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Early detection of melanoma in high-risk individualsThe role of partner assistance and physician support of skin self-examination Annett Körner, PhD, Julia DiMillo, MA, PhD(c), Zofia Czajkowska, MA, PhD(c), Adina Coroiu, MA, and Robin Canuel, MLIS, McGill University, Montreal

AbstrAct

Cutaneous melanoma is the fastest growing skin cancer, yet is highly curable when detected early. Skin self-examination is essential to melanoma fol-

lowup care, as it leads to earlier detection of recurrences. Survivors of early-stage melanoma live with a strong risk for subsequent melanomas, but only a minority practices monthly whole-body exams.

Our study of barriers and facilitators of skin self-exam-ination found that physician support was related to stronger intentions and greater self-efficacy for this potentially life-saving health behaviour. Yet about one-third of the patients

reported that skin self-exams did not seem important to their physician. Being encouraged and assisted with self-exams by an intimate partner also increased self-efficacy. Receiving the dermatologic education together with one’s partner was particularly beneficial for patients who were less comfortable with partner-assisted skin exams at home.

This research aims at improving educational interven-tions for high-risk individuals and healthcare professionals to facilitate the earlier detection of melanoma and thus reduce mortality.

Keywords: Melanoma, skin self-examination, early detection

bAckgroundCutaneous melanoma is the deadliest and fastest growing tumour of the skin, with almost 60% of melanomas occur-ring in younger and middle-aged individuals.1 Melanomas

Annett körner, Phd, is an Associate Professor in the Counselling Psychology Program and the Department of Oncology at mcGill University. She holds appointments as a research Associate at the Lady Davis Institute, the Segal Cancer Centre, and the mcGill University Health Centre (mUHC). Julia diMillo, MA, Phd(c), is a doctoral student in the Counselling Psychology Program at mcGill University and a member of Dr. Körner’s Health Psychology research Group, writing her dissertation on partner involvement in skin self-examination among patients with melanoma.Zofia czajkowska, MA, Phd(c), is a doctoral student in the Counselling Psychology Program at mcGill University and a member of Dr. Körner’s Health Psychology research Group, writing her dissertation on physician support of skin self-examination among patients with melanoma.Adina coroiu, MA, is a doctoral student in the Counselling Psychology Program at mcGill University and a member of Dr. Körner’s Health Psychology research Group who contributed to the selection of the measures for this project and has been overseeing data collection and management.robin canuel, MLIs, is the Liaison Librarian for Psychology and Anthropology Programs in the Humanities and Social Sciences Library at mcGill University who contributed to the literature review for this project.

are able to metastasize at a depth of 1mm, while most other human cancers do not metastasize before reaching 1cm2. Despite melanoma being visible, recognizable, and relatively easy to cure in its early stages, there are no effective treatment options once the tumour has spread. However, melanoma develops with a significant preclinical phase, making it conducive to detection and treatment while in its curable stage. Hence, early detection and excision of the melanoma is one of the most effective measures to decrease melanoma-related mortality in high-risk populations.3 In practice, most melanomas are self-detected, and skin self-examination has been associated with earlier detection and a reduced risk of mortality.4

A personal history of melanoma is a strong risk factor for subsequent melanomas. Compared to the general popula-tion, a survivor of stage I or II melanoma is 25 times more likely to be diagnosed with a second primary melanoma within 5 years.5 Consequently, worldwide clinical care guidelines strongly advocate monthly skin self-exams as an essential part of melanoma followup care.6 Only a minority of individuals at risk for melanoma practice thorough self-exams on a regular basis,5,7 and little is known about why individuals do not adopt this potentially life-saving behav-iour. This is especially surprising since the most prevalent coping strategies of patients in melanoma followup care are “to trust their doctors and to follow medical advice exactly.”8 This gap between intention and practice is acknowledged, but there is little research on potentially important psycho-social factors in melanoma survivor behaviour, such as dis-tress, coping strategy, or partner and physician support.

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One focus of McGill’s Health Psychology Research Group (HPRG) is the secondary prevention of melanoma through early detection via skin self-examination. An ongoing project funded by the Fonds de Recherche du Québec, Santé (FRQS), the Ride to Conquer Cancer initiative, and the Canadian Institutes of Health Research (CIHR) aims to investigate the psychosocial barriers to, and facilitators of adherence to, medical advice regarding the practice of skin self exami-nation (SSE) among individuals at high risk for melanoma.9

MAterIALs And MethodsA longitudinal study with 5 assessment points is currently underway at 2 university-affiliated hospitals in Montréal (Québec). Participants filled out baseline questionnaires at Time 1 and received a dermatologic education session at Time 2 on how to effectively examine skin for early signs of melanoma. Followup assessments at 3 months (Time 3), 12 months (Time 4), and 24 months (Time 5), document the uptake of skin self-examination practice following dermato-logic education. Self-report measures to assess variables hypothesized to affect adherence to this health-protective behaviour (e.g., distress, fear of tumour recurrence, coping strategies, physician and partner support, comfort with being assisted with skin self-exams, empowerment, imple-mentation intentions, and self-efficacy for skin self-exami-nation), are also being administered at various time points. Illness-related information, such as melanoma stage and depth, as well as subsequent melanoma diagnoses, is being retrieved from hospital medical records and tumour registries.

resuLtsPreliminary analyses conducted with 242 participants showed that physician support of skin self-examination is related to higher self-efficacy for this health behaviour and to higher intentions to perform self-exam over the follow-ing 12 months. Yet about 1/3 of patients reported that skin self-examination did not seem important to their phy-sician. Less than 2/3 of the study participants reported having been advised by their physician to perform self-exams on a regular basis. Finally, about 1/2 of the sample reported that they had not been advised to examine their whole body, or that they should seek someone else’s help to examine hard-to-see areas of their body.10

The 137 participants who were involved in an intimate relationship during the study reported higher self-efficacy when their partners were supportive of skin self-examina-tion (i.e. reminding, encouraging or assisting the patient). Comfort with having one’s partner assist with the skin exams, including the examination of sexually sensitive and hard-to-see areas of the body, was found to predict patient self-efficacy. Moreover, patients who reported less comfort with being assisted by their partner showed increased self-efficacy when their partner was present at the dermatologic education session. Relationship quality and general illness support, which were also assessed, did not predict the patients’ self-efficacy for skin examination.11

dIscussIon And concLusIonsThese findings illustrate how the practice of skin self-exami-nation can be affected by the support provided by impor-tant individuals in patients’ lives. For instance, a physician’s support for self-exam may impact patients’ intentions to engage in this health behaviour. Furthermore, learning about melanoma prevention through dermatologic educa-tion provided to the patient and their intimate partner appears to affect patient self-efficacy. While general illness support provided by an intimate partner and relationship satisfaction were found to be unrelated to self-efficacy for skin-exam, patients who reported less comfort with part-ner-assisted self-exam were especially likely to benefit from their partner being included in the education session.

As the project progresses and the practice of skin self-exam is recorded over time, the study findings will inform healthcare professionals who strive to better address patient difficulties in adhering to this life-saving health behaviour. Consequently, these findings may guide secondary preven-tion strategies in other high-risk populations, such as per-sons with dysplastic nevi, those with a great number of moles, or those with a family history of nonmelanoma skin cancer.

references1. Horner MJ, Ries LAG, Krapcho M, et al. SEER Cancer Statistics Review, 1975-

2006. Bethesda, MD: National Cancer Institute;2009.2. Yang EV, Kim SJ, Donovan EL, et al. Norepinephrine upregulates VEGF, IL-8, and

IL-6 expression in human melanoma tumor cell lines: implications for stress-related enhancement of tumor progression. Brain Behav Immun 2009;23(2):267-275.

3. Markovic SN, Erickson LA, Rao RD, et al. Malignant melanoma in the 21st century, part 1: Epidemiology, risk factors, screening, prevention, and diagnosis. Mayo Clin Proc 2007;82:364-380.

4. Geller AC, Swetter SM, Brooks K, Demierre MF, Yaroch AL. Screening, early detection, and trends for melanoma: Current status (2000-2006) and future directions. J Am Acad Dermatol 2007;57:555-572.

5. Mujumdar UJ, Hay JL, Monroe-Hinds YC, et al. Sun protection and skin self-examination in melanoma survivors. Psychooncology. 2009;18(10):1106-1115.

6. Trotter SC, Sroa N, Winkelmann RR, Olencki T, Bechtel M. A Global Review of Melanoma Follow-up Guidelines. J Clin Aesthet Dermatol 2013;6(9):18-26.

7. Manne S, Lessin S. Prevalence and correlates of sun protection and skin self-examination practices among cutaneous malignant melanoma survivors. J Behav Med 2006;29:419-434.

8. Körner A, Augustin M, Zschocke I. [Health behaviors of skin cancer patients in melanoma follow-up care]. Z Gesundh 2011;19(1):2-12.

9. Körner A, Drapeau M, Thombs BD, et al. Barriers and facilitators of adherence to medical advice on skin self-examination during melanoma follow-up care. BMC Dermatol 2013;13:3.

10. Czajkowska Z, Khanna M, Chawla N, Körner A. The role of medical advice for secondary prevention of melanoma–patients’ intentions and adherence. Poster presented at the Annual Convention of the American Psychological Association. 2014; Washington, DC.

11. DiMillo J, Brosseau DC, Gomez-Garibello C, et al. Self-efficacy and comfort with partner-assisted skin examination in patients at high risk for melanoma recurrence. Submitted.