Opinion
EDITORIAL
Worry About Developing Melanoma in the Pigmented Lesion Clinic Does It Warrant a Solution? Jennifer L. Hay, PhD
In this issue Moye and colleagues1 examine psychological distress in patients with atypical mole syndrome attending a pigmented lesion clinic (PLC) who are receiving biannual total body skin examination using total body digital photography (TBDP). The authors propose that TBDP, which involves Related article page 137 high-resolution digital photography with professional lighting and standardized patient poses to document the body surface, has potentially important psychological benefits. The photographs generated through TBDP provide the physician with a record to compare potentially new and changing lesions in subsequent PLC visits; TBDP photographs can also be provided to the patient to aid in skin self-examination. Apart from whether use of TBDP leads to reduced biopsy rates or improvements in the benign to malignant ratio, the authors propose that the use of repeated TBDP justifies the time and associated costs because TBDP reduces worry about melanoma in those patients who might otherwise have to wait for biopsy results. In the study by Moye et al,1 137 patients with atypical mole syndrome (defined as having ≥50 nevi with at least 1 nevus measured at ≥8 mm in diameter and 1 atypical nevus with irregular borders or color variation) were recruited prior to their TBDP in PLCs at Emory University and University of Arizona; 50% of the participants had a personal history of melanoma. Participants were recruited, and their worry about melanoma was evaluated twice using standardized measures— both before a PLC visit and then on average 7 months later. There are 2 prominent study findings. First, at baseline, distress about melanoma was low, with little impact of any distress on participants’ mood or daily activities. These findings are consistent with the documented low levels of cancer-specific distress among those at increased risk for other cancers.2,3 Similarly, this study found that levels of general distress (anxiety and depression) fell below cutoffs for clinically significant symptomatology. These low distress levels do not provide a strong argument for the adoption of systematic methods to reduce distress in PLC patients with atypical mole syndrome. However, the study identified participant characteristics associated with somewhat higher distress levels, such as sex (women were more distressed), personal history of melanoma, and higher general distress. In the context of the growing focus on patient-centered approaches to medical care, the identification of specific patient subgroups through, for example, brief, standardized self-assessment4 or standardized der128
matologist inquiry, may lead physicians to tailor skin cancer screening methods to address these concerns by using new screening strategies such as TBDP. Yet even in those with a personal history of melanoma, general distress levels would be expected to be low and comparable to the general population, and melanoma-specific worry, to be low to moderate.5 Palpable anxiety noted in clinic consultation by the dermatologist likely does not translate to clinical levels of anxiety in substantial numbers in the PLC population. In the few cases where high distress is identified, an ongoing collaboration with a consulting psychiatrist or psychologist can be helpful in guiding the patient to appropriate clinical services to address it. The second prominent study finding involves the fact that even though worry levels were low, rates were, in fact, further reduced to negligible by TBDP. Unfortunately, the study did not report on whether worry levels were equally reduced among those participants who received positive vs negative TBDP findings and whether worry levels were equally reduced among those who received positive vs negative biopsy results among those with positive TBDP findings. Another examination of PLC patients found that distress levels were, not surprisingly, related to biopsy findings.6 Research examining the influence of cancer screening on distress levels among those at risk for other cancers attests to the important influence that screening results have on distress levels, albeit only in the short term. For example, Slatore and colleagues7 recently conducted a systematic review of psychological outcomes of lung cancer screening via computed tomography (CT) among older, longstanding smokers and found short-term increases in distress in those with positive findings; over time these levels became comparable to those who received negative findings. In the breast cancer screening context, even the receipt of false-positive mammograms increased only short-term distress about breast cancer specifically but had no effect on general distress levels.8 Furthermore, as Moye et al1 note, it was not possible to distinguish specific effects of TBDP from other aspects of the PLC visit. If most TBDP examination results for these study participants were negative, it would not be possible to generalize study findings to those patients who received positive TBDP results and subsequent biopsy. Furthermore, as Moye et al1 also point out, follow-up distress levels were assessed at 7 months, on average, which may have been after a subsequent 6-month PLC visit, further complicating trajectories of worry. Is TBDP important over and above improved surveillance in PLC alone? Clearly, additional work to tease apart the influence on distress of TBDP
JAMA Dermatology February 2015 Volume 151, Number 2 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a Nanyang Technological University User on 05/21/2015
jamadermatology.com
Editorial Opinion
specifically, as well as positive vs negative findings, will help clarify the unique utility of TBDP vs other clinical skin cancer screening approaches used in PLCs. The question can also be raised whether further distinguishing (and treating) the generally low melanoma-specific worry found in PLC patients might have a potential downside. The study authors provide a perspective concerning worry as a problem to be eliminated in the PLC setting. Yet, the available systematic reviews indicate that cancer-specific worry promotes screening rather than impeding it.3,9 There is a substantial psychological literature on the important role of emotion in risk perception and health behavior adoption and maintenance, since emotion tends to provide guidance concerning salient concerns and actionable personal priorities through a number of strategies, such as enhancing planning and active coping.10 There is a developing research base attesting to the fact that even those with risk factors for melanoma, such as those with risk factors such as a melanoma family history, are inconsistent in getting screened for skin cancer and practicing skin cancer risk reduction behaviors such as sun protection (sunscreen use, shade seeking, wearing hats or protective clothing). This could be seen as a problem of too little worry, rather than too much. For example, up to half of first-degree relatives of patients with melanoma have never received a total cutaneous examination by a health care practitioner and even more (70%) have never performed a self-skin examination.11,12 In a study examining those with large numbers of nevi as well as a family history of melanoma, 8% had never performed skin self-examination.13 Less than one-third of first-degree relatives of melanoma survivors in one study used sunscreen routinely when in the sun; even fewer stayed in the shade or used protective clothing frequently.14 The key clinical question raised by these findings is why some individuals with a clearly ARTICLE INFORMATION Author Affiliation: Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York. Corresponding Author: Jennifer L. Hay, PhD, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave, Seventh Floor, New York, NY 10022 ([email protected]). Published Online: November 12, 2014. doi:10.1001/jamadermatol.2014.2228. Conflict of Interest Disclosures: None reported. REFERENCES 1. Moye MS, King SMC, Rice ZP, et al. Effects of total-body digital photography on cancer worry in patients with atypical mole syndrome [published online November 12, 2014]. JAMA Dermatol. doi:10 .1001/jamadermatol.2014.2229. 2. Hay JL, Buckley TR, Ostroff JS. The role of cancer worry in cancer screening: a theoretical and empirical review of the literature. Psychooncology. 2005;14(7):517-534. 3. Hay JL, McCaul KD, Magnan RE. Does worry about breast cancer predict screening behaviors? a meta-analysis of the prospective evidence. Prev Med. 2006;42(6):401-408.
jamadermatology.com
elevated risk of melanoma choose not to take steps to prevent themselves from developing the disease, or do so only intermittently. Perhaps addressing higher worry in the PLC setting should also be paired with examining low worry in those who were referred to PLC but do not attend, those who attend sporadically or once and never again, as well as those who forgo risk reduction altogether in the higher risk context. This may be a potential sequelae of multiple negative results provided in the PLC; people may fail to come because their skin cancer concerns diminish over time. In summary, some melanoma-specific worry may be a good thing, leading to greater vigilance with self-screenings, PLC appointments, and sun protection. Certainly, further research is warranted. For the general population of patients at increased melanoma risk, melanoma-specific worry is likely transient. Patient engagement and activation15 with prevention behaviors, defined as the extent to which patients take an active role in managing their health and health care—whether skin cancer screening or sun protection—is probably a worthwhile area for research and may better predict future screening behavior over and above worry alone. Furthermore, waiting for the results of biopsy may be a different form of anticipatory anxiety than more general cancer worry per se, and this requires examination. An additional question worthy of research concerns whether use of handheld dermoscopes would be comparable or more favorable in terms of cost, feasibility, and acceptability compared with TBDP. Finally, longitudinal examination of melanoma-specific worry, based on findings from TBDP and biopsy, could confirm whether there are specific subgroups that have higher worry or do not spontaneously recover over time to baseline levels of low worry. These subgroups may indeed require intervention or specific screening strategies such as TBDP to help address their worry about developing melanoma.
4. van Dooren S, Duivenvoorden HJ, Passchier J, et al. The Distress Thermometer assessed in women at risk of developing hereditary breast cancer. Psychooncology. 2009;18(10):1080-1087. 5. Atkinson TM, Noce NS, Hay J, Rafferty BT, Brady MS. Illness-related distress in women with clinically localized cutaneous melanoma. Ann Surg Oncol. 2013;20(2):675-679. 6. Al-Shakhli H, Harcourt D, Kenealy J. Psychological distress surrounding diagnosis of malignant and nonmalignant skin lesions at a pigmented lesion clinic. J Plast Reconstr Aesthet Surg. 2006;59(5):479-486. 7. Slatore CG, Sullivan DR, Pappas M, Humphrey LL. Patient-centered outcomes among lung cancer screening recipients with computed tomography: a systematic review. J Thorac Oncol. 2014;9(7):927934. 8. Salz T, Richman AR, Brewer NT. Meta-analyses of the effect of false-positive mammograms on generic and specific psychosocial outcomes. Psychooncology. 2010;19(10):1026-1034. 9. Consedine NS, Magai C, Krivoshekova YS, Ryzewicz L, Neugut AI. Fear, anxiety, worry, and breast cancer screening behavior: a critical review. Cancer Epidemiol Biomarkers Prev. 2004;13(4):501510.
10. Slovic P, Peters E, Finucane ML, Macgregor DG. Affect, risk, and decision making. Health Psychol. 2005;24(4)(suppl):S35-S40. 11. Gaber R, Desai S, Smith M, et al. Communication by mothers with breast cancer or melanoma with their children. Int J Environ Res Public Health. 2013; 10(8):3483-3501. 12. Manne S, Fasanella N, Connors J, Floyd B, Wang H, Lessin S. Sun protection and skin surveillance practices among relatives of patients with malignant melanoma: prevalence and predictors. Prev Med. 2004;39(1):36-47. 13. Mesters I, Jonkman L, Vasen H, de Vries H. Skin self-examination of persons from families with familial atypical multiple mole melanoma (FAMMM). Patient Educ Couns. 2009;75(2):251-255. 14. Azzarello LM, Dessureault S, Jacobsen PB. Sun-protective behavior among individuals with a family history of melanoma. Cancer Epidemiol Biomarkers Prev. 2006;15(1):142-145. 15. Institute of Medicine. Partnering With Patients to Drive Shared Decisions, Better Value, and Care Improvement: Workshop Proceedings. Washington, DC: The National Academies Press; 2014.
(Reprinted) JAMA Dermatology February 2015 Volume 151, Number 2
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a Nanyang Technological University User on 05/21/2015
129
EDITORIAL
Worry About Developing Melanoma in the Pigmented Lesion Clinic Does It Warrant a Solution? Jennifer L. Hay, PhD
In this issue Moye and colleagues1 examine psychological distress in patients with atypical mole syndrome attending a pigmented lesion clinic (PLC) who are receiving biannual total body skin examination using total body digital photography (TBDP). The authors propose that TBDP, which involves Related article page 137 high-resolution digital photography with professional lighting and standardized patient poses to document the body surface, has potentially important psychological benefits. The photographs generated through TBDP provide the physician with a record to compare potentially new and changing lesions in subsequent PLC visits; TBDP photographs can also be provided to the patient to aid in skin self-examination. Apart from whether use of TBDP leads to reduced biopsy rates or improvements in the benign to malignant ratio, the authors propose that the use of repeated TBDP justifies the time and associated costs because TBDP reduces worry about melanoma in those patients who might otherwise have to wait for biopsy results. In the study by Moye et al,1 137 patients with atypical mole syndrome (defined as having ≥50 nevi with at least 1 nevus measured at ≥8 mm in diameter and 1 atypical nevus with irregular borders or color variation) were recruited prior to their TBDP in PLCs at Emory University and University of Arizona; 50% of the participants had a personal history of melanoma. Participants were recruited, and their worry about melanoma was evaluated twice using standardized measures— both before a PLC visit and then on average 7 months later. There are 2 prominent study findings. First, at baseline, distress about melanoma was low, with little impact of any distress on participants’ mood or daily activities. These findings are consistent with the documented low levels of cancer-specific distress among those at increased risk for other cancers.2,3 Similarly, this study found that levels of general distress (anxiety and depression) fell below cutoffs for clinically significant symptomatology. These low distress levels do not provide a strong argument for the adoption of systematic methods to reduce distress in PLC patients with atypical mole syndrome. However, the study identified participant characteristics associated with somewhat higher distress levels, such as sex (women were more distressed), personal history of melanoma, and higher general distress. In the context of the growing focus on patient-centered approaches to medical care, the identification of specific patient subgroups through, for example, brief, standardized self-assessment4 or standardized der128
matologist inquiry, may lead physicians to tailor skin cancer screening methods to address these concerns by using new screening strategies such as TBDP. Yet even in those with a personal history of melanoma, general distress levels would be expected to be low and comparable to the general population, and melanoma-specific worry, to be low to moderate.5 Palpable anxiety noted in clinic consultation by the dermatologist likely does not translate to clinical levels of anxiety in substantial numbers in the PLC population. In the few cases where high distress is identified, an ongoing collaboration with a consulting psychiatrist or psychologist can be helpful in guiding the patient to appropriate clinical services to address it. The second prominent study finding involves the fact that even though worry levels were low, rates were, in fact, further reduced to negligible by TBDP. Unfortunately, the study did not report on whether worry levels were equally reduced among those participants who received positive vs negative TBDP findings and whether worry levels were equally reduced among those who received positive vs negative biopsy results among those with positive TBDP findings. Another examination of PLC patients found that distress levels were, not surprisingly, related to biopsy findings.6 Research examining the influence of cancer screening on distress levels among those at risk for other cancers attests to the important influence that screening results have on distress levels, albeit only in the short term. For example, Slatore and colleagues7 recently conducted a systematic review of psychological outcomes of lung cancer screening via computed tomography (CT) among older, longstanding smokers and found short-term increases in distress in those with positive findings; over time these levels became comparable to those who received negative findings. In the breast cancer screening context, even the receipt of false-positive mammograms increased only short-term distress about breast cancer specifically but had no effect on general distress levels.8 Furthermore, as Moye et al1 note, it was not possible to distinguish specific effects of TBDP from other aspects of the PLC visit. If most TBDP examination results for these study participants were negative, it would not be possible to generalize study findings to those patients who received positive TBDP results and subsequent biopsy. Furthermore, as Moye et al1 also point out, follow-up distress levels were assessed at 7 months, on average, which may have been after a subsequent 6-month PLC visit, further complicating trajectories of worry. Is TBDP important over and above improved surveillance in PLC alone? Clearly, additional work to tease apart the influence on distress of TBDP
JAMA Dermatology February 2015 Volume 151, Number 2 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a Nanyang Technological University User on 05/21/2015
jamadermatology.com
Editorial Opinion
specifically, as well as positive vs negative findings, will help clarify the unique utility of TBDP vs other clinical skin cancer screening approaches used in PLCs. The question can also be raised whether further distinguishing (and treating) the generally low melanoma-specific worry found in PLC patients might have a potential downside. The study authors provide a perspective concerning worry as a problem to be eliminated in the PLC setting. Yet, the available systematic reviews indicate that cancer-specific worry promotes screening rather than impeding it.3,9 There is a substantial psychological literature on the important role of emotion in risk perception and health behavior adoption and maintenance, since emotion tends to provide guidance concerning salient concerns and actionable personal priorities through a number of strategies, such as enhancing planning and active coping.10 There is a developing research base attesting to the fact that even those with risk factors for melanoma, such as those with risk factors such as a melanoma family history, are inconsistent in getting screened for skin cancer and practicing skin cancer risk reduction behaviors such as sun protection (sunscreen use, shade seeking, wearing hats or protective clothing). This could be seen as a problem of too little worry, rather than too much. For example, up to half of first-degree relatives of patients with melanoma have never received a total cutaneous examination by a health care practitioner and even more (70%) have never performed a self-skin examination.11,12 In a study examining those with large numbers of nevi as well as a family history of melanoma, 8% had never performed skin self-examination.13 Less than one-third of first-degree relatives of melanoma survivors in one study used sunscreen routinely when in the sun; even fewer stayed in the shade or used protective clothing frequently.14 The key clinical question raised by these findings is why some individuals with a clearly ARTICLE INFORMATION Author Affiliation: Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York. Corresponding Author: Jennifer L. Hay, PhD, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave, Seventh Floor, New York, NY 10022 ([email protected]). Published Online: November 12, 2014. doi:10.1001/jamadermatol.2014.2228. Conflict of Interest Disclosures: None reported. REFERENCES 1. Moye MS, King SMC, Rice ZP, et al. Effects of total-body digital photography on cancer worry in patients with atypical mole syndrome [published online November 12, 2014]. JAMA Dermatol. doi:10 .1001/jamadermatol.2014.2229. 2. Hay JL, Buckley TR, Ostroff JS. The role of cancer worry in cancer screening: a theoretical and empirical review of the literature. Psychooncology. 2005;14(7):517-534. 3. Hay JL, McCaul KD, Magnan RE. Does worry about breast cancer predict screening behaviors? a meta-analysis of the prospective evidence. Prev Med. 2006;42(6):401-408.
jamadermatology.com
elevated risk of melanoma choose not to take steps to prevent themselves from developing the disease, or do so only intermittently. Perhaps addressing higher worry in the PLC setting should also be paired with examining low worry in those who were referred to PLC but do not attend, those who attend sporadically or once and never again, as well as those who forgo risk reduction altogether in the higher risk context. This may be a potential sequelae of multiple negative results provided in the PLC; people may fail to come because their skin cancer concerns diminish over time. In summary, some melanoma-specific worry may be a good thing, leading to greater vigilance with self-screenings, PLC appointments, and sun protection. Certainly, further research is warranted. For the general population of patients at increased melanoma risk, melanoma-specific worry is likely transient. Patient engagement and activation15 with prevention behaviors, defined as the extent to which patients take an active role in managing their health and health care—whether skin cancer screening or sun protection—is probably a worthwhile area for research and may better predict future screening behavior over and above worry alone. Furthermore, waiting for the results of biopsy may be a different form of anticipatory anxiety than more general cancer worry per se, and this requires examination. An additional question worthy of research concerns whether use of handheld dermoscopes would be comparable or more favorable in terms of cost, feasibility, and acceptability compared with TBDP. Finally, longitudinal examination of melanoma-specific worry, based on findings from TBDP and biopsy, could confirm whether there are specific subgroups that have higher worry or do not spontaneously recover over time to baseline levels of low worry. These subgroups may indeed require intervention or specific screening strategies such as TBDP to help address their worry about developing melanoma.
4. van Dooren S, Duivenvoorden HJ, Passchier J, et al. The Distress Thermometer assessed in women at risk of developing hereditary breast cancer. Psychooncology. 2009;18(10):1080-1087. 5. Atkinson TM, Noce NS, Hay J, Rafferty BT, Brady MS. Illness-related distress in women with clinically localized cutaneous melanoma. Ann Surg Oncol. 2013;20(2):675-679. 6. Al-Shakhli H, Harcourt D, Kenealy J. Psychological distress surrounding diagnosis of malignant and nonmalignant skin lesions at a pigmented lesion clinic. J Plast Reconstr Aesthet Surg. 2006;59(5):479-486. 7. Slatore CG, Sullivan DR, Pappas M, Humphrey LL. Patient-centered outcomes among lung cancer screening recipients with computed tomography: a systematic review. J Thorac Oncol. 2014;9(7):927934. 8. Salz T, Richman AR, Brewer NT. Meta-analyses of the effect of false-positive mammograms on generic and specific psychosocial outcomes. Psychooncology. 2010;19(10):1026-1034. 9. Consedine NS, Magai C, Krivoshekova YS, Ryzewicz L, Neugut AI. Fear, anxiety, worry, and breast cancer screening behavior: a critical review. Cancer Epidemiol Biomarkers Prev. 2004;13(4):501510.
10. Slovic P, Peters E, Finucane ML, Macgregor DG. Affect, risk, and decision making. Health Psychol. 2005;24(4)(suppl):S35-S40. 11. Gaber R, Desai S, Smith M, et al. Communication by mothers with breast cancer or melanoma with their children. Int J Environ Res Public Health. 2013; 10(8):3483-3501. 12. Manne S, Fasanella N, Connors J, Floyd B, Wang H, Lessin S. Sun protection and skin surveillance practices among relatives of patients with malignant melanoma: prevalence and predictors. Prev Med. 2004;39(1):36-47. 13. Mesters I, Jonkman L, Vasen H, de Vries H. Skin self-examination of persons from families with familial atypical multiple mole melanoma (FAMMM). Patient Educ Couns. 2009;75(2):251-255. 14. Azzarello LM, Dessureault S, Jacobsen PB. Sun-protective behavior among individuals with a family history of melanoma. Cancer Epidemiol Biomarkers Prev. 2006;15(1):142-145. 15. Institute of Medicine. Partnering With Patients to Drive Shared Decisions, Better Value, and Care Improvement: Workshop Proceedings. Washington, DC: The National Academies Press; 2014.
(Reprinted) JAMA Dermatology February 2015 Volume 151, Number 2
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a Nanyang Technological University User on 05/21/2015
129
