ARTICLE
Auteur(s) : Marjam-Jeanette Barysch1, Antonio
Cozzio1, Isabel Kolm1, Susanne Ruf
Hrdlicka2, Christoph Brand3, Robert
Hunger4, Oliver Kreyden5, Reto
Schaffner6, Thomas Zaugg7, Reinhard Dummer1
1Department of Dermatology, University Hospital
of Zurich, Gloriastr. 31, CH-8091 Zurich, Switzerland
2La Roche-Posay, Cosmétique Active, Industriestrasse 9,
CH-5432 Neuenhof, Switzerland
3Department of Dermatology, Kantonsspital Luzern,
Spitalstr. 16, CH-6000 Luzerne, Switzerland
4Department of Dermatology, Inselspital Bern,
Freiburgstr. 14, CH-3010 Bern, Switzerland
5Dermatological Practice, Baselstr. 9, 4132 Muttenz,
Switzerland
6Dermatological Practice, Neubruchstr. 19, 7000 Chur,
Switzerland
7Dermatological Practice, Bälliz 75, 3600 Thun,
Switzerland
accepté le 8 Septembre 2009
Skin cancer accounts for the majority of all cancers world-wide.
Because UV irradiation is responsible for the majority of all skin
cancers [1, 2], extensive health promotion programs regarding sun
protection have been conducted in recent times. Nevertheless,
incidence rates of skin cancer continue to rise worldwide [2], and
Switzerland leads in incidence in the list of equivalent countries
[3, 4].
Melanoma is dreaded as there is no standard and efficient
treatment for metastasized melanoma. In young and middle-aged
populations, melanoma is one of the leading causes of cancer deaths
[5]. However, melanoma in early stages has an excellent prognosis
[6, 7]. Therefore, primary prevention (in terms of knowledge about
skin cancer and avoidance of risk factors) and secondary prevention
(in terms of early detection) are of the utmost importance. Studies
have shown an association between health promotion campaigns and
melanoma incidence rates, citing increases in melanoma rates during
periods of decreased prevention campaign funding [2]. The
improvements since 1983 in the general population’s knowledge about
sun protection and the trend towards smaller tumors at the time of
diagnosis, can be attributed to improved education [8, 9].
A large Australian cross-sectional study interviewed almost
12,000 adults between 1987 and 2002 and found a significant
improvement in sun protective behaviors with the nationwide
televised skin cancer health promotion campaign SunSmart [10,
11].
In Switzerland, skin cancer prevention campaigns have been
conducted since 1988 [12]. Nevertheless, public knowledge is often
still insufficient, and sun protective behavior and periodic self
examination of the skin usually decreases significantly after
specific health programs. Thus, continuous promotion activities are
required in order to maximize public awareness [10, 13, 14]. The
national Skin Cancer Day, which has taken place annually in
Switzerland since 2006, is a service run by the Swiss Cancer League
and the Swiss Society of Dermatologists. On this day, people may
present skin lesions without an appointment and free of charge.
Every year, men consistently use these screening activities at a
lower frequency in all age groups [15, 16]. Interestingly, there is
an especially marked gender difference in the population between 30
and 49 years, with females in this population (and overall) more
actively participating in screening activities. In 2008,
participants were 56% female (n = 3953) and 44% male (n = 2920),
and in the age group between 30-49, 1281 females and 878 males
chose to participate in the screening. The reasons for this have
not yet been elucidated but may potentially be found in reduced
attention, risk awareness, or concern about the body [17] as well
as in lack of time or convenience issues. It may be assumed that it
is mainly the full-time labor force, with the impossibility of
consulting a physician during the operating hours of a hospital or
a private practice, which participated more infrequently than other
population groups. It may be further supposed that males, in
particular, show less motivation to spend time waiting and
travelling to participate in health campaigns against skin
cancer.
Regarding the fact that men reveal more rapidly increasing
incidence rates of melanoma, higher Breslow thickness at the time
of diagnosis [8, 18], underestimation of their individual skin
cancer risk based on their skin type, and lower attendance in
previous skin cancer prevention programs than women [13, 15],
additional health promotion programs should be established to
better target at higher risk population.
Dermatology provides ideal preconditions for telemedicine
techniques. Teledermatology provides an efficient and
cost-effective [19-21] diagnostic tool for populations unable or
unwilling to refer to a dermatologist. In a store-and-forward (SAF)
system, photographs may be sent via email to specialists for
management recommendations [22]. Compared to a physical
dermatologist’s visit, this approach requires only minimal effort;
thus, acceptance of teledermatology in specific populations is
expected to be higher. Several studies have achieved a high
accuracy for the diagnosis of skin cancer, pigmented lesions
[23-25], and various skin diseases [25-29] in store-and-forward
systems when compared to face-to-face consultations. Used as a tool
for consulting a second opinion, almost 80% accuracy was achieved
using teledermatology (confirmation was conducted by histopathology
afterwards) [30]. The internet is becoming increasingly important.
Studies have revealed a high usage of the internet in
health-related questions and health promotion campaigns,
particularly in our targeted groups i.e. males and middle aged
populations [31-38]. However, skin cancer education web sites are
often of poor quality due to incomplete or incorrect information
[39, 40].
Based on these data, we established a teledermatological service
called Skincheck®. Skincheck® is provided by
a group of board-certified dermatologists in Switzerland. The
lesion assessment portion of Skincheck® was only
available during the month of May 2008, was free of charge and
available for everybody with internet access. Participants sent
images of skin lesions via internet for evaluation and standardized
management recommendations from the specialist group. The
participation was anonymous; participants received individual
passwords to upload their images and view the responses from the
dermatologist.
In Autumn 2008, participants who agreed to participate in the
data analysis were interviewed via email with follow-up questions
regarding the rate of compliance with the management
recommendations given by the Skincheck® team and the
final histological diagnoses, if available. Here, we present the
data of the first Skincheck® in Switzerland.
Patients and methods
Internet access was a prerequisite. In order to increase
participation in the program, Skincheck® was intensively
promoted in the mass media, internet, and via on-site promotions in
pharmacies during April 2008. The Skincheck® website
(www.skincheck.ch) provides a wealth of educational information
about skin cancer, its risk factors, and instructions for self
examination, based on the ABCD rule. Tables 1
and 2 list the questions which were answered prior to self
and expert evaluation. Table 3 shows the
risk assessment and standardized management recommendations that
were performed based on the answers. All lesions were judged by the
specialists as 1) “Your lesion is harmless”, or 2) “Your picture is
of insufficient quality”, or 3) “Your lesion is suspicious”.
3-5 months later, 97 participants who had been advised to attend
a physician and agreed to be contacted (68.8%) were questioned
about their compliance to the management recommendations via email.
The following questions were asked:
- 1) Did you show your skin lesion to a physician?
- 2) Location of the skin lesion?
- 3) Has the skin lesion been removed?
- 4) Did the physician classify the skin lesion as benign or
malignant?
- 5) What was the physician’s final diagnosis?
Table 1 Evaluation of risk factors (the more positive
answers the higher the skin cancer risk)
|
1) Fair skin type (fair skin, eye and hair color)
|
|
2) Genetic factors
|
|
– Multiple pigmented moles
|
|
– Skin cancer in your or your family’s medical history
|
|
3) Intense and numerous sunburns in the past:
|
|
– Particularly during childhood under the age of 15
|
|
4) Frequent usage of sun beds
|
Table 2 Evaluation of skin lesions (Answers on the
right side argue for a more malignant lesion)
|
1) How does the shape look?
|
|
|
|
Round and symmetric
|
OR
|
Asymmetric
|
|
2) How does the outline look?
|
|
|
|
Regular and sharply demarcated
|
OR
|
Irregular, not sharply demarcated
|
|
3) How many colors in the lesion?
|
|
|
|
One
|
OR
|
More
|
|
4) Did the lesion change rapidly?
|
|
|
|
No
|
OR
|
Yes
|
Table 3 Advice given by the dermatologists after
evaluation of the images
|
1) Your skin lesion is harmless. If you do not observe any
change over the next 6 months, you may be reassured. If you should
notice any change, please consult a dermatologist.
|
|
2) The quality of your photograph is insufficient for
diagnostic purposes. Please send a new photograph with a higher
resolution.
|
|
3) Your lesion is suspicious. Please immediately consult a
physician or dermatologist.
|
Statistics
Data were collected from August until October 2008. The answers to
the above mentioned questions were classified as follows:
- Answer to question (Q) 1: dermatologist/other physician/no
consultation
- Answer to Q2: face/thorax/back/abdomen/upper extremities/lower
extremities
- Answer to Q3: Yes/No
- Answer to Q4: benign/malignant/unknown
- Answer to Q5: melanoma in situ/ basal cell carcinoma/ squamous
cell carcinoma/ dysplastic melanocytic nevus/ melanocytic nevus/
lentigo benigna/ seborrhoic keratoses/ others (lipoma, fibroma,
angioma, and mycosis)
- Frequency and descriptive statistics were conducted with SPSS
16.0.
Results
More than 12,000 visitors visited the webpage during May 2008;
between May 2008 and May 2009, there were over 22,000. 494 digital
photographs were sent in for evaluation (232 originated from
females (47%), and 262 from males (53%)). The mean age of all users
was 37.6 years (females: 34.33 years, males: 40.5 years). 141 of
494 lesions were teledermatologically classified as suspicious, 63
of these derived from females (45%) and 77 from males (55%).
Participants with lesions classified as suspicious were recommended
to consult a dermatologist or a general practitioner. 97 (68.8%) of
the 141 participants with suspicious lesions agreed to answer
follow-up questions. 75 of the 97 (29 females, 46.0% of all females
with suspicious lesions, and 46 males, 59.7% of all males with
suspicious lesions) answered the follow up questions. The gender
distribution of the 75 patients from whom we received data, was
38.7% females and 61.3% males. The mean age of females was 33.4
years (median: 29 years); in males it was 47.7 years (median 48.5
years). They represented a total of 94 lesions.
Follow-up questions
61% of the participants who answered follow-up questions were male
(n = 46), 38.7% (n = 29) were female. 48 of the 75 patients who
answered follow-up questions declared their age (64%). The majority
of them were younger than 50 years of age (32 patients; 66.7%).
Beyond the age of 30, there were more males than females in each
age class; beyond the age of 64 years, only males participated.
Remarkably, the majority of females were represented in the age
class below 30 years (figure 1).
Adherence to management recommendation
60 (80%) of the 75 recalled participants informed us that they had
visited a dermatologist; 3 (4%) had visited another physician (2
general practitioners (male patients), 1 pediatrician (female
patient)). Altogether, 86.2% of the females (n = 25) and 82.6% of
the males (n = 38) followed the online recommendation. 12 (16%) of
the 75 responding participants did not follow the advice to refer
to a physician; female patients did not refer to a physician in 4
cases (13.8%), male patients in 8 cases (17.4%).
Excisions
The 75 participants who answered our feedback questions presented a
total of 94 lesions, 80 of which were shown to physicians (85.2%).
34 lesions (42.5% of all lesions shown to a physician) were
excised; all of these were shown to a dermatologist. 60 lesions
(63.8% of all lesions) were not excised.
Anatomical distribution
The majority of all documented skin lesions (56 out of 94; 59.6%)
were located on the trunk (29 lesions on the back (30.9%), 21 on
the thorax (22.3%), 6 on the abdomen (6.4%)) and 18 out of 94
(19.2%) on the face. Lesions on the upper (N = 10; 10.6%) and lower
(N = 8; 8.5%) extremities presented less frequently. Locations of 2
lesions were not declared (2.1%).
Diagnosis
72 of the 94 lesions (76.6%) were evaluated as benign by the
consulted physician. The 8 lesions (8.5% of the 94 lesions) that
were evaluated as malignant all occurred in males (14.0% of all
known males’ lesions). 68.4% of the lesions (n = 39) in male
patients and 86.5% in female patients (n = 32) presented as benign.
Malignant lesions were found predominantly in age groups over 50
years old (4 cases, 4.3% of the 94 lesions); in 50% of all
malignancies (n = 4) age was not declared. Diagnoses were performed
clinically in 61 cases (64.9% of 94 lesions) and
histopathologically in 34 cases (36.2% of 94 lesions).
Unfortunately, in 43 cases (45.8% of 94 lesions) the participants
could not provide the definitive diagnosis. In 15 of these cases
without diagnosis (34.9% of the 43 cases) participants did not
refer to a physician. Three participants who visited a doctor
reported having received cryotherapy but could not indicate a
definitive diagnosis; in these cases we suspected actinic keratoses
as a probable diagnosis.
The benign diagnoses included 30 melanocytic nevi, 3 dysplastic
nevi, 4 benign lentigines, 4 seborrheic keratoses, 1 fibroma, 1
lipoma, 1 angioma, and 1 tinea corporis.
Based on the participants’ surveys, the 8 malignant lesions
consisted of 1 melanoma in situ, 4 basal cell carcinomas, 1
squamous cell carcinoma, and 2 with unknown diagnoses (figure 2).
Finally, 22 participants (22.7%), who were advised to present
their skin lesion to a physician and gave permission for follow-up
questions, did not respond, resulting in 47 suspicious lesions
(33.3% of all 141 suspicious lesions), on which all information is
lacking. Information about grading is missing on 63 suspicious
lesions (44.7% of all suspicious lesions).
Discussion
Prevention is essential in the fight against skin cancer, and a
combination of primary [41] and secondary prevention [42] is
predicted to yield the best results. Because in the majority of
melanoma cases the lesion is first recognized by the patient or
their partner and not by a physician [43], skin health education is
of utmost importance. Effective prevention programs, therefore,
ought to include interactive educational activities. In order to
maximize their benefits, prevention programs should appeal to and
elicit maximum participation from the populations at highest risk
of skin cancer. The traditional “walk-in” skin cancer prevention
activities as well as increased awareness of doctors and of the
general population has led to earlier detection of malignant
melanoma, a decreased Breslow-Index at the time of diagnosis, and
thus increased overall survival in newly diagnosed malignant
melanoma. However, men use the traditional walk-in preventive
activities significantly less frequently than women. In addition,
men reveal more drastically increasing incidence rates of melanoma,
higher Breslow indices at the time of diagnosis, and a generally
lower attendance at skin cancer prevention programs than women [9,
13, 15, 43-45]. Additionally, on Swiss Skin Cancer Day, conducted
between 2006 and 2008, which was offered by dermatologists and
dermatological university clinics for free, women used this service
much more frequently than men (In 2008 participants consisted of
56% of female and 44% of males) [16].
Due to the rising incidence of melanoma worldwide, government
run health campaigns against skin cancer are conducted in several
countries. These health campaigns are conducted most aggressively
in Australia, the country with, by far, the highest skin cancer
rate. One example is the SunSmart program, a combination of public
education with mass media campaigns. In the US, there is a similar
program called SunSmart. Both programs educate about skin cancer
and sun protective behaviors via television advertisements, but
also in schools, work places, and other public institutions. Both
programs have proven the effectiveness of mass media education,
evidencing improvements in sun protective behavior and lower rates
of sunburns [10, 11, 46].
Another nationwide strategy for improving secondary prevention
would be the institution of designated dermatological consultation
days, on which suspicious lesions may be shown to physicians gratis
and appointment-free. In several countries there are skin
protection TV advertisements to improve primary prevention; in
Switzerland, for example, this is conducted by the Swiss Cancer
League [47]. Additionally, in Germany, skin assessment for the
population over 35 years is supported every 2nd year by
the common health insurance for secondary prevention issues [48].
Important, but yet not fully sufficient, these efforts should be
expanded further to appeal to the whole population.
Large and partly multicentered studies have evaluated the
accuracy of teledermatological techniques compared to face-to-face
dermatology and histopathology. They found the accuracy of
teledermatological diagnoses comparable to that of face-to-face
consultation and histopathological diagnoses (concordance > 80%)
for pigmented lesions and skin cancer [23, 25, 49, 50].
Teledermatological techniques reduce waiting times. Due to high
patient and physician satisfaction with teledermatological
techniques, teledermatology might play an increasing role in ruling
out melanoma and other skin cancers in the future [23, 25, 49].
Over recent years, the internet has become an increasingly
important tool for seeking out healthcare information. Particularly
amongst middle aged populations, the internet is a common source of
information [31-36]. Further studies predict that internet-based
health campaigns will elicit good results in the public,
particularly in the population between 31 and 50, as well as in
males [31-35, 37, 38, 51-54]. Since health education websites are
often of poor quality and contain incorrect information [39, 40], a
widely used, easy to understand, fundamental skin cancer education
website for all populations is required. This led us to create
Skincheck®, an internet-based health education and
prevention program which targets groups that do not participate in
common prevention campaigns because of lack of time or for other
reasons. The web-site describes skin cancer’s underlying causes and
gives descriptive instructions for self examination of the skin.
With the help of illustrations, the sites are easy to understand
yet well founded and informative. Skincheck® was
received with strong interest. By modifying the recruitment we were
able to target more male participants and generally both a younger
and more middle aged population. Thus, we were able to focus on
groups with higher potential benefit from primary and secondary
prevention.
A limitation of this study was that participation in follow-up
questions was voluntary. Hence, we have data of about half of the
participants with a teledermoscopically suspicious lesion and
definitive diagnoses of half of this population. This results in a
high number of unknown cases. Nevertheless, as participants had to
give up anonymity and by agreeing to follow-up questions, the
participation of more than 50% is higher than expected. It might be
further discussed particularly whether those participants who
showed a malignant lesion might not have answered more frequently
due to data protection.
Additionally, Skincheck® interactive learning
emphasizes early recognition of skin cancer. Participants were
introduced into primary and secondary prevention. Importantly, even
patients with unsuspicious skin lesions were advised to
periodically reassess their lesions.
Before sending in photographs, users had to think critically
about their skin lesions by answering several educational
questions. Consequently, participants became familiar with relevant
skin cancer risk factors and characteristics of suspicious skin
lesions, based mainly on the ABCD rules.
Aside from our main aim, skin cancer education, at least 8
malignancies were detected. Because those malignancies were found
in a sample of only about 50% of lesions, even more malignancies
are suspected to have been identified via Skincheck®
during the month of May 2008.
Further studies of internet-based prevention campaigns in the
fields of colorectal cancer, back pain, atherosclerosis, and
physical activity have educated participants about primary and
secondary prevention and produced significant long lasting changes
in life-style [37, 38, 51, 55]. Additionally, an internet-based
teledermatological training program for laymen about early
recognition of melanoma increased the recognition rate of early
melanoma [54]. Because of different primary aims, these commonly
conducted internet-based health campaigns are not comparable to the
unique study design of Skincheck. Nevertheless, online interactive
health prevention campaigns, such as Skincheck®, are
important, innovative complementary tools to add to conventional
health prevention in this web-oriented age and should be utilized
more frequently to increase health awareness and knowledge about
health issues, particularly in the prevention-resistant,
middle-aged male population.
Acknowledgement
We greatly thank Lauren L Lockwood for critical revision of this
manuscript. Financial support. The project was financially
supported by LaRoche Posay. Marjam-Jeanette Barysch and Reinhard
Dummer are supported by grants from the Gottfried and Julia
Bangerter Rhyner Stiftung and the Skin Cancer Research Association
(www.skincancer.ch). Conflict of interest: none.
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