Effect of Teledermatology on the Prognosis of Patients With Cutaneous Melanoma

Objective To evaluate differences in the initial prognosis of patients with cutaneous melanoma managed by teledermatology (TD) vs other non-TD referral systems.

Design Descriptive and longitudinal study of a store-and-forward TD system aimed at the triage of patients with suspicious pigmented lesions.

Setting In 2003, a store-and-forward TD triage system aimed at the selection of patients with skin growths suggestive of cancer was implemented at a skin cancer clinic. This system has been shown to be accurate and reliable and able to significantly shorten waiting periods for consultation with a dermatologist.

Participants Patients with primary cutaneous melanoma referred to the Melanoma Clinic of the Dermatology Unit, Hospital Universitario Virgen Macarena, Seville, Spain, by TD or non-TD tracks were included in the study.

Main Outcome Measures Decisions on the referral of patients with suspicious skin lesions by store-and-forward TD vs by a conventional referral system. Breslow thickness and tumor stage were recorded in each study group (TD and non-TD) and were compared.

Results Two hundred one patients with primary cutaneous melanoma were enrolled in the study. In total, 33.3% were managed at their primary care center by teleconsultation, whereas 66.7% were managed by a conventional referral system. The mean Breslow thickness was significantly lower among patients in the TD group than among patients in the non-TD group (1.06 vs 1.64 mm, P = .03). The frequency of melanoma with a favorable initial prognosis (tumor stages Tis and T1a) was significantly higher in the TD group (70.1% vs 56.9%, P = .03). The odds ratio of having a cutaneous melanoma with a favorable initial prognosis in the TD group was 1.96 (95% CI, 1.14-3.50; P = .04).

Conclusion Teledermatology as a screening system for cutaneous melanoma has a favorable effect on the initial prognosis of patients with melanoma.

In 2003, a store-and-forward teledermatology (SFTD) triage system aimed at the selection of patients with skin growths suggestive of cancer was implemented at our skin cancer clinic.¹ Since then, the facility has been thoroughly evaluated in terms of validity, effectiveness, and efficiency as a triage and referral system for patients with skin cancer.^1-3 In these analyses, teledermatology (TD) was shown to be accurate and reliable and able to significantly shorten the waiting periods for consultation with a dermatologist.¹ Seven years after its initiation, the SFTD system had managed 25 252 patients and has become the routine referral system for the skin cancer and melanoma units.

Despite the SFTD system's having demonstrated excellent outcomes (a sensitivity of 99%, a specificity of 62%, and a waiting interval for face-to-face visits of 12 days), these represent proxy but not final outcomes of the health status among the populations involved.¹ Therefore, the real effect of telemedicine on the prognosis of patients with skin cancer, especially those with cutaneous melanoma, remains to be elucidated. This brief article attempts to evaluate differences in the initial prognosis of patients with cutaneous melanoma managed by TD vs those managed by a conventional (non-TD) referral system.

A descriptive and longitudinal study of an SFTD system aimed at the triage of patients with suspicious pigmented lesions was conducted at the Melanoma Clinic of the Dermatology Unit, Hospital Universitario Virgen Macarena, Seville, Spain, between January 9, 2006, and December 23, 2010. Patients who were older than 18 years, had a histopathological diagnosis of primary cutaneous melanoma reported by the Pathology Unit of the hospital during the study period, and were referred by teleconsultation or by other non-TD tracks were enrolled in the study. In the TD system evaluated, eligible patients to be managed by teleconsultation had to be seen at their primary care center with a circumscribed lesion fulfilling at least 1 of the following criteria: recently growing lesions, recent history of a lesion, local symptoms (pain, itching, or bleeding), or ABCD changes (asymmetry, border irregularity, color variation, and diameter >6 mm). After obtaining consent, a panoramic photograph of the anatomic location and a macrophotograph were obtained of patients using standard digital photo cameras (Coolpix 4300; Nikon or Cybershot DSC-W30 or DSC-W300; Sony). Photographs and clinical information (identification code, age, sex, anatomic location, and time evolution) were uploaded to templates (Word; Microsoft) and then submitted via e-mail attachment to the public health service intranet^1,4,5 (Figure 1). After November 3, 2008, the mail-based teleconsultation was replaced by the current web-based system in which the clinical photographs are uploaded to a local server and the clinical information is inserted in a predefined form. After evaluation of the teleconsultation by the remote dermatologist (L.F., A.R.C., F.J.M.G., F.P.R., and D.M.R.), a report with the possible diagnosis and the referral decision to the Melanoma Clinic is returned to the primary care center. During the study period, dermoscopic photographs were not routinely obtained and transmitted for melanoma triage; therefore, the triage system evaluated in this study consists of a decision making process based on intranet-transmitted clinical photographs of pigmented suspicious lesions.

The Melanoma Clinic, which conducted this study, is a reference center that covers a population of 550 000 inhabitants distributed among 32 primary care centers in which the TD system is fully implemented. The Melanoma Clinic also receives patients from other geographic areas not joined to the TD network, whose inclusion in the study allowed comparisons among referral systems. Eligible patients in the non-TD group were seen with cutaneous lesions considered suspicious by general practitioners (GPs) from primary care centers at geographic areas not served by TD; the lesions were surgically removed and pathologically diagnosed at our Melanoma Clinic.

Demographic data (age and sex), year of diagnosis, referral system (TD or non-TD), Breslow thickness, and tumor stage (Tis, T1a, T1b, T2a, T2b, T3a, T3b, T4a, or T4b) were recorded from the TD unit database and the Pathology Unit reports. According to Breslow thickness of the primary melanoma, the study cohort was divided into the following 2 categories: patients with primary tumor stages Tis and T1a and patients with primary tumor stages T1b to T4b. This cutoff point was established on the basis of the 10-year overall survival curves for melanoma published in 2009 by the American Joint Committee on Cancer.⁶ The main outcomes assessed were the mean Breslow thickness and the frequency of early tumor stages (Tis and T1a) in each study group (TD and non-TD).

For statistical analysis, commercially available software (SPSS 15.0; SPSS Inc) was used. Statistically significant differences were demonstrated using the Mann-Whitney test for quantitative data (age and Breslow thickness) and the χ² test with Fisher product moment correction for qualitative variables (year of diagnosis, referral system, and tumor stage). To assess the strength of association between the referral method (TD vs non-TD) and tumor stage (patients with tumor stages Tis and T1a vs patients with tumor stages T1b to T4b), the odds ratio (95% CI) was calculated using a bivariate model based on 2 × 2 tables. All significance tests were 2-sided, with P < .05 considered statistically significant.

A total of 201 patients with primary cutaneous melanoma and valid data were enrolled during the study period. Their mean age was 57.5 (95% CI, 55.0-60.0) years, and there was a nonsignificant predominance of women among the group that was managed with TD (52.4% vs 47.6%, P = .20).

Sixty-seven patients with melanoma (33.3%) were initially managed at their primary care center by teleconsultation (TD group), whereas 134 patients with melanoma (66.7%) were initially managed by a conventional referral system (non-TD group). No meaningful differences were observed in the mean age (56.9 years in the TD group vs 57.8 years in the non-TD group, P = .70) or sex distribution between the groups.

At the end of the study period, the mean Breslow thickness was significantly less among patients in the TD group compared with patients in the non-TD group (mean, 1.06 vs 1.64 mm, P = .03); the median values were 0.55 vs 0.75 mm. Intermediate analysis throughout the study period also showed statistically significant differences in Breslow thickness between the groups in 2008 and in 2010 (Figure 2).

After completion of the study, the frequency of melanoma with a favorable initial prognosis (tumor stages Tis and T1a) was significantly higher in the TD group than in the non-TD group (70.1% vs 56.9%, P = .03). The odds ratio of having a cutaneous melanoma with a favorable initial prognosis in the TD group was 1.96 (95% CI, 1.14-3.50; P = .04). The intermediate analysis demonstrated no statistically significant differences in the frequency of a favorable prognosis of melanoma during each period of the study.

As a routine tool for melanoma triage, SFTD was shown herein to improve the initial prognosis of patients having cutaneous melanoma compared with patients referred by other means. This specific use of TD has been previously validated in studies^7,8 showing the advantages of transmitted images of melanoma for screening purposes, even from mobile devices. Nevertheless, the aims and findings of the present study go further because we attempt to look at the translation of this technical advantage in terms of health care benefits.

Early diagnosis and treatment of melanoma remain the intervention with the greatest effect on the final outcomes in patients with melanoma. Improving the accessibility to specialized care has been a common strategy implemented in several health systems to achieve these results (ie, “the 2-week-rule” in the United Kingdom).⁹ The SFTD facility assessed in this study was set up in an attempt to shorten access times to see a dermatologist and to facilitate early treatment of skin cancer and melanoma. Although these proxy results were largely achieved shortly after the implementation of the SFTD system,^1,5 the effect of the intervention in terms of the health status of the populations studied represents a long-term evaluation that is now coming to fruition.

Breslow thickness and tumor stage of the primary tumor are not final outcomes, and their validity is being discussed as equivalent to “early” or “late” diagnosis.¹⁰ However, according to the American Joint Committee on Cancer TNM staging system,⁶ Breslow thickness and tumor stage remain the most important initial prognostic factors in patients with melanoma. Whereas patients with Tis and T1a tumors have an overall survival similar to that of persons without melanoma, a more advanced T stage is associated with a more unfavorable initial prognosis for the patient.⁶ Therefore, any intervention capable of detecting primary cutaneous melanoma at a lower Breslow thickness would lead to a better prognosis for the patient. In our experience, this was observed for those patients with melanoma whose referrals to the Melanoma Clinic were managed by means of TD vs the non-TD access tracks, with Breslow thicknesses of 1.06 vs 1.64 mm (P = .03).

From the point of view of the population studied, it should also be considered that the advantage gained in Breslow thickness is related to the shorter waiting intervals to see a dermatologist, along with other complementary factors. In primary care centers associated with the SFTD network, the early diagnosis of cutaneous melanoma may be attributed to several characteristics, including the following: the best knowledge of pigmented lesions among GPs (who have been working with TD for 7 years), the lower threshold applied by these GPs to decide to initiate a teleconsultation, the enhanced awareness of the need to screen for melanoma among the physician practices with the capacity to perform TD, and the knowledge among citizens from these areas about a system that leads to a fast specialized opinion (outside of a hospital environment). As a result, for early diagnosis of malignant melanoma, better decisions about the referral of patients to the Melanoma Clinic were made after the implementation of TD in our area. The benefits of TD are associated not only with the feasibility and validity of transmitted clinical photographs for diagnostic purposes but also (and probably mainly) with the improvement in GPs' capabilities and knowledge of skin cancer triage, the reorganization of dermatological care access, and the changes in working methods of GPs and dermatologists as a consequence of implementing SFTD.

The observations described herein should be considered carefully because of limitations resulting from the observational and single-center nature of the series. First, the observational nonrandomized approach might carry potential confounding bias from the populations compared. Second, the sample size recruited by this single-center series might limit the statistical power of the differences observed. However, the design of large multicenter studies is not expected in the short term because the implementation of TD systems aimed at skin cancer triage has not been widespread in routine clinical practice of skin cancer and melanoma units. Third, longer follow-up periods will be needed to clearly define the real effect of telemedicine in the survival of patients with melanoma and on the health status of populations served with this technology.

In the long term, the use of TD for the routine management of patients with cutaneous melanoma may improve the initial prognosis of these patients. Our early findings may help to convince policy makers about the usefulness of TD not only in underserved areas but also for melanoma units in otherwise well-served populations.

Correspondence: Lara Ferrándiz, PhD, Dermatology Unit, Hospital Universitario Virgen Macarena, Avenue Dr Fedriani s/n, 41073 Seville, Spain (lferrandiz@e-derma.org).

Accepted for Publication: February 9, 2012.

Author Contributions: Drs Ferrándiz and Moreno-Ramirez had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Acquisition of data: Ferrándiz, Ruiz-de-Casas, Martin-Gutierrez, Peral-Rubio, Mendez-Abad, Rios-Martin, and Moreno-Ramirez. Critical revision of the manuscript for important intellectual content: Ferrándiz, Ruiz-de-Casas, Martin-Gutierrez, Peral-Rubio, Mendez-Abad, Rios-Martin, and Moreno-Ramirez. Statistical analysis: Moreno-Ramirez. Study supervision: Ferrándiz, Rios-Martin, and Moreno-Ramirez.