Melanoma In Primary Care Research Articles

Evaluation of an artificial intelligence-based decision support for the detection of cutaneous melanoma in primary care: a prospective real-life clinical trial.

Use of artificial intelligence (AI), or machine learning, to assess dermoscopic images of skin lesions to detect melanoma has, in several retrospective studies, shown high levels of diagnostic accuracy on par with - or even outperforming - experienced dermatologists. However, the enthusiasm around these algorithms has not yet been matched by prospective clinical trials performed in authentic clinical settings. In several European countries, including Sweden, the initial clinical assessment of suspected skin cancer is principally conducted in the primary healthcare setting by primary care physicians, with or without access to teledermoscopic support from dermatology clinics. To determine the diagnostic performance of an AI-based clinical decision support tool for cutaneous melanoma detection, operated by a smartphone application (app), when used prospectively by primary care physicians to assess skin lesions of concern due to some degree of melanoma suspicion. This prospective multicentre clinical trial was conducted at 36 primary care centres in Sweden. Physicians used the smartphone app on skin lesions of concern by photographing them dermoscopically, which resulted in a dichotomous decision support text regarding evidence for melanoma. Regardless of the app outcome, all lesions underwent standard diagnostic procedures (surgical excision or referral to a dermatologist). After investigations were complete, lesion diagnoses were collected from the patients' medical records and compared with the app's outcome and other lesion data. In total, 253 lesions of concern in 228 patients were included, of which 21 proved to be melanomas, with 11 thin invasive melanomas and 10 melanomas in situ. The app's accuracy in identifying melanomas was reflected in an area under the receiver operating characteristic (AUROC) curve of 0.960 [95% confidence interval (CI) 0.928-0.980], corresponding to a maximum sensitivity and specificity of 95.2% and 84.5%, respectively. For invasive melanomas alone, the AUROC was 0.988 (95% CI 0.965-0.997), corresponding to a maximum sensitivity and specificity of 100% and 92.6%, respectively. The clinical decision support tool evaluated in this investigation showed high diagnostic accuracy when used prospectively in primary care patients, which could add significant clinical value for primary care physicians assessing skin lesions for melanoma.

Exploring the feasibility of an artificial intelligence based clinical decision support system for cutaneous melanoma detection in primary care – a mixed method study

Objective: Skin examination to detect cutaneous melanomas is commonly performed in primary care. In recent years, clinical decision support systems (CDSS) based on artificial intelligence (AI) have been introduced within several diagnostic fields. Setting: This study employs a variety of qualitative and quantitative methodologies to investigate the feasibility of an AI-based CDSS to detect cutaneous melanoma in primary care. Subjects and Design: Fifteen primary care physicians (PCPs) underwent near-live simulations using the CDSS on a simulated patient, and subsequent individual semi-structured interviews were explored with a hybrid thematic analysis approach. Additionally, twenty-five PCPs performed a reader study (diagnostic assessment on the basis of image interpretation) of 18 dermoscopic images, both with and without help from AI, investigating the value of adding AI support to a PCPs decision. Perceived instrument usability was rated on the System Usability Scale (SUS). Results: From the interviews, the importance of trust in the CDSS emerged as a central concern. Scientific evidence supporting sufficient diagnostic accuracy of the CDSS was expressed as an important factor that could increase trust. Access to AI decision support when evaluating dermoscopic images proved valuable as it formally increased the physician’s diagnostic accuracy. A mean SUS score of 84.8, corresponding to ‘good’ usability, was measured. Conclusion: AI-based CDSS might play an important future role in cutaneous melanoma diagnostics, provided sufficient evidence of diagnostic accuracy and usability supporting its trustworthiness among the users.

Lead Time from First Suspicion of Malignant Melanoma in Primary Care to Diagnostic Excision: a Cohort Study Comparing Teledermatoscopy and Traditional Referral to a Dermatology Clinic at a Tertiary Hospital.

The increasing use of teledermatoscopy in clinical practice has led to demands to evaluate the effects of this new technology on traditional healthcare systems. To study lead times from first consultation in primary care to diagnostic excision of suspected malignant melanoma lesions in traditional referrals to a tertiary hospital-based dermatology clinic compared with mobile teledermatoscopy referrals. A retrospective cohort study design was used. Data on sex, age, pathology, caregivers, clinical diagnosis, date for first visit to primary care unit, and date for diagnostic excision were collected from medical records. Patients managed through traditional referral (n=53) were compared with patients managed at primary care units using teledermatoscopy (n=128) regarding lead time from first visit to diagnostic excision. Mean time from date of first visit at primary care unit to diagnostic excision did not differ between the traditional referral and teledermatoscopy groups (16.2 vs. 15.7 days, median 10 vs. 13 days, p=0.657). Lead times from date of referral to diagnostic excision did not significantly differ (15.7 vs. 12.8 days, median 10 vs. 9 days, p=0.464). Our study indicates that lead time to diagnostic excision for patients with suspected malignant melanoma managed by teledermatoscopy was comparable and not inferior to that of the traditional referral pathway. If teledermatoscopy is used at first consultation in primary care, it could potentially be more efficient than traditional referral.

Assessing and managing malignant melanoma in primary care

Margaret Perry explains how nurses can spot signs of skin cancer, and treat it effectively

Screening for Melanoma in Primary Care

Screening for Melanoma in Primary Care

Is initial excision of cutaneous melanoma by General Practitioners (GPs) dangerous? Comparing patient outcomes following excision of melanoma by GPs or in hospital using national datasets and meta-analysis

BackgroundMelanomas are initially excised in primary care, and rates vary internationally. Until now, there has been no strong evidence one way or the other that excising melanomas in primary care is safe or unsafe. European guidelines make no recommendations, and the United Kingdom (UK) melanoma guidelines require all suspicious skin lesions to be initially treated in secondary care based on an expert consensus, which lacks supporting evidence, that primary care excision represents substandard care. Despite this, studies have found that up to 20% of melanomas in the UK are excised by general practitioners (GPs). Patients receiving primary care melanoma excision may fear that their care is substandard and their long-term survival threatened, neither of which may be justified. MethodsScottish cancer registry data from 9367 people diagnosed with melanoma in Scotland between 2005 and 2013 were linked to pathology records, hospital data and death records. A Cox proportional hazards regression analysis, adjusting for key confounders, explored the association between morbidity and mortality and setting of primary melanoma excision (primary versus secondary care). A pooled estimate of the relative hazard of death of having a melanoma excised in primary versus secondary care including 7116 patients from a similar Irish study was also performed. ResultsThe adjusted hazard ratio (95% CI) of death from melanoma for those having primary care excision was 0.82 (0.61–1.10). Those receiving primary care excision had a median (IQR) of 8 (3–14) out-patient attendances compared to 10 (4–17) for the secondary care group with an adjusted relative risk (RR) (95% CI) of 0.98 (0.96–1.01). Both groups had a median of 1 (0–2) hospital admissions with an adjusted rate ratio of 1.05 (0.98–1.13). In the meta-analysis, with primary care as the reference, the pooled adjusted hazard ratio (HR, 95% CI) was 1.26 (1.07–1.50) indicating a significantly higher all-cause mortality among those with excision in secondary care. ConclusionsThe results of the Scottish and pooled analyses suggest that those receiving an initial excision for melanoma in primary care do not have poorer survival or increased morbidity compared to those being initially treated in secondary care. A randomised controlled trial to inform a greater role for GPs in the initial excision of melanoma is justified in the light of these results.

Melanoma in primary care. The role of the general practitioner

The British Association of Dermatologists and the National Cancer Control Programme in Ireland discourage all GPs from biopsying any lesions suspicious of melanoma. The aim of this study was to assess whether or not it is safe and practical for a general practitioner with extra training in dermatology and skin surgery to assess suspicious skin lesions and treat low risk melanomas. The outcome of 56 new melanomas (31 invasive, 7 in situ and 18 lentigo maligna) in 53 patients, managed by a GP with extra training in dermatology and skin surgery, over a 20 year period, was examined. Forty-eight (86 %) of the melanomas had the initial biopsy carried out in primary care. The average time from presentation to the practice to the date of the biopsy was 8 days for the in situ and invasive melanomas and 17 days for the lentigo malignas. Twenty-eight (50 %) of the melanomas were considered low risk (in situ, invasive <1 mm deep or lentigo maligna) and were treated successfully in primary care according to the Australian and New Zealand guidelines, without any surgical complications. GPs with extra training in skin cancer and skin surgery could assess most suspicious skin lesions with dermoscopy and if necessary, biopsy most of these lesions in primary care. This would lead to a quicker diagnosis, more rapid pathway to definitive treatment, lower cost and more convenience to the patient, especially for those living in rural areas.

Mortality and morbidity after initial diagnostic excision biopsy of cutaneous melanoma in primary versus secondary care

Current UK melanoma guidelines do not support the initial diagnostic excision biopsy of pigmented lesions in primary care, although this is standard in other countries such as Australia. Previous research in Northeast Scotland found that initial diagnostic excision biopsies in primary care that prove to be melanoma were no more likely to be incomplete than those performed in secondary care, but data on longer-term outcomes were not available. To determine whether initial diagnostic excision biopsy of cutaneous melanoma in primary versus secondary care leads to poorer survival and increased morbidity. Analysis of a linked dataset comprising pathological data from melanoma cases diagnosed in Northeast Scotland between 1991 and 2007, the General Registry Office (Scotland) death registry, and an NHS Scotland episode of care database. Patient data from three sources were matched using the Community Health Index (CHI) number. Cox proportional hazards regression, with robust standard error estimates, was used to examine the hazard ratio (95% confidence interval) of key mortality and morbidity outcomes based on excision in primary versus secondary care. Analysis was conducted before and after adjustment for operator and patient-level factors, using a multilevel approach. Patients receiving their initial diagnostic excision biopsy for melanoma in primary versus secondary care were no more likely to be dead, or to have died of metastatic malignant melanoma. Patients who had their initial diagnostic excision biopsy for melanoma in primary care had significantly fewer subsequent hospital admissions and spent fewer days in hospital. These findings suggest that initial diagnostic excision biopsy of melanoma in primary care does not lead to poorer long-term outcomes.

The Role of Gender in Examination and Counseling for Melanoma in Primary Care

The Role of Gender in Examination and Counseling for Melanoma in Primary Care