An interview with a dermatologist on skin cancer
“The problem with skin cancer is that many people wait too long to check suspicious skin lesions. A consultation may also take longer than expected, because it is so difficult to get an appointment with a dermatologist. One way to shorten the wait is to allow the specialists to make a rapid assessment looking at digital images with a short description online.”
According to Dr John Paoli, specialist in skin cancer surgery at the Sahlgrenska University Hospital in Gothenburg, this is an efficient way to get the right patients to clinic in time.
Malignant melanoma is less common than both squamous cell carcinoma and basal cell carcinoma, but it is far more dangerous. Out of the 3000 Swedes who get this diagnosis every year, at least one out of ten will die within the next ten years. Most of these people could have been saved if the melanoma had been removed in time.
The long wait for a dermatologist appointment
There are several reasons why patients with malignant tumors come in for surgery too late. For one, it can be difficult to motivate yourself to see a doctor about a mole which you have noticed at times, but that does not give any major symptoms or disturb your daily rhythm.
John Paoli and his colleagues see lots of cases where the partner, or family, has tried to encourage the patient to go and check a mole or a blemish, but when it finally happens, it’s too late:
And even if a person seeks treatment, the administration procedures may take longer than expected. If the lesion looks alarming, the patient is often referred to a dermatologist. The wait to see a specialist is usually two to three months, depending on how the referral is written, and in which area the patient lives.
In Sweden, there are only about 350 dermatologists in total, many of whom work part time. It’s not easy to get an appointment. Also, it is difficult for a dermatology clinic to prioritize the most urgent cases because the referrals are often too brief, with short notes such as “suspicious mole on the leg”.
Moles can be removed immediately in the general practitioner’s office. Unfortunately, most “just-in-case” surgeries are done in vain, as most lesions are benign. Still, every lesion has to be sent for analysis. And since there are so many samples submitted, there will be a waiting period even in the pathology department where these are to be analyzed. It usually takes at least a month before the referring doctor gets the test results.
This is an unnecessary bottleneck, say Dr John Paoli:
If the dermatologist is given a chance to assess the changes from the very start, fewer unnecessary surgeries will be performed, and thus there will be a shorter wait for analysis. Today, many people have harmless moles removed just-in-case, also resulting in unnecessary scars.
Digital image assessment in an ongoing research prjoject
At Sahlgrenska and Skaraborg Hospital, on the west coast of Sweden, there is an ongoing research project based on the same idea as iDoc24’s advice service – dermatologists make an initial assessment online with the use of an iPhone and a dermoscope attachment. However, in this case, it is not the patient who sends in the picture and the description, but the regional family doctor. The family doctor receives a rapid consultation from a dermatologist with specialist training in dermoscopy.
The family doctor sends in a comprehensive description of the patient’s skin lesion, together with two images: An image of the lesion as it looks to the naked eye, and an image which is provided through a dermoscope, a special instrument with a magnifying glass and a lamp.
Within a few hours, the family doctor receives an answer on whether the patient should have a referral for emergency surgery (within about two weeks), or whether the lesion looks harmless. Often, the answer may be something in between – the spot looks harmless but the patient should be scheduled for a face to face visit within a few months to check that the lesion does not change or grow.
Currently, four dermatologists are actively assessing the consultations. Their assessments has so far proved more reliable than those usually made based on standard paper referrals from health centers. About 8% of the referrals in this project have been diagnosed with malignant melanoma, and diagnoses have been verified with an analysis.
Anonymous data over networks or phones
How can the patient data of a skin lesion be sent securely over the Internet? This problem has been solved using the iDoc24 technology, explains John Paoli:
In the first consultation, no personal data is sent in; the patient therefore remains anonymous to the assessing dermatologist. If the referral advises that the patient should be seen by the dermatology department, the family doctor will send in a traditional consultation with all relevant patient information via fax machine.
The preliminary research findings – from 450 patients – indicate that the system with an initial long-distance assessment is working out very well. Both length of waits and the number of unnecessary treatments decrease. The “right” patients hopefully receive the right care, at the right time.
The service offered by iDoc24 is also based on digital images. A photo is taken with a mobile telephone and sent off to the experts together with a description of the skin lesion. The dermoscopy image is not included here, but a dermatologist can still provide an indication on whether the patient should seek medical attention immediately or not.
It’s about counseling, and an anonymous one – therefore, a person who has used iDoc24’s service will not be automatically prioritized in healthcare. However, it is a good idea to tell the family doctor or dermatologist that you have already received an initial assessment from iDoc24 when booking an appointment. Also, it could be of help to bring the statement when vistiting the doctor.
Diagnosing more accurately – the future of technology
The best practice would be if everyone who has a suspicious skin lesion could get a quick face-to-face appointment with a dermatologist, according to John Paolis.
But unfortunately, dermatologists are scarce and can not accommodate the increasing number of patients. Teledermatology, an initial assessment via a mobile telephone, can filter the right patients to the right care. Teledermatology is probably at least as accurate as if you go to your local health center and meet with your family doctor. There are studies that show that a family doctor can only diagnose half of the cases when looking at the 20 most common skin diseases, while a dermatologist gets the diagnosis right it in at least nine out of ten cases. A dermatologist at a distance may very well prove to be better at assessing a skin lesion than a family doctor who examines you physically.
John Paoli believes that a rapid assessment of skin conditions from a distance will become more common in the future. And the technique does not only apply to potentially dangerous skin lesions.
This kind of service is excellent for cases of sexually transmitted infections (STIs) that may cause embarrassment, infections of the skin that need to be treated with antibiotics, eczema in young children, and many other skin conditions.