We recently spoke with June Robinson, MD (Research Professor of Dermatology, Northwestern University Feinberg School of Medicine, IL, USA). In this interview, she discusses the impact that COVID-19 has had on melanoma diagnosis and early detection, and how skin self-examination (SSE) can help overcome these challenges. Robinson highlights the importance of SSE and discusses the potential to translate self-examination across cancer during the current pandemic.
My research focus is primary (sun protection) and secondary (early detection) prevention of melanoma in at-risk populations. My 35 years of academic clinical practice providing care and long-term follow-up for melanoma skin cancer patients gives me a unique perspective about ways to improve patient-centered care to reduce the burden of melanoma skin cancer for patients and their families. The team that I lead developed and assessed methods of skills training and performing SSE among at-risk patients and their ‘skin check partners’. In addition to early detection research, I led multidisciplinary teams to develop and assess ways to improve reduction of harmful exposure to UV radiation. This includes sun protection in at-risk patient populations of young children and kidney transplant recipients, and reduction of indoor tanning by 17–21 year old females. Our research resulted in numerous publications in peer-reviewed journals, book chapters and textbooks, as well as my service on national and international consensus panels addressing melanoma skin cancer prevention.
Melanoma SSE, as described in our research, is the periodic systematic observation of pigmented skin ‘spots’ (moles) on all skin surfaces by a melanoma survivor, who may benefit from having a skin check partner check hard-to-see locations, such as the bald spot on the top of the head. The mole is assessed using a millimeter ruler and a lighted magnifying lens, like the one used to read road maps. Skills training over a few months is needed to gain confidence in assigning a score to the border, color and diameter of a mole and reach a decision about the next step. The next steps are a) benign and stop checking the mole, b) check the mole in one month for change or c) make an appointment with the health care provider to have the mole checked. The location of the clinically suspicious mole and the scores assigned to the border, color and diameter are recorded in a dairy. Assessing the features and recording the scores creates a record. The next month the scores are compared to decide if the mole changed. This targeted melanoma detection is performed by patients at-risk to develop a melanoma.
In the USA, the stay at home orders that began in March 2020 removed patient access to physicians for nonurgent care. Also, there was no indication about when regularly scheduled physician appointments would resume. Melanoma survivors rely upon physicians, especially dermatologists, to provide surveillance to detect clinically concerning moles at regular intervals. Physician appointments may vary from 6–12 months. The COVID-19 pandemic created restraints on healthcare that made it difficult for physicians to allay melanoma survivors’ anxiety over missed regularly scheduled appointments or concern about self-perceived new or changing moles.
Our previous research has shown that melanoma survivors and their skin check partners used their skills training to reduce worry about missed appointments by doing SSE. Observing and scoring the features of the mole may result in a decision that the mole was benign, and nothing further was needed. Even when their decision was to follow the mole for change in a month, the pair felt in control of the process. The physician, who has a diary documenting change in a mole, may decide to arrange a diagnostic biopsy as an outpatient procedure with limited exposure to other patients and staff. Thorough SSE supports skin examination by a healthcare provider.
As physicians try to provide telehealth evaluations during the COVID-19 pandemic, it may be helpful to use the following criteria to determine if a patient is at-risk:
If a physician has a patient, who has one or more of these criteria, then the patient may be referred to the American Academy of Dermatology website to find information about how to perform an SSE. This website provides a link to dermatology offices. During the COVID-19 pandemic, many dermatologists offer telemedicine visits.
However, this website does not provide the intensive program of SSE skills training offered in our research program. In our research, melanoma survivors and their skin check partners learned SSE with a 32-page workbook consisting of color illustrations and training exercises. Pairs used it as a reference when they did SSE.
Breast self-examination with an intensive program of instruction may detect breast cancer at an earlier stage. Testicular self-examination for men aged 20–40 years has assisted early detection. While breast and testicular self-examination enhance awareness, the efficacy of early detection reducing treatment-related morbidity is debated. Currently, there is no evidence that self-examination for breast or testicular cancer reduces mortality. A 20-year follow-up case control study of people newly diagnosed with melanoma in 1987–1989 demonstrated the benefit of SSE . In this study, skin awareness prompted by SSE was associated independently with decreased risk of melanoma death.
Another type of cancer self-management is self-sampling. For adults, 45 years of age and older, Cologuard (Exact Sciences, WI, USA) for colorectal cancer, which was approved by the US Food and Drug Administration in 2014, is an early detection stool self-sampling test that is ordered by a physician and obtained at home.
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The opinions expressed in this interview are those of the interviewee and do not necessarily reflect the views of Oncology Central or Future Science Group.