In the USA, there will be an estimated 100,350 new cases of melanoma and 6850 deaths
in 2020 [1]. By 2030, the number of newly diagnosed cases is expected to be more than
double and the annual cost of treating newly diagnosed melanomas is estimated to triple
from $457 million in 2011 to $1.6 billion in 2030 [2–4]. Early detection determines
the disease stage, prognosis, treatment and cost to the payer [5]. Time to presentation
for care is a key determinant of patients’ outcome. Compared with other cancers, melanoma
has the longest delays measured as the median time from symptom onset to patient presentation
[6]. Since most melanomas are visible on the surface of the skin at a curable phase
in their evolution, people at-risk to develop melanoma can check their moles by performing
skin self-examination (SSE). In the general community, the annual prevalence of self-reported
SSE, defined as any area of skin checked sporadically, ranges from 8 to 21% [7]. Women
self-detect more than half of melanomas and melanomas detected by women had a better
prognosis than those detected by men because they were identified at an earlier stage
[8,9].
Waiting times for appointments with dermatologists, dermatologist shortages in rural
areas, out of pocket costs and distance to the nearest dermatologist may discourage
people from receiving dermatological care. A health disparity exists in the USA for
residents of rural counties. Rural counties in the USA have higher incidence rates
for melanoma than metropolitan counties and higher mortality rates [10]. The higher
incidence is most likely due to unprotected sun exposure in a predominantly non-Hispanic
white population engaged in agricultural and other outdoor occupations. Rural residents,
who are older, more socioeconomically disadvantaged and less educated than their urban
counterparts, have greater travel distances and transportation difficulties in reaching
healthcare providers (HCPs) for both general and specialty care than urban residents
[11]. Until self-management for early detection of melanoma among at-risk people and
health disparities are effectively addressed, patients will present late in the disease
incurring significant mortality, morbidity and healthcare costs.
In 2018, the US Preventive Services Task Force concluded that current evidence is
insufficient to assess the balance of benefits and harms of SSE to prevent skin cancer
[12]. This US Preventive Services Task Force recommendation does not address SSE among
people at-risk to develop melanoma. Organizations defined individuals at-risk of developing
melanoma as people with:
Skin type Fitzpatrick scale I–III (skin that sustains a sunburn);
A personal or family history of melanoma;
A personal history of nonmelanoma skin cancer (basal or squamous cell carcinoma);
A history of multiple sunburns;
A history of 10 or more indoor tanning sessions in a lifetime;
Having multiple atypical nevi and/or;
Having ongoing immuocompromise [13].
The American Academy of Dermatology encourages self-advocacy through routine SSE and
regular skin cancer screening by dermatologists for at-risk patients, who require
routine physician screening [14]. Physician endorsement of SSE to at-risk patients
and access to SSE skills training are needed to help patients self-manage early detection
of melanoma. Among those at-risk to develop melanoma, melanoma survivors may be reached
by physicians because patients receive routine follow-up care from physicians every
3–12 months [13], While the importance of early detection is usually recognized by
melanoma survivors, they may not realize that 7–12% of patients with a history of
melanoma develop a second primary melanoma [15]. Thus, physicians need to inform melanoma
survivors of their risk of developing another melanoma. Since a new melanoma may arise
in the interval between physician follow-up visits, physician endorsement of SSE is
worthwhile. The benefit of SSE was demonstrated in a 20 year follow-up case control
study of people newly diagnosed with melanoma in 1987–89 [16]. In this study, skin
awareness prompted by SSE was associated independently with decreased risk of melanoma
death (HR: 0.46; 95% CI: 0.28–0.75; p < 0.01) [16].
In our randomized clinical trial, SSE skills training for at-risk melanoma survivors
and their skin check partners enabled pairs to accurately assess moles and track concerning
moles for change [17,18]. This evidence–based systematic assessment of moles on most
areas of the skin, including scalp, back, buttocks and feet was taught and performed
by melanoma survivors and their skin check partners. Skills training was provided
in a workbook with color illustrations that taught the pair to score the following
three features of a mole using a scale of 1-3 (1 = normal, 2 = unsure, 3 = not normal):
border (smooth = 1 or jagged = 3);
color (one-two colors = 1 or a variety of colors = 3) and;
diameter of a mole (<4 mm = 1, 5 mm = 2, or >6 mm = 3).
The pair was encouraged to start by checking a mole that they both could easily see,
for example, the forearm. Then, the pair worked together using a mm ruler to measure
the widest part of the mole and a lighted magnifying lens to see the border and color
of the mole. Pairs discussed the scores they gave to each feature and agreed upon
the score for border, color, and diameter before entering the scores in a diary. The
decision about seeking healthcare for a concerning mole was based upon the sum of
the features as follows:
• 3 = benign, stop checking the mole;
• 4–7 = check the mole in one month;
• 8–9 = make an appointment with the HCP to have the mole checked in about 2–3 weeks.
The recommendation to have a mole with a score of 8–9 checked by the HCP in 2–3 weeks
was supported by study physicians seeing patients within 2–3 weeks. Acceptance of
SSE by melanoma survivors in our study may have been enabled by the assurance of ready
access to study physicians if a concerning mole was detected. SSE was an adjunct to
HCP examination. The patients’ diary documenting change in a mole assisted HCPs in
deciding to perform a skin biopsy. Partner-assisted SSE and subsequent clinical presentation
to the HCP for concerning moles rely on self-management, adoption of decision rules
and taking appropriate action.
The skin check partner served three important functions: the partner saw areas of
the body that the at-risk person cannot easily see themselves (ears, back of neck,
scalp); reinforced the need to do SSE by reminding the melanoma survivor to do SSE
or scheduling times to do partner assisted SSE and helped to build confidence in making
decisions about scoring the features of the mole and seeking an appointment with the
HCP. Each pair developed their own way of doing SSE. For some, the melanoma survivor
checked all the places he or she was able to see alone and invited the partner to
check places that were hard to see. Others did the total body skin check together.
Pairs were encouraged to reward themselves after completing SSE by doing something
they would enjoy doing together, for example going to a movie. The case example of
a wife of a 65-year-old man, who was a survivor of stage II A melanoma, illustrates
the benefit of partner assisted SSE. The wife invited her husband, the melanoma survivor,
to sit down so she could see the vertex of his balding scalp. She found a suspicious
looking dark spot and started to score the border, color and diameter. As she assessed
each feature, she told him the score. He placed the score in his diary. The border
was jagged (score 3), the diameter was 7 mm (score 3), and she could not decide about
the color (score = 2). The total score was 8. She and her husband decided they needed
to have the HCP check the concerning mole on the scalp. In this example, the partner’s
help in identifying this concerning mole of the scalp was especially important because
patients with melanoma of the scalp died at 1.84-times (HR: 1.84; 95% CI: 1.62–2.10)
the rate of those with melanoma in any other location [19]. The reason for the increased
mortality of scalp melanoma may be presentation for care at a more advanced stage
than other locations, which are easier for the patient to see. In this case, for example,
the concerning mole of the scalp was biopsied and was a stage IA melanoma. Further
support for the role of the partner came from a study showing that there was increased
melanoma mortality among bereaved melanoma survivors, whose partners died [20]. This
may be partly explained by delayed detection resulting from the loss of a partner
who checks difficult to see areas of the body.
Common patient burdens such as HCP appointment scheduling difficulties, time away
from work and family, transportation constraints and the cost of the physician visit
may be reduced by SSE training. Lack of confidence in SSE skills may cause some people
to doubt their self-diagnosis and fail to make an appointment with the HCP or follow
a mole for change. Physicians may boost patients’ SSE confidence by saying, “You are
doing really well checking moles”. Another form of encouragement that physicians may
offer is the advice that asking a relative to check places that are hard to see would
be helpful. People may find SSE too much of ‘a bother’, cease monthly SSE, and perform
SSE at 2–3-monthly intervals. It is best if physicians recognize the difficulty of
monthly SSE, which was intended to form a sustainable habit and support SSE at the
less frequent interval of every 2–3 months, which in our research was sufficient to
detect change in a concerning mole without having disease detected at an advanced
stage. In times of restricted access to healthcare, such as during the COVID-19 pandemic,
people at-risk of developing melanoma may benefit from having the skills to self-manage
early detection of melanoma. Self-management may reduce patient demand for physician
screening of benign moles and improve access to physician screening for concerning
moles.