < .05) in BD compared to GD. General Hypochondriasis scale of the IBQ in GD was significantly lower than both in EMD (p < .05) and BD (p < .01) groups. Affective disturbance and irritability scales of the IBQ were higher in BD than in GD patients (respectively p < .05 and p < .01). This latter scale was also significantly higher in EMD compared to GD patients (p < .01). None of the Meechan Scale items statistically differed in the four groups.
Table 1 Sociodemographic characteristics of the study population

Discussion

However, it is still unclear if and how personality factors influence patient-related delay in cancer diagnosis. Considering surgical resection the gold standard intervention for MM, early diagnosis is still nowadays the most useful instrument to guarantee a better prognosis in term of morbidity and mortality [11, 12].

Prevention campaigns are designed to reach early stage asymptomatic MM patients who, otherwise, would ask for dermatological consultation later in their clinical history. Despite their availability, preventive campaigns fail in their aim to involve targeted patients who could benefit from dermatological early detection and intervention. The aim of our study was to compare people adhering to a skin cancer prevention campaign, representative of a targeted, health conscious and alerted population, with MM patients diagnosed after having followed the usual clinical pathway. Another aim was to identify significant differences in psychological characteristics in order to better design preventive campaigns, aiming at the recruitment of subjects more prone to delay diagnosis and have thick MMs.

Previous studies considered Breslow's thickness the sole proxy- “measure” of delay and did not take into account specific kinds of MMs, such as the nodular type, hypo/amelanotic MMs, desmoplastic ones, which are characterized by a rapidly growing index and uncommon clinical presentation [26]. For these reasons, patient delay could not be attributed in all cases to a poor ability to self-detect the tumour, but it could be partially referred to peculiar neoplastic biologic behaviours [27, 28]. Therefore, we supposed that patients showing thin “inconspicuous” MMs, located in not easily explorable body sites, may be characterized by a sort of “awareness” for skin conditions. They probably tend to take care of their health status by performing skin-self examination or attending periodical medical visits, in contrast with patients presenting thicker and very anaesthetic cancers, located in easily explorable body sites, where the diagnostic delay may be strongly related to patient factors. Even though several subjective criteria influence the individual process leading to consult the clinician, we limited ourselves to defining delay entity with the help of strictly objective measurable indexes, the subjective ones being not clearly defined and measurable.

Thus, we divided the MM patient population into two subgroups to explore differences in psychological features and to generate hypotheses on the causes of delay in patients where efforts for early diagnosis may be realistically effective in reducing the incidence of thick tumours, as similarly investigated for rectal and breast cancers [29, 32]. Risvedt and Trinkaus explored patient delay for treatment in rectal cancer, identifying a relationship between symptom appraisal, accounting for over two thirds of the delay, and low scores registered at the TCI Harm Avoidance scale [29]. Other studies exploring patient delay in breast cancer [24, 30-32] found that symptom-specific anxiety, but not general anxiety and initial emotional response to the discovery of breast symptoms, were related to diagnostic delay. Both in rectal and breast cancer studies, sociodemographic factors were not significantly related to delay.

In our study, MM patients were generally living in a rural area whereas EMD ones usually came from an urban context. It is possible that in urban settings a more accurate diffusion of information concerning screening campaigns is available. Also, these subjects may have had easier access to the Hospitals involved in the campaign. As in previous research in the melanoma field, the BD group patients were predominantly male and rural-area inhabitants, but we could not find any statistical difference in age, living situation and educational level, in contrast with previous investigations [11, 12, 28]. Sociodemographic data depicting the EMD population in our research only partially overlap those gathered in studies conducted in other countries on melanoma screening campaign subjects. Data showed a less consistent sociodemographic gap between EMD and MM patients, possibly suggesting that the general MM population is not too far from the one attending the screening campaign and this might be an encouraging stimulus in trying to further reduce the distance between the two.

We could not find any statistical differences between the EMD and MM groups in terms of personality traits potentially involved, coping strategies generally used to face illness conditions, health control modalities, dysfunctional reaction and emotional response toward disease, although the objective stressing situation in which participants were at the moment they were interviewed consistently differed: the EMD subjects having voluntarily decided to attend the screening campaign, the MM patients having been summoned for removal of a suspected skin lesion.

Data showed significant statistical differences only when the GD and BD sub-groups were compared. Even though we found no statistical difference in TCI Harm Avoidance total scores, the Fearful subscale scored significantly higher in BD patients. Interestingly, BD were furthermore characterized by higher scores in MHLC Powerful Others and IBQ General Hypochondriasis, Affective Disturbance and Irritability subscales, suggesting that denial or indifference toward the presence of a modified skin lesion were not specific features of BD patients. On the contrary, they appeared as people generally worried about illness but who did not usually tend to address their physical problems effectively, lacked self-confidence and believed they could control and master their health problems. BD patients usually tended to be more affectively disturbed and feel helpless towards events, passively waiting for an external modification of their situation. This could suggest the influence of a depressive condition in this group of patients, as also reported for other kinds of malignant lesions [33, 34].

Our research represents a preliminary attempt to investigate potential variables which might explain why, despite the increasing availability of melanoma preventive campaigns, we still fail to reach the targeted population who might benefit from an early diagnosis intervention. In fact, as already showed by previous studies [3-5], none of the attendants at the screening had a malignant lesion diagnosed during the prevention campaign. Following previous studies, which have already underlined the potential relationship between delay and patient psychological variables, we focused on a possible connection existing between general individual attitudes towards illness and reasons for delaying medical consultation in the dermatological field. Despite preliminary data presented for other kind of tumours, we found significant differences only when we specifically explored the MM population comparing GD to BD patients. This suggests that other psychopathological variables, not personality traits, related but more stressful event states, induced and connected psychiatric comorbidities, could have a prevalent role in the patient decision process to see a clinician.

Moreover, our study presents several limitations to be considered, such as the small sample size, especially concerning the two MM sub-groups analyzed. It should be underlined that the psychometric testing was specifically tailored and required about 40 minutes for each patient to complete, usually including the presence of a trained operator to answer participants’ questions. Furthermore, the design of the study did not allow for the exploration of possible causal effects which were not previously included in the protocol, both from a dermatological and psychopathological point of view. Despite this, our preliminary data suggest that there is a need to better explore the psychological traits of BD patients with the help of validated psychometric instruments, in order to identify possible preventive strategies. Future studies should better explore the possible impact on diagnostic delay of mood and anxiety alterations in MM patients, as reported for other cancers [29]. Psychometric scores indicated that BD patients are generally aware and tend to react in a phobic manner to medical recommendation. At the same time they appear to favour external and more assertive help, which would suggest choosing a more direct approach in proposing a different prevention campaign, relying on nominal leaflets in patient-addressed letters.

Conclusion

Disclosure

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