Skin cancer is one of the commonest

Skin cancer is
one of the commonest malignancies in the United Kingdom(UK) population, and the
prevalence is increasing1. In 2013, there were 14,509 new cases of
malignant melanoma and 72,100 new cases of non-melanoma skin cancers (Basal
cell carcinoma and Squamous cell carcinoma accounting for the majority of these)2.

Other than a significant health burden to the society, skin cancer also
represents a strain to the National Health Service (NHS) resources, with an
average cost for each malignant melanoma case being £2607 and for each non-melanoma skin
cancer £889 (overall cost of approximately £102
million in 2013)3,4.  The
optimal method to reduce the morbidities, mortalities and subsequent costs of
skin cancer is the early recognition and treatment of these lesions. Treatment
delay leads to increased tumour size and higher rates of metastasis, and their
surgical management leads to more extensive and disfiguring surgical excisions5.

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It is therefore vital to explore safe, efficient and fast dermatological methods
of early detection and diagnosis of skin cancers. One such method is the
patients use of dermatology smartphone applications6. There are
currently over 230 smartphone dermatology applications (‘apps’) encompassing a
great spectrum of functions, including photography-based diagnosis of skin
lesions, databases for information of dermatological conditions or apps that facilitate
patient self-monitoring. Since skin condition diagnosis is largely based on
visual examination, digital photography may provide an efficient method of promoting
the prompt identification of malignancies, resulting into better patient
outcomes. The aim of this essay is to explore the effectiveness of the current patients’
use of smartphone applications in dermatology in terms of their ability to
prevent or to readily identify potential skin malignancies and their potential
to be part of the future of dermatological healthcare provision.

 

            A common
type of dermatological smartphone applications (17.4%) are those created for
self-surveillance and diagnosis of skin lesions6. These allow the
user to upload a photographic image of their skin lesion, and then receive
feedback on the malignancy potential of the lesion based on dermatologist or algorithm-based
feedback. Smartphone applications using an algorithm to provide feedback (by
analysing photographs of moles and using a pattern recognition software) may
then assist a non-clinically trained individual to make decisions on whether
the lesion is malignant and may require further follow up or treatment. This
technology may therefore increase rates of self-detection of skin malignancies
and may reduce avoidable consultations in primary care for non-malignant
lesions and their subsequent strain to NHS resources. These applications may
also increase access to health and care in the most rural parts of the country,
where access to a dermatology specialist is more limited. However, the benefits
of these applications are largely theoretical, without published evidence of
their effectiveness in reducing number appointments or healthcare costs.

 

In the contrary, concerns have been
raised for the safety of this technology over its remarkably low accuracy and
the publics overconfidence in using such applications as a substitute for
medical advice8. In a study of the 4 most popular tested
applications claiming the ability to assists users in determining the
malignancy of a lesion, it was found that their effectiveness is suboptimal and
unsafe. After uploading the photographs 188 diagnosed cutaneous lesions (60
melanoma cases and 128 benign lesions) to the most popular dermatology apps,
the results illustrated that for melanoma diagnosis, the sensitivity of these
applications ranged from 6.8% to 98.1% and the specificity from 30.4% to 93.7%.

Notably, the highest sensitivity of identification of malignant lesions was
found in apps in which photographs were examined by a dermatologist, and the
lowest for the apps using a pattern – recognition algorithm. However, neither
demonstrated the accuracy required to provide safe and high-quality care, and
may even be hazardous if used in confidence as an alternative to medical advice,
delaying necessary early medical care and increasing the prevalence of
morbidities of skin cancers.

 

Another common category of dermatology
smartphone applications is designed to provide the user with easy access to information
on skin conditions for the purposes of patient education (26% up to 33% of all
dermatology apps)7,10. These allow patients and general public to
access information, ranging from databases common dermatological conditions to
complete dermatology textbooks, or lifestyle advice, such as on how to reduce
Ultraviolet Radiation (UVR) exposure.  Through
this access to information, patients may expand their understanding of their
skin condition and become more involved in their recommended management and
care11,12. Dermatology apps may therefore promote a sense of
responsibility of the patients’ own management, promoting self-care and prevention
of risk factors for skin malignancies, subsequently reducing their incidence. This
may be achieved by promoting approved apps to patients that have already been consulted
by a healthcare professional, since information alone is unlikely to improve
long-term self-management of the patients’ condition in primary care13,14.

 

 

The information provided by these
apps, however, is largely unregulated. Any software engineer may create an app
and control its content, which results in the lack of sufficient academic
reference in the information provided. This may be as low as one peer-reviewed
reference for a whole app database, resulting to misleading claims and non-evidence
based patient advice15. Further, some apps have not been updated for
years, thus provide out-of-date information without incorporating new evidence
into their databases. This is a potential threat to patient safety, as possibly
inaccurate advice may be followed by users.

 

Another common category of dermatology
apps is involved with the monitoring of already existing lesions through the
storage of serial digital images over long periods of time10. This visual
evidence is potentially useful for the dermatologist to identify malignancies,
as it provides more information and may be more accurate than a patients’
history of presenting complaint. These may then also be given by the patient to
the responsible clinician, with particular caution over informed consent and
confidentiality along the UK guidelines of the use of mobile photographic
devices in dermatology16. These digital images may then help the
dermatologist create a clinical record which will assist the early
identification of malignancies by their progression and ensuring high quality
service and continuity of care. In doing so, however, it is important for the
doctor to ensure the images are of high quality to avoid adverse patient care.

 

It is important to also consider the
patient views on the use of mobile apps for dermatology and to evaluate whether
the aforementioned services are preferred over traditional patient-doctor
consultations without smartphone apps. The majority of owners of health-related
apps found these beneficial, and the majority of the public indicates that they
believe they have led to healthier behaviour change17. Applied to dermatology,
the aforementioned application uses may promote a preventative health behaviour
in relation to skin cancers, such as reducing UVR exposure and close monitoring
of new skin lesions. It is important to note, however, that only 24% of
smartphone owners have downloaded and used a health-related app, demonstrating
that the levels of awareness of these is still low. It is also unknown as to
whether perceived behaviour change correlates with actual behaviour change in
dermatological patients.

 

It is therefore evident that health
related apps are perceived as beneficial by the public, but the quality of
existing dermatology apps is suboptimal. This indicates that an intervention to
improve the regulation of standards of available smartphone applications may be
widely adopted and used by patients. A method of doing this is through the centralisation
of apps into a single high quality, validated and up-to-date national
smartphone application, created by a national body such as British Society of
Dermatological Surgery or NHS. This may include most of the aforementioned uses,
including up-to-date information and advice for dermatological conditions and a
confidential software for self-monitoring of lesions. This may then be
recommended by general practitioners and dermatologists, increasing awareness
and promoting primary prevention and self-monitoring. After launch, it would be
prudent to evaluate the apps effectiveness in terms of leading to beneficial
behaviour change, as its continuous software and content updates is likely to
be costly.

 

Regarding the software for risk
stratification of lesions, the evidence suggests that apps using pattern
recognition are inaccurate and possibly even hazardous, and thus should be
avoided. Apps that allow the patient to directly communicate with a
dermatologist tend to have higher specificity and sensitivity, but are still of
suboptimal standard and a potential threat to patient safety. An alternative
use of this technology may, however, increase access to specialist advice and
provide higher quality care. This may be achieved through the use of these apps
by healthcare professionals in the form of teledermatology, instead of patients
using them without specialised input. This has been suggested in a study in
Devon after evaluating the effectiveness of a specialised nurse-led community
dermatology service in 500 patients9. After assessment, a referral form
was subsequently sent to a dermatologist with an accompanied digital photograph
of the skin lesion. This resulted into 42% of the patients being referred back
to their GP with a management plan, 28% being booked directly into a skin
surgery list, and the remainder 30% being booked for an outpatient appointment.

The service acts to collect the relevant clinical history, and through using
digital services, provides a complete and coherent report of the patient
condition. This may provide increased access to specialised advise (as there is
a dermatologist input for every case), and possibly earlier identification and
treatment of skin cancers. Further cost-analysis of this intervention is needed
to assess its viability, as during this intervention the number of total
referrals increased by 20%, making it a less sustainable option in resource restrained
rural areas.

 

In conclusion, the current patients’
use of apps is a cause of concern in skin cancer identification and management.

The technology marketed in freely available apps in stratifying the risk of the
lesions malignancy is highly unreliable, providing false re-assurance that may
prove to be detrimental when used instead of medical advice. Further, the
information provided for risk minimisation and healthy behaviours is
out-of-date and unreferenced to available medical literature. Patients’ use of
apps, however, has the potential to act as an integral part of healthcare
provision through the creation of a new high-quality, up-to-date new
application created by a national UK body. Healthcare apps are perceived as
beneficial by the public, and may therefore lead to engagement of protective
behaviours, reducing the incidence of skin cancers and may also increase access
to specialised advice and lead to faster diagnosis once a patient is already
affected.