Anna Finnane

Lymphedema after breast or gynecological cancer : use and effectiveness of mainstream and complementary therapies

OBJECTIVES The purpose of this study was to describe the use, as well as perceived effectiveness, of mainstream and complementary and alternative medicine (CAM) therapies in the treatment of lymphedema following breast or gynecological cancer. Further, the study assessed the relationship between the characteristics of lymphedema (including type, severity, stability, and duration), and the use of CAM and/or mainstream treatment. METHODS This was a cross-sectional study using a convenience sample of women with lymphedema following breast and gynecological cancers. A self-administered questionnaire was sent to 247 potentially eligible women. Of those returned (50%), 23 were ineligible and 6 were excluded due to level of missing data. RESULTS In the previous 12 months, the majority of women (90%) had used mainstream treatments to treat their lymphedema, with massage being the most commonly used (86%). One (1) in 2 women had used CAM to treat their lymphedema, and 98% of those using CAM were also using mainstream treatments. Over 27 types of CAM were reported, with use of a chi machine, vitamin E supplements, yoga, and meditation being the most commonly reported forms. The perceived effectiveness ratings (1-7 with 7=completely effective) of mainstream (mean±standard deviation (SD): 5.3±1.5) and CAM therapies (mean±SD: 5.2+1.6) were considered high. CONCLUSIONS These results demonstrate that mainstream and CAM treatment use is common, varied, and considered to be effective among women with lymphedema following breast or gynecological cancer. Furthermore, it highlights the immediate need for larger prospective studies assessing the inter-relationship between the use of mainstream and CAM therapies for treatment success.

Cost-effectiveness of Store-and-Forward Teledermatology: A Systematic Review

IMPORTANCE Teledermatology is a topical clinical approach being tested in Australia and elsewhere. With most dermatologists residing in metropolitan areas, teledermatology provides an apparent low-cost and convenient means of access for individuals living outside these areas. It is important that any proposed new addition to a health care system is assessed on the grounds of economic cost and effectiveness. OBJECTIVE To summarize and evaluate the current economic evidence comparing store-and-forward teledermatology (S&FTD) with conventional face-to-face care. EVIDENCE REVIEW Search terms with appropriate amendments were used to identify S&FTD articles that included economic analysis. Six databases were searched, and title, abstract and full-text reviews were conducted by 2 researchers. References of all unique returned articles were searched by hand. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used to evaluate quality of the included articles. FINDINGS Eleven articles were selected for inclusion, including 1 cost analysis, 4 cost-minimization analyses, 4 cost-effectiveness analyses, and 2 cost-utility analyses. CHEERS scores ranged from 7 to 21 out of a possible 24 points, with a median score of 17. CONCLUSIONS AND RELEVANCE Current evidence is sparse but suggests that S&FTD can be cost-effective. It appears to be cost-effective when used as a triage mechanism to reduce face-to-face appointment requirements. The cost-effectiveness of S&FTD increases when patients are required to travel farther distances to access dermatology services. Further economic research is required for the emerging S&FTD, which uses dermoscopes in combination with smartphone applications, as well as regarding the possibility and consequences of patients self-capturing and transmitting images.

Teledermatology for the Diagnosis and Management of Skin Cancer: A Systematic Review

Importance As technology becomes more commonplace in dermatological practice, it is essential to continuously review the accuracy of teledermatology devices and services compared with in-person care. The last systematic review was conducted over 5 years ago. Objective To synthesize and assess the quality of the evidence to address 3 research questions: (1) How accurate is teledermatology for skin cancer diagnosis compared with usual care (face-to-face [FTF] diagnosis)? (2) Does teledermatology save clinician and/or patient time, compared with usual care? (3) What are the enablers and barriers to adoption of teledermatology in clinical practice for the diagnosis of skin cancer? Evidence Review The review protocol was registered in the PROSPERO database. Six databases (Cochrane, PubMed, Medline, Science Direct, Embase, and Web of Science) were searched for studies investigating the diagnostic accuracy and concordance, management accuracy and concordance, measures of time (waiting times, delay to diagnosis), and enablers and barriers to implementation. Potentially eligible articles were screened by 2 reviewers. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to evaluate the risk of bias and applicability of individual studies assessing diagnostic accuracy. Findings Twenty-one studies were reviewed. The diagnostic accuracy (defined as agreement with histopathology for excised lesions or clinical diagnosis for nonexcised lesions) of FTF dermatology consultation remains higher (67%-85% agreement with reference standard, Cohen &kgr;, 0.90) when compared with teledermatology (51%-85% agreement with reference standard, &kgr;, 0.41-0.63), for the diagnosis of skin cancer. However, some studies do report high accuracy of teledermatology diagnoses. Most studies of diagnostic accuracy and concordance had significant methodological limitations. Studies of health service outcomes found teledermatology reduced waiting times and could result in earlier assessment and treatment. Patients reported high satisfaction and were willing to pay out of pocket for access to such services. Conclusions and Relevance Robust implementation studies of teledermatology are needed, paying careful attention to reducing risk of bias when assessing diagnostic accuracy. Teledermatology services consistently reduced waiting times to assessment and diagnosis, and patient satisfaction was high.

Review of the evidence of lymphedema treatment effect.

ABSTRACTLymphedema treatment aims to alleviate symptoms, prevent progression, and reduce risk for skin infection. Mainstream treatment options have been investigated in more than 160 studies. Findings from these studies have been included in at least 1 of more than 20 literature reviews. A critique of these reviews was undertaken to summarize efficacy findings. The quality of the reviews was evaluated, and gaps in the research were identified to better guide clinical practice. Overall, there was wide variation in review methods. The quality of studies included in reviews, in study design and reporting overall, has been poor. Reviews consistently concluded that complex physical therapy is effective at reducing limb volume. Volume reductions were also reported after the use of compression garments, pumps, and manual lymphatic drainage. However, greatest improvements were reported when these treatments formed a combined treatment program. Large, well-designed, evaluated, and reported randomised, controlled trials are needed to evaluate and compare treatments. Consistent outcome measures will allow better quality reviews and meta-analysis in the future.

Efficacy of smartphone applications in high-risk pigmented lesions

Melanoma apps are smartphone applications that assess risk of pigmented lesions using a smartphone camera and underlying algorithm. We aimed to assess the capability of melanoma smartphone applications (apps) in making clinical decisions about risk, compared with lesion assessment by specialist trained dermatologists.

Proposed Technical Guidelines for the Acquisition of Clinical Images of Skin-Related Conditions

Importance Standardizing dermatological imaging is important to improve monitoring of skin lesions and skin conditions, ensure the availability of high-quality images for teledermatology, and contribute to the development of a robust archive of skin images to be used for research. Objective To provide guidelines for the clinical application of the Standards for Dermatological Imaging set forward by the ISIC. Evidence Review The ISIC recommendations were developed through a hybrid Delphi methodology. The methods for achieving consensus have been described previously. The practical application of these recommendations was evaluated by 2 clinical photographers with expertise in skin imaging. Images corresponding to each recommendation were taken by a clinical photographer and provided as visual examples of how these recommendations can be implemented in clinical practice. Results The Standards for Dermatological Imaging developed by the ISIC members could be followed in the clinical setting. Images showing appropriate lighting, background color, field of view, image orientation, focus and depth of field, resolution, and scale and color calibration were obtained by the clinical photographer, by following the detailed recommendations for regional, close-up and dermoscopic images. Conclusions and Relevance Adhering to the recommendations is both feasible and achievable in practice. Adopting these Standards is the first step in achieving international standardization of skin imaging, with the potential to improve clinical outcomes and research activities.

The growth of a skin emergency teledermatology service from 2008 to 2014.

To conduct an audit of the Skin Emergency Telemedicine Service at Princess Alexandra Hospital in Brisbane from January to December 2014, and determine whether there has been any change in the number, type and location of referrals.

Technique Standards for Skin Lesion Imaging: A Delphi Consensus Statement

Importance Variability in the metrics for image acquisition at the total body, regional, close-up, and dermoscopic levels impacts the quality and generalizability of skin images. Consensus guidelines are indicated to achieve universal imaging standards in dermatology. Objective To achieve consensus among members of the International Skin Imaging Collaboration (ISIC) on standards for image acquisition metrics using a hybrid Delphi method. Evidence Review Delphi study with 5 rounds of ratings and revisions until relative consensus was achieved. The initial set of statements was developed by a core group (CG) on the basis of a literature review and clinical experience followed by 2 rounds of rating and revisions. The consensus process was validated by an extended group (EG) of ISIC members through 2 rounds of scoring and revisions. In all rounds, respondents rated the draft recommendations on a 1 (strongly agree) to 5 (strongly disagree) scale, explained ratings of less than 5, and optionally provided comments. At any stage, a recommendation was retained if both mean and median rating was 4 or higher. Results The initial set of 45 items (round 1) was expanded by the CG to 56 variants in round 2, subsequently reduced to 42 items scored by the EG in round 3, yielding an EG set of 33 recommendations (rounds 4 and 5): general recommendation (1 guideline), lighting (5), background color (3), field of view (3), image orientation (8), focus/depth of field (3), resolution (4), scale (3), color calibration (2), and image storage (1). Conclusions and Relevance This iterative process of ratings and comments yielded a strong consensus on standards for skin imaging in dermatology practice. Adoption of these methods for image standardization is likely to improve clinical practice, information exchange, electronic health record documentation, harmonization of clinical studies and database development, and clinical decision support. Feasibility and validity testing under real-world clinical conditions is indicated.

Smartphone diagnosis of skin cancer: there's not yet an app for that

Mobile health technology is growing at such speed that it is difficult to regulate. Mobile applications that seek to serve as diagnostic tools without the input from qualified medical professionals are rightfully scrutinized because of concerns for patient safety. While companies producing the large number of health apps that are designed to assist consumers to track their own health information, share information with health professionals or interact with electronic health records are not required to list their apps with the U.S. Food and Drug Administration (FDA), the FDA does regulate the development of all apps that are intended for diagnostic, treatment or prevention purposes. Dermatology is an obvious speciality for health-related app developers to explore, because the skin is so easily visible and smartphones with high-quality in-built cameras are becoming commonplace. Melanoma and skin cancer have received particular attention from the commercial sector, with a large number of apps currently available. The potential of such devices and apps to speed up consultation processes, triage lesions more effectively and facilitate early detection of skin cancers is both exciting and appealing. Considering the majority of melanomas are found by patients or their partners, any technology that can improve the ability of the general population to identify suspicious or changing lesions early could have enormous benefits. However, until these apps have been rigorously tested and found to have high sensitivity and specificity, it remains inappropriate to support their use. It is possible that such apps could contribute to dangerous, false reassurance in patients and/or increases in unnecessary excisions. Researchers and clinicians have previously submitted images of lesions to a number of individual apps, and these studies have confirmed the limited sensitivity and in some cases very low specificity for diagnosing melanoma. In this issue of the BJD, Kassianos and colleagues review the 39 available apps that aim to improve detection of melanoma. The authors evaluate the content of the apps as well as the evidence used to support their development. The apps varied significantly in their purpose, with some focusing on the provision of information and prevention advice, and others offering assessment of lesions either using an in-built algorithm or sending images to a specialist. Perhaps of greatest concern is the finding that none of the apps appeared to have been validated for diagnostic accuracy or utility using established research methods. However, the authors conducted their evaluation using the information provided by app developers in their app description and did not download the full versions of the apps. It is possible the app developers neglected to include such information in their app description, even if the research had been done. The improved prognosis when melanoma is detected early provides enough reason to continually improve these new technologies, rather than resist them. The International Skin Imaging Collaboration (ISIC) Melanoma Project is bringing together experts in dermatology and bioinformatics who are committed to keeping up with the pace of technology development in medicine. The establishment of a large, publicly available archive of skin images, as well as efforts to standardize the terminology, technology and imaging techniques used in the clinical imaging of skin lesions are the focus of ISIC, and will support the development and subsequent testing of high-quality mobile medical applications. Ongoing comparison of these apps with the current gold standard of face-to-face assessment by dermatologists and store-and-forward teledermoscopy using carefully designed studies is necessary and important research. In our estimation, this technology is a disruptive innovation and has the potential to save clinician time, reduce patient burden, reduce healthcare costs and potentially enable more effective triage and earlier detection of skin cancers.

Outreach dermatology services provided by telehealth: Enabling access to specialist dermatology care for patients in regional and rural areas

Results: Over the study there were 25,313 patient visits with 480,085 lesions reviewed. There were 1743 clinical diagnoses of melanoma made by a dermatologist. Patients self-reported 18,608 lesions of concern, of which 414 had been diagnosed as suspicious of melanoma (OR 1:45), indicating 76% of clinically diagnosed melanomas were missed by patients. The majority of melanomas not detected by patients were located on the back of the body.