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e-Health Tools for Targeting and Improving Melanoma Screening: A Review

e-Health Tools for Targeting and Improving Melanoma Screening: A Review Hindawi Publishing Corporation Journal of Skin Cancer Volume 2012, Article ID 437502, 8 pages doi:10.1155/2012/437502 Review Article e-Health Tools for Targeting and Improving Melanoma Screening: A Review 1 2 2 Abhilasha Tyagi, Kimberly Miller, and Myles Cockburn Keck School of Medicine of USC, Los Angeles, CA 90089, USA Department of Preventive Medicine, Keck School of Medicine of USC, Los Angeles, CA 90089, USA Correspondence should be addressed to Myles Cockburn, mylesc@usc.edu Received 10 August 2012; Accepted 22 October 2012 Academic Editor: Silvia Moretti Copyright © 2012 Abhilasha Tyagi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The key to improved prognosis for melanoma is early detection and diagnosis, achieved by skin surveillance and secondary pre- vention (screening). However, adherence to screening guidelines is low, with population-based estimates of approximately 26% for physician-based skin cancer screening and 20–25% for skin self-examination. The recent proliferation of melanoma detection “e- Health” tools, digital resources that facilitate screening in patients often outside of the clinical setting, may offer new strategies to promote adherence and expand the proportion and range of individuals performing skin self-examination. The purpose of this paper is to catalog and categorize melanoma screening e-Health tools to aid in the determination of their efficacy and potential for adoption. The availability and accessibility of such tools, their costs, target audience, and, where possible, information on their effi- cacy, will be discussed with potential benefits and limitations considered. While e-Health tools targeting melanoma screening are widely available, little has been done to formally evaluate their efficacy and ability to aid in overcoming screening barriers. Future research needs to formally evaluate the potential role of e-Health tools in melanoma prevention. 1. Introduction individuals [6], whereas observational studies have found evidence that both physician-based screening and SSE result While the rates of many cancers are declining, melanoma in detection of thinner melanomas and, as a result, decreased rates are increasing worldwide [1]. In the United States, mortality [7–9]. melanoma rates in white populations have been increasing by Despite these findings, and possibly due in part to con- 2.4% annually [2]. Despite improved survival, mortality and flicting guidelines, skin screening rates for melanoma remain morbidity remain significant for melanoma. Prevention low in the general population. According to data from the efforts are thus critically important for this aggressive and National Health Interview Survey (NHIS), physician-based often rapidly fatal disease [3]. screening rates are estimated at 16.5% in the US [10]. Skin Secondary prevention of melanoma is recommended as self-examination estimates range between 20% and 25% the disease is more easily treated and survival dramatically [11]; however, these rates depend on the definition of SSE. improved with early detection [4, 5]. Secondary prevention When thoroughness or frequency of exam is included in of melanoma is achieved by screening and skin surveillance variable measurement, SSE rates substantially decrease to as performed by a clinician (dermatologist or other healthcare low as 7–9% [12, 13]. professional) or skin self-exam (SSE) performed by the indi- While early detection is key to improved melanoma vidual. However, the value of population-based skin screen- survival in general, individuals in certain populations are at ing in melanoma prevention remains controversial. The US increased risk of poor outcomes as a result of advanced-stage Preventive Services Task Force finds insufficient evidence diagnosis. In California Hispanics, rates of thick tumors from randomized controlled trials to recommend for or whose prognosis is poor but that could be detected early with against whole-body skin examination by either clinicians or screening are increasing the most rapidly [14, 15]. Prevalence 2 Journal of Skin Cancer rates for skin examination, both physician-based and SSE, melanoma rather than directly aiding in early diagnoses of have been found to be lower in Hispanics and other minority melanoma, but included video-based tools that specifically populations [16, 17] as a lack of skin cancer awareness and aimed to educate in skin examination or diagnostic features poorer perception of risk may impede screening practices. of melanoma. To increase skin screening rates and broaden the range of We summarized the available tools, including where and individuals performing screening, strategies are needed that how to obtain them, their cost, and by and for whom they reduce adherence issues. A potential new approach to skin were developed, and, where possible, information on their screening is in the proliferation of patient-oriented “e-Health accuracy and efficacy. tools,” digital resources that facilitate active self-management of patient health practices and information [18]. Low-cost 3. Results and widely available e-Health technologies for skin surveil- lance may reduce practical and psychological barriers as they Table 1 provides an at-a-glance summary of the tools dis- are patient-initiated, performed outside of clinical settings, covered in our search according to the means by which they and often personalized and interactive. With nearly half of improve early diagnoses of melanoma. Many of the tools the American adults using smartphones [19], and with 8 in use a combination of methods, but each is categorized by its 10 of the 82% of Americans who use the internet accessing principle means. For example, the My MoleChecker applica- health information online [20], e-Health tools for skin tion has an embedded video demonstration on self-examina- screening may more seamlessly match individuals’ cus- tion technique, but it is categorized as a mole tracking and tomary behaviors and open new channels for screening reminder application because this is the primary method of adherence. melanoma screening for the application [60]. This paper provides a review of e-Health melanoma Searching for “melanoma” in the iTunes store for iPhone secondary prevention tools currently available as a reference apps yielded 37 results, 17 of which were excluded based on source. In contextualizing and categorizing such tools, we the criteria described in Section 2. “Melanoma” was searched aim to help focus formal research on their adoption and effi- on the Google Play app store and yielded 29 results, 3 of cacy and to aid in determining which tools are most likely to which were also found in the iTunes searches and 21 of which provide effective ad hoc screening options in the future. We were excluded according to exclusion criteria described in will examine how these screening tools work, how they are Section 2. A search for “melanoma” on the Amazon.com accessed, and whether and how they are validated. While Android app store, produced 5 results—3 applications were detailed assessment of efficacy is beyond the scope of this discovered in other searches and 1 application was excluded paper, we will comment on the benefits and limitations of the previously mentioned criteria. The 26 unique applica- these tools and their potential for patient adoption. tions discovered by these searches are included in Table 1. Table 1 also includes those tools that were discovered in subsequent searches for tools in the same categories as these 2. Methods applications. Altogether, there are 46 e-Health tools summa- rized. We performed initial searches for Apple iPhone applications (apps) via the iTunes app store and Android apps via Amazon.com and Google Play app stores for the search term 3.1. Mobile Teledermoscopy. A dermoscope in a clinical set- “melanoma.” We included mobile applications whose pur- ting magnifies a lesion to better elucidate its features beyond pose is to increase user-dependent early diagnoses of what is apparent by the naked eye for analysis by a clinician. melanoma. The means by which these mobile applications Particularly in the past decade, teledermoscopy has been used aid users in reaching diagnostic conclusions about moles to capture images of skin lesions to send to other clinicians include the use of mathematical algorithms to analyze skin for second opinions or diagnoses. Mobile teledermoscopy lesions, education on skin self-examination or diagnostic utilizes a dermoscope which attaches to the camera of a smart criteria of melanomas, and photographic mole tracking and phone to capture standardized images. In a feasibility study, scheduled reminders to perform SSE. two teleconsultants evaluating images of skin lesions taken We searched for additional e-Health tools via the Google with the DermLite II PRO HR dermoscope were able to reach Scholar database, Google search engine, and youtube.com. correct diagnoses on 91.5% of skin lesion images presented We also searched in the iTunes, Amazon.com,and Google [67]. Play app stores for apps that use similar means to increase Several companies are making pocket dermoscopes, and early diagnoses of melanoma used by those apps discovered while the devices are not currently targeted to consumers, in the initial searches. The search terms we used included pocket dermoscopes for smart phones capture images that “melanoma,” “algorithm,” “video,” “mole,” “SSE,” “self- yield high concordance diagnoses. Canfield, a well-regarded examination,” “interactive,” “mobile,” “e-Health,” “applica- dermoscope manufacturer, produces the DermScope which tion,” “computer,” “online,” and “internet.” We further used fastens over an iPhone camera [23]. Canfield also produced a the reference lists from articles to find additional e-Health specific mobile application which serves to manage and store tools. the images captured via that dermoscope. The dermoscope We excluded e-Health tools that did not directly concern is targeted toward dermatology residents, primary care melanoma or that only gave informational material about physicians who do not have access to dermatologists, and Journal of Skin Cancer 3 Table 1: e-Health tools for early diagnosis of melanoma. Device Accessible via Target Developer Cost Mobile teledermoscopy $609.59 Handyscope [21] http://handyscope.net/ Physicians FotoFinder Systems GmbH DermLite II PRO HR [22] http://www.dermlite.com/cms/ Physicians 3Gen LLC $1,295.00 DermScope [23] http://www.dermscope.com/ Physicians Canfield $895.00 Algorithm analysis apps $7500 MelaFind [24] http://www.melafind.com/ Physicians MELA Sciences Inc. MelApp [25] Apple app store Consumers Health Discovery Corp. $1.99 Mole Detective [26] Apple and Android app stores Consumers New Consumer Solutions LLC $4.99 Free Doctor Mole [27] Android app store Consumers Mark Shippen $31.28 Moletest [28] http://www.moletestuk.com/ Consumers Moletestuk http//dermoscopy.k.hosei.ac.jp/ “Internet-based” [29] Consumers Iyatomi et al. Free DermoPerl/ $4.99 Skin Scan [30] Apple app store Consumers Skin Scan University of Pennsylvania Free SkinMD [31] Apple app store Consumers students Medical Image Mining Free Skin Of Mine [32] Apple app store Consumers Laboratories, LLC Free SpotMole [33] Android app store Consumers Cristian Munteanu SpotMolePlus [34] Android app store Consumers Cristian Munteanu $1.53–1.64 Demonstrative videos Cutaneous Arizona Cancer Center Skin Free “Skin Cancer: Learn to Spot it Early” [35] http://azcc.arizona.edu/ oncology Cancer Inst. patients Primary “Check it Out” [36] (not online) care American Cancer Society Free patients High risk Skin Awareness Study [37] (not online) Janda, et al. Free patients Free Saving Our Skin [38] http://www.youtube.com/ Consumers Cancer Council Queensland Free Save Your Skin [39] http://preventcancer.org/ Consumers Prevent Cancer Foundation Skin Self-Exam [40] thedoctorstv.com Consumers 2012 STAGE 29, LLC. Free Melanoma educational apps Free Mollie’s Fund [41] Apple and Android app Stores Consumers MCS Advertising $0.99 iSkin [42] Apple app store Consumers DKLO Inc. Free Melanoma Watch [43] Apple app store Consumers Stroika Mole Checker [44] Apple app store Consumers Stroika $2.99 Mole Checker [45] Android app store Consumers Harry Arden $2.49 $2.99 Smack a Mole [46] Apple app store Consumers SilkyDragon Free ABCDEs of Melanoma [47] Android app store Consumers Mouhammad Aouthmany http://www.melanomaexposed Free MelanomaExposed [48] Consumers Bristol Myers Squibb .com/ Free Cancer Council Queensland [49] http://cancerqld.org.au/ Consumers Cancer Council Queensland My Self Checker [50] Apple app store Consumers Channel 4 Free Interactive teaching apps http://www.westportal.com/ Physicians, eDerm [51] West Portal Software Corp. Free prodederm.htm students Free Melanoma Visual Risk Calculator [52] Apple app store Consumers SigveDhondup Holmen MD $2.99 SPOT IT & NAME IT [53] Apple app store Consumers ECD-Network, LLC Primary Free Skinsafe [54] http://nottingham.ac.uk/ care University of Nottingham patients 4 Journal of Skin Cancer Table 1: Continued. Device Accessible via Target Developer Cost Mole tracking and reminder apps Free UMSkinCheck [55] Apple app store Consumers University of Michigan $0.99 MoleTrac [56] Apple app store Consumers Depthmine Software Free Track-A-Mole [57] Apple app store Consumers Peak Mobile Designs $6.99 Skin Prevention [58] Apple app store Consumers DIMENSION S.r.l. $0.99 LoveMySkin [59] Apple app store Consumers Steven Romej Free My MoleChecker [60] Apple app store Consumers Channel 4 $0.99 Skin Scanner [61] Apple app store Consumers Intelligent Life Solutions Free SkinTagger [62] Apple app store Consumers Coriumedic Systems LLC $3.99 SkinKeeper [63] Apple app store Consumers Health Safari Pty Ltd. $2.99 nevus ¯ [64] Apple and Android app stores Consumers Shonik IDEAS $4.99 Mole Measure [65] Apple app store Consumers Robert Dewhurst Free YourSkinDiary [66] Apple app store Consumers Buiss Ultimo Conversion of 495.80C price. Conversion of £19.95 price. $1.53 price quoted from the Amazon.com App Store and $1.64 price quoted from Google Play App Store. Collaborative effort of the Arizona Cancer Center Skin Cancer Institute, the College of Nursing and the Office of Instruction and Assessment (OIA). physicians who want to store and forward their images to a have had specificities (benign detection accuracy) ranging clinician who may have more expertise in making a diagnosis from 65% to 93.8% and sensitivities (malignant detection or suggesting a referral [23]. There are limited reports of accuracy) ranging from 71.1% to 100% [29]. patients performing dermoscopy as part of a self-exam [68]. MelaFind is a device intended for physician use that has premarket approval from the FDA [24]. Data from a multicenter prospective trial found that the sensitivity of 3.2. Algorithm Analysis Apps. Algorithmic analysis e-Health MelaFind was 98.4% with a 95% lower confidence bound at tools work by analyzing the features of a user-provided 95.6% and biopsy ratio of 10.8 : 1 [24]. While arguably the picture of a suspect skin lesion and determining a risk profile Gold Standard for algorithm-based approaches, this applica- for the lesion. The user typically manually inputs other infor- tion is not widely and readily available for the general public. mation such as size and evolution of the lesion to further factor into the tool’s risk assessment. Unlike the store-and- forward teledermatology devices in which a picture of a 3.3. Demonstrative Videos. A number of e-Health apps lesion is taken and sent to medical personnel for diagnosis, include videos about melanoma and skin safety. Of interest the algorithmic analyses provide diagnoses entirely without here are those videos which include a demonstration of how the oversight of a clinician. Although the particular algo- to perform an SSE and how to identify suspect lesions and rithms vary from tool to tool, the evaluation of images specific elements of melanoma prevention. Most videos that approximate clinical criteria of melanoma such as asymme- are produced for distribution to patients include not only try, border irregularity, color, diameter, and evolution of the information about SSE, but also incorporate skin safety skin lesion (ABCDE criteria) [29, 69]. For example, MelApp advice, education on melanoma prevention, and motiva- compares user-taken photographs to a database of skin lesion tional techniques to encourage frequent SSE. The “Skin images to ultimately provide the user with a risk assessment Cancer: Learn to Spot it Early” video first includes facts about of a particular mole [25]. The algorithmic tools are available the risks of skin cancer and the benefits of early detection via internet websites and smartphone applications. While the before demonstrating how to perform SSE [35]. internet sites require an image to be uploaded with a separate Although not all of the videos shown to be efficacious in camera, the smartphone applications are able to make use of changing patient behaviors are available online, they could the cameras built into the smartphone. The image quality, quite easily be uploaded onto a website for easy distribution however, is limited by the quality of the camera used. The to patients. For example, the videos from the “Check It Out” pricefor consumersrangesfromfreetoaone-time feefor trial and Skin Awareness Study demonstrated efficacy in unlimited use to fee-per-use service. changing patient behaviors [36, 37]; these videos are not The SkinMD application developed by students at the currently available to stream on the internet. Many health University of Pennsylvania is free to download and allows organizations produce videos, but the majority of the videos users unlimited use of the application [31]. The majority of available online have not been assessed for their efficacy in algorithmic programs available and advertised for consumer changing viewer behaviors. For example, Saving Our Skin use have not yet undergone rigorous testing for validity. and Save Your Skin videos are easily accessible online for Those that have undergone testing for diagnostic accuracy patients to access and use [38, 39], but there is no available Journal of Skin Cancer 5 data to confirm that these videos are utilized by patients at applications are usually paired with a reminder feature to risk. SSE videos may be accessed through the websites of dif- remind the user to perform another skin exam at a certain ferent organizations, on video websites such as youtube.com, time in the future, in order to track the evolution of the and within mobile phone apps such as My MoleChecker mole. The UMSkinCheck application guides users through [60]. Videos demonstrating SSE have been shown to increase full-body skin surveys, tracking specific lesion, and allows viewer frequency of SSE in the short term [36, 37, 70–72]. users to set up self-exam frequencies [55]. In addition, There is limited evidence that videos are preferred to written UMSkinCheck provides information on the ABCDE of materials particularly in older persons at risk for melanoma, melanoma, common skin lesions, and sun protection [55]. rather than preferentially utilized by younger people who are Similarly, the Track-A-Mole application allows users to set less at risk, as has been assumed in the past [70]. alarms for subsequent skin examinations [57]. Mole tracking software is largely available via mobile applications, which utilizes the camera hardware already in the phone. While 3.4. Melanoma Educational Apps. Many websites and apps mole tracking and reminder applications have not been stud- offer informational material about how to perform SSE. ied for their effectiveness in particular, reminder functions Generally these are expository tools without an interactive via mobile phones have been shown to increase sun-safe component that provide diagrams and text to explain how to behaviors such as to apply sunscreen and wear sun-protective perform a skin exam and how to recognize the features of a clothing [75]. melanoma. The Mollie’s Fund application provides informa- tion on SSE viaa“5StepSkinCheck”aswellasdescribingthe ABCDE of moles using text and sample photographs in the app [41]. The Smack a Mole application offers images 4. Discussion demonstrating the ABCDE of melanoma, as well as other In the past several years, there have been many advances in e- general educational facts about skin cancer [46]. This partic- Health that have potential to improve melanoma screening: ular application incorporates a game to draw the users’ atten- all of the mobile applications and the majority of the e- tion and keep them engaged. Although there are many of Health tools cataloged in this paper were released within the these types of educational e-Health tools, most have not been past four years. assessed for their efficacy. The central appeal of e-Health devices in the context of melanoma is to increase patients’ involvement in their 3.5. Interactive Teaching Apps. Interactive teaching methods own healthcare and ultimately change patients’ behaviors so range in their complexity, but involve the user performing that melanomas can be found at earlier stages when treating some task such as answering quiz questions in order to with curative intent is possible. e-Health may achieve these progress through the tutorial. Skinsafe, an interactive app ends through various means including serving as diagnostic available for download via the University of Nottingham devices, teaching skin self-exams (SSE) through demon- website, goes through various teaching modules and quizzes stration, explaining the ABCDE diagnostic features of mela- the user on recently presented information [54]. One of these noma through interactive teaching or exposition, and by modules entitled, “Spotting Melanoma,” explains how to offering mole tracking and SSE date reminders to assist users discern moles from freckles and what warning signs may war- in regularly evaluating their moles. rant a clinical consultation. This module finishes with a brief By encouraging greater and more autonomous involve- quiz which challenges the user to determine which moles in a ment in health care, the use of e-Health tools offers oppor- series of photographs show warning signs of melanoma [54]. tunities to providemorecomprehensive patientcareand In a randomized trial, general practitioners and nurses were bolster the relationships between patients and clinicians asked to prescribe Skinsafe to at-risk patients. Patients who [37]. e-Health tools for screening might resolve the gap for received the Skinsafe intervention improved both skin cancer primary care physicians as well, providing easily accessible knowledge and screening behaviors, reporting more skin training on performing clinical skin exams [71](e.g.,bysuch mole checks than did patients without Skinsafe at 6-month websitesaseDerm)[72]. In a survey of primary care physi- followup [73]. cians (PCPs), nearly half of the respondents reported that More sophisticated melanoma programs, such as eDerm, they did not perform skin exams and that a common barrier are targeted to educate medical personnel to better discern to performing exams was a lack of confidence in identifying melanomas [51]. This program includes a lecture on skin skin lesions [41]. e-Health devices may address these issues cancers as well as benign skin lesions and rashes as well as from the physician’s side as they may encourage greater interactive lessons with individualized feedback to increase screening and referral in the primary care setting. the user’s ability to distinguish skin lesions. Practitioners who The increasing availability of e-Health devices might also completed the eDerm training program sent fewer of their benefit patients in remote locations without access to specia- patients to receive unnecessary biopsies [74]. lists, or patients with physical barriers that affect access to care. With an increasingly aging population and limited 3.6. Mole Tracking and Reminder Apps. Mole mapping soft- number of health facilities, e-Health technologies might be ware allows consumers to photograph moles and concur- particularly useful in elderly populations that tend to be rently save the date and time of the mole for future compari- more isolated [46]. While older adults use technology less son of “evolution” (the “E” in ABCDE). Mole tracking [54, 73], studies have indicated that elderly patients trained 6 Journal of Skin Cancer to use certain devices found the technology easy to use and melanoma screening, but all share a common drawback that demonstrated a high level of satisfaction with the delivery of levels of uptake and screening adoption are too low for even e-Health services [51, 55, 74]. Thus there is potential for such an accurate screening method to effectively reduce mortality. tools to improve screening rates in this at-risk population The availability of e-Health tools to a large proportion of the [57]. population with access to mobile devices offers one avenue Conversely, the use of e-Health devices may potentially for improving adoption and uptake of simple screening tools. disrupt collaborative relationships between patients and However, as is the case with any screening method, careful physicians [75] as information is presented within a limited analysis of the accuracy and efficacy of each of these tools is context which may lead to miscomprehension of medical required, and that evaluation should include analysis of the diagnoses. e-Health tools may be used in lieu of clinical visits, potential drawbacks to their use, such as generating a false and patients may overestimate their accuracy. Such overcon- sense of security with a false negative outcome. fidence might lead patients to neglect a physician’s consult While e-Health applications offer much promise for the that may have been essential to discovering a melanoma at a improvement of melanoma screening, current production treatable stage [21, 22, 26]. and evaluation efforts are ad hoc, and most apps have some, Thus, while e-Health tools have tremendous potential but not all, required features. Very few have been formally to diagnose melanomas at an earlier stage, we must also tested, and doing so could be an excellent step forward in consider the potential harms of e-Health tools to screen for widening the scope of effective melanoma screening. melanoma that derive from the limited oversight of their use by professionals. As is the case with any screening approach, Authors’ Contribution we should consider the potential harms of e-Health as a screening method, as well as the potential benefits, and this A. Tyagi and K. Miller contributed equally to this work. should be done in a formal and systematic manner. Acknowledgment 4.1. Envisioning e-Health Device Use. A significant barrier to This work was supported in part by Federal grant CA121052 widespread promotion of existing e-Health tools is an (Cockburn, PI). absence of efficacy testing. Increasing the independent testing of e-Health tools can aid in determining which tools may have life-saving benefits to individuals and eliminating other References tools that may potentially harm users. A study comparing the efficacy and accuracy of e-Health devices with similar [1] C. Bevona and A. J. Sober, “Melanoma incidence trends,” Der- matologic Clinics, vol. 20, no. 4, pp. 589–595, 2002. purposes may be beneficial to determine whether health care [2] C. Eheman, S. J. Henley, R. 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e-Health Tools for Targeting and Improving Melanoma Screening: A Review

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Hindawi Publishing Corporation
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Copyright © 2012 Abhilasha Tyagi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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10.1155/2012/437502
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Hindawi Publishing Corporation Journal of Skin Cancer Volume 2012, Article ID 437502, 8 pages doi:10.1155/2012/437502 Review Article e-Health Tools for Targeting and Improving Melanoma Screening: A Review 1 2 2 Abhilasha Tyagi, Kimberly Miller, and Myles Cockburn Keck School of Medicine of USC, Los Angeles, CA 90089, USA Department of Preventive Medicine, Keck School of Medicine of USC, Los Angeles, CA 90089, USA Correspondence should be addressed to Myles Cockburn, mylesc@usc.edu Received 10 August 2012; Accepted 22 October 2012 Academic Editor: Silvia Moretti Copyright © 2012 Abhilasha Tyagi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The key to improved prognosis for melanoma is early detection and diagnosis, achieved by skin surveillance and secondary pre- vention (screening). However, adherence to screening guidelines is low, with population-based estimates of approximately 26% for physician-based skin cancer screening and 20–25% for skin self-examination. The recent proliferation of melanoma detection “e- Health” tools, digital resources that facilitate screening in patients often outside of the clinical setting, may offer new strategies to promote adherence and expand the proportion and range of individuals performing skin self-examination. The purpose of this paper is to catalog and categorize melanoma screening e-Health tools to aid in the determination of their efficacy and potential for adoption. The availability and accessibility of such tools, their costs, target audience, and, where possible, information on their effi- cacy, will be discussed with potential benefits and limitations considered. While e-Health tools targeting melanoma screening are widely available, little has been done to formally evaluate their efficacy and ability to aid in overcoming screening barriers. Future research needs to formally evaluate the potential role of e-Health tools in melanoma prevention. 1. Introduction individuals [6], whereas observational studies have found evidence that both physician-based screening and SSE result While the rates of many cancers are declining, melanoma in detection of thinner melanomas and, as a result, decreased rates are increasing worldwide [1]. In the United States, mortality [7–9]. melanoma rates in white populations have been increasing by Despite these findings, and possibly due in part to con- 2.4% annually [2]. Despite improved survival, mortality and flicting guidelines, skin screening rates for melanoma remain morbidity remain significant for melanoma. Prevention low in the general population. According to data from the efforts are thus critically important for this aggressive and National Health Interview Survey (NHIS), physician-based often rapidly fatal disease [3]. screening rates are estimated at 16.5% in the US [10]. Skin Secondary prevention of melanoma is recommended as self-examination estimates range between 20% and 25% the disease is more easily treated and survival dramatically [11]; however, these rates depend on the definition of SSE. improved with early detection [4, 5]. Secondary prevention When thoroughness or frequency of exam is included in of melanoma is achieved by screening and skin surveillance variable measurement, SSE rates substantially decrease to as performed by a clinician (dermatologist or other healthcare low as 7–9% [12, 13]. professional) or skin self-exam (SSE) performed by the indi- While early detection is key to improved melanoma vidual. However, the value of population-based skin screen- survival in general, individuals in certain populations are at ing in melanoma prevention remains controversial. The US increased risk of poor outcomes as a result of advanced-stage Preventive Services Task Force finds insufficient evidence diagnosis. In California Hispanics, rates of thick tumors from randomized controlled trials to recommend for or whose prognosis is poor but that could be detected early with against whole-body skin examination by either clinicians or screening are increasing the most rapidly [14, 15]. Prevalence 2 Journal of Skin Cancer rates for skin examination, both physician-based and SSE, melanoma rather than directly aiding in early diagnoses of have been found to be lower in Hispanics and other minority melanoma, but included video-based tools that specifically populations [16, 17] as a lack of skin cancer awareness and aimed to educate in skin examination or diagnostic features poorer perception of risk may impede screening practices. of melanoma. To increase skin screening rates and broaden the range of We summarized the available tools, including where and individuals performing screening, strategies are needed that how to obtain them, their cost, and by and for whom they reduce adherence issues. A potential new approach to skin were developed, and, where possible, information on their screening is in the proliferation of patient-oriented “e-Health accuracy and efficacy. tools,” digital resources that facilitate active self-management of patient health practices and information [18]. Low-cost 3. Results and widely available e-Health technologies for skin surveil- lance may reduce practical and psychological barriers as they Table 1 provides an at-a-glance summary of the tools dis- are patient-initiated, performed outside of clinical settings, covered in our search according to the means by which they and often personalized and interactive. With nearly half of improve early diagnoses of melanoma. Many of the tools the American adults using smartphones [19], and with 8 in use a combination of methods, but each is categorized by its 10 of the 82% of Americans who use the internet accessing principle means. For example, the My MoleChecker applica- health information online [20], e-Health tools for skin tion has an embedded video demonstration on self-examina- screening may more seamlessly match individuals’ cus- tion technique, but it is categorized as a mole tracking and tomary behaviors and open new channels for screening reminder application because this is the primary method of adherence. melanoma screening for the application [60]. This paper provides a review of e-Health melanoma Searching for “melanoma” in the iTunes store for iPhone secondary prevention tools currently available as a reference apps yielded 37 results, 17 of which were excluded based on source. In contextualizing and categorizing such tools, we the criteria described in Section 2. “Melanoma” was searched aim to help focus formal research on their adoption and effi- on the Google Play app store and yielded 29 results, 3 of cacy and to aid in determining which tools are most likely to which were also found in the iTunes searches and 21 of which provide effective ad hoc screening options in the future. We were excluded according to exclusion criteria described in will examine how these screening tools work, how they are Section 2. A search for “melanoma” on the Amazon.com accessed, and whether and how they are validated. While Android app store, produced 5 results—3 applications were detailed assessment of efficacy is beyond the scope of this discovered in other searches and 1 application was excluded paper, we will comment on the benefits and limitations of the previously mentioned criteria. The 26 unique applica- these tools and their potential for patient adoption. tions discovered by these searches are included in Table 1. Table 1 also includes those tools that were discovered in subsequent searches for tools in the same categories as these 2. Methods applications. Altogether, there are 46 e-Health tools summa- rized. We performed initial searches for Apple iPhone applications (apps) via the iTunes app store and Android apps via Amazon.com and Google Play app stores for the search term 3.1. Mobile Teledermoscopy. A dermoscope in a clinical set- “melanoma.” We included mobile applications whose pur- ting magnifies a lesion to better elucidate its features beyond pose is to increase user-dependent early diagnoses of what is apparent by the naked eye for analysis by a clinician. melanoma. The means by which these mobile applications Particularly in the past decade, teledermoscopy has been used aid users in reaching diagnostic conclusions about moles to capture images of skin lesions to send to other clinicians include the use of mathematical algorithms to analyze skin for second opinions or diagnoses. Mobile teledermoscopy lesions, education on skin self-examination or diagnostic utilizes a dermoscope which attaches to the camera of a smart criteria of melanomas, and photographic mole tracking and phone to capture standardized images. In a feasibility study, scheduled reminders to perform SSE. two teleconsultants evaluating images of skin lesions taken We searched for additional e-Health tools via the Google with the DermLite II PRO HR dermoscope were able to reach Scholar database, Google search engine, and youtube.com. correct diagnoses on 91.5% of skin lesion images presented We also searched in the iTunes, Amazon.com,and Google [67]. Play app stores for apps that use similar means to increase Several companies are making pocket dermoscopes, and early diagnoses of melanoma used by those apps discovered while the devices are not currently targeted to consumers, in the initial searches. The search terms we used included pocket dermoscopes for smart phones capture images that “melanoma,” “algorithm,” “video,” “mole,” “SSE,” “self- yield high concordance diagnoses. Canfield, a well-regarded examination,” “interactive,” “mobile,” “e-Health,” “applica- dermoscope manufacturer, produces the DermScope which tion,” “computer,” “online,” and “internet.” We further used fastens over an iPhone camera [23]. Canfield also produced a the reference lists from articles to find additional e-Health specific mobile application which serves to manage and store tools. the images captured via that dermoscope. The dermoscope We excluded e-Health tools that did not directly concern is targeted toward dermatology residents, primary care melanoma or that only gave informational material about physicians who do not have access to dermatologists, and Journal of Skin Cancer 3 Table 1: e-Health tools for early diagnosis of melanoma. Device Accessible via Target Developer Cost Mobile teledermoscopy $609.59 Handyscope [21] http://handyscope.net/ Physicians FotoFinder Systems GmbH DermLite II PRO HR [22] http://www.dermlite.com/cms/ Physicians 3Gen LLC $1,295.00 DermScope [23] http://www.dermscope.com/ Physicians Canfield $895.00 Algorithm analysis apps $7500 MelaFind [24] http://www.melafind.com/ Physicians MELA Sciences Inc. MelApp [25] Apple app store Consumers Health Discovery Corp. $1.99 Mole Detective [26] Apple and Android app stores Consumers New Consumer Solutions LLC $4.99 Free Doctor Mole [27] Android app store Consumers Mark Shippen $31.28 Moletest [28] http://www.moletestuk.com/ Consumers Moletestuk http//dermoscopy.k.hosei.ac.jp/ “Internet-based” [29] Consumers Iyatomi et al. Free DermoPerl/ $4.99 Skin Scan [30] Apple app store Consumers Skin Scan University of Pennsylvania Free SkinMD [31] Apple app store Consumers students Medical Image Mining Free Skin Of Mine [32] Apple app store Consumers Laboratories, LLC Free SpotMole [33] Android app store Consumers Cristian Munteanu SpotMolePlus [34] Android app store Consumers Cristian Munteanu $1.53–1.64 Demonstrative videos Cutaneous Arizona Cancer Center Skin Free “Skin Cancer: Learn to Spot it Early” [35] http://azcc.arizona.edu/ oncology Cancer Inst. patients Primary “Check it Out” [36] (not online) care American Cancer Society Free patients High risk Skin Awareness Study [37] (not online) Janda, et al. Free patients Free Saving Our Skin [38] http://www.youtube.com/ Consumers Cancer Council Queensland Free Save Your Skin [39] http://preventcancer.org/ Consumers Prevent Cancer Foundation Skin Self-Exam [40] thedoctorstv.com Consumers 2012 STAGE 29, LLC. Free Melanoma educational apps Free Mollie’s Fund [41] Apple and Android app Stores Consumers MCS Advertising $0.99 iSkin [42] Apple app store Consumers DKLO Inc. Free Melanoma Watch [43] Apple app store Consumers Stroika Mole Checker [44] Apple app store Consumers Stroika $2.99 Mole Checker [45] Android app store Consumers Harry Arden $2.49 $2.99 Smack a Mole [46] Apple app store Consumers SilkyDragon Free ABCDEs of Melanoma [47] Android app store Consumers Mouhammad Aouthmany http://www.melanomaexposed Free MelanomaExposed [48] Consumers Bristol Myers Squibb .com/ Free Cancer Council Queensland [49] http://cancerqld.org.au/ Consumers Cancer Council Queensland My Self Checker [50] Apple app store Consumers Channel 4 Free Interactive teaching apps http://www.westportal.com/ Physicians, eDerm [51] West Portal Software Corp. Free prodederm.htm students Free Melanoma Visual Risk Calculator [52] Apple app store Consumers SigveDhondup Holmen MD $2.99 SPOT IT & NAME IT [53] Apple app store Consumers ECD-Network, LLC Primary Free Skinsafe [54] http://nottingham.ac.uk/ care University of Nottingham patients 4 Journal of Skin Cancer Table 1: Continued. Device Accessible via Target Developer Cost Mole tracking and reminder apps Free UMSkinCheck [55] Apple app store Consumers University of Michigan $0.99 MoleTrac [56] Apple app store Consumers Depthmine Software Free Track-A-Mole [57] Apple app store Consumers Peak Mobile Designs $6.99 Skin Prevention [58] Apple app store Consumers DIMENSION S.r.l. $0.99 LoveMySkin [59] Apple app store Consumers Steven Romej Free My MoleChecker [60] Apple app store Consumers Channel 4 $0.99 Skin Scanner [61] Apple app store Consumers Intelligent Life Solutions Free SkinTagger [62] Apple app store Consumers Coriumedic Systems LLC $3.99 SkinKeeper [63] Apple app store Consumers Health Safari Pty Ltd. $2.99 nevus ¯ [64] Apple and Android app stores Consumers Shonik IDEAS $4.99 Mole Measure [65] Apple app store Consumers Robert Dewhurst Free YourSkinDiary [66] Apple app store Consumers Buiss Ultimo Conversion of 495.80C price. Conversion of £19.95 price. $1.53 price quoted from the Amazon.com App Store and $1.64 price quoted from Google Play App Store. Collaborative effort of the Arizona Cancer Center Skin Cancer Institute, the College of Nursing and the Office of Instruction and Assessment (OIA). physicians who want to store and forward their images to a have had specificities (benign detection accuracy) ranging clinician who may have more expertise in making a diagnosis from 65% to 93.8% and sensitivities (malignant detection or suggesting a referral [23]. There are limited reports of accuracy) ranging from 71.1% to 100% [29]. patients performing dermoscopy as part of a self-exam [68]. MelaFind is a device intended for physician use that has premarket approval from the FDA [24]. Data from a multicenter prospective trial found that the sensitivity of 3.2. Algorithm Analysis Apps. Algorithmic analysis e-Health MelaFind was 98.4% with a 95% lower confidence bound at tools work by analyzing the features of a user-provided 95.6% and biopsy ratio of 10.8 : 1 [24]. While arguably the picture of a suspect skin lesion and determining a risk profile Gold Standard for algorithm-based approaches, this applica- for the lesion. The user typically manually inputs other infor- tion is not widely and readily available for the general public. mation such as size and evolution of the lesion to further factor into the tool’s risk assessment. Unlike the store-and- forward teledermatology devices in which a picture of a 3.3. Demonstrative Videos. A number of e-Health apps lesion is taken and sent to medical personnel for diagnosis, include videos about melanoma and skin safety. Of interest the algorithmic analyses provide diagnoses entirely without here are those videos which include a demonstration of how the oversight of a clinician. Although the particular algo- to perform an SSE and how to identify suspect lesions and rithms vary from tool to tool, the evaluation of images specific elements of melanoma prevention. Most videos that approximate clinical criteria of melanoma such as asymme- are produced for distribution to patients include not only try, border irregularity, color, diameter, and evolution of the information about SSE, but also incorporate skin safety skin lesion (ABCDE criteria) [29, 69]. For example, MelApp advice, education on melanoma prevention, and motiva- compares user-taken photographs to a database of skin lesion tional techniques to encourage frequent SSE. The “Skin images to ultimately provide the user with a risk assessment Cancer: Learn to Spot it Early” video first includes facts about of a particular mole [25]. The algorithmic tools are available the risks of skin cancer and the benefits of early detection via internet websites and smartphone applications. While the before demonstrating how to perform SSE [35]. internet sites require an image to be uploaded with a separate Although not all of the videos shown to be efficacious in camera, the smartphone applications are able to make use of changing patient behaviors are available online, they could the cameras built into the smartphone. The image quality, quite easily be uploaded onto a website for easy distribution however, is limited by the quality of the camera used. The to patients. For example, the videos from the “Check It Out” pricefor consumersrangesfromfreetoaone-time feefor trial and Skin Awareness Study demonstrated efficacy in unlimited use to fee-per-use service. changing patient behaviors [36, 37]; these videos are not The SkinMD application developed by students at the currently available to stream on the internet. Many health University of Pennsylvania is free to download and allows organizations produce videos, but the majority of the videos users unlimited use of the application [31]. The majority of available online have not been assessed for their efficacy in algorithmic programs available and advertised for consumer changing viewer behaviors. For example, Saving Our Skin use have not yet undergone rigorous testing for validity. and Save Your Skin videos are easily accessible online for Those that have undergone testing for diagnostic accuracy patients to access and use [38, 39], but there is no available Journal of Skin Cancer 5 data to confirm that these videos are utilized by patients at applications are usually paired with a reminder feature to risk. SSE videos may be accessed through the websites of dif- remind the user to perform another skin exam at a certain ferent organizations, on video websites such as youtube.com, time in the future, in order to track the evolution of the and within mobile phone apps such as My MoleChecker mole. The UMSkinCheck application guides users through [60]. Videos demonstrating SSE have been shown to increase full-body skin surveys, tracking specific lesion, and allows viewer frequency of SSE in the short term [36, 37, 70–72]. users to set up self-exam frequencies [55]. In addition, There is limited evidence that videos are preferred to written UMSkinCheck provides information on the ABCDE of materials particularly in older persons at risk for melanoma, melanoma, common skin lesions, and sun protection [55]. rather than preferentially utilized by younger people who are Similarly, the Track-A-Mole application allows users to set less at risk, as has been assumed in the past [70]. alarms for subsequent skin examinations [57]. Mole tracking software is largely available via mobile applications, which utilizes the camera hardware already in the phone. While 3.4. Melanoma Educational Apps. Many websites and apps mole tracking and reminder applications have not been stud- offer informational material about how to perform SSE. ied for their effectiveness in particular, reminder functions Generally these are expository tools without an interactive via mobile phones have been shown to increase sun-safe component that provide diagrams and text to explain how to behaviors such as to apply sunscreen and wear sun-protective perform a skin exam and how to recognize the features of a clothing [75]. melanoma. The Mollie’s Fund application provides informa- tion on SSE viaa“5StepSkinCheck”aswellasdescribingthe ABCDE of moles using text and sample photographs in the app [41]. The Smack a Mole application offers images 4. Discussion demonstrating the ABCDE of melanoma, as well as other In the past several years, there have been many advances in e- general educational facts about skin cancer [46]. This partic- Health that have potential to improve melanoma screening: ular application incorporates a game to draw the users’ atten- all of the mobile applications and the majority of the e- tion and keep them engaged. Although there are many of Health tools cataloged in this paper were released within the these types of educational e-Health tools, most have not been past four years. assessed for their efficacy. The central appeal of e-Health devices in the context of melanoma is to increase patients’ involvement in their 3.5. Interactive Teaching Apps. Interactive teaching methods own healthcare and ultimately change patients’ behaviors so range in their complexity, but involve the user performing that melanomas can be found at earlier stages when treating some task such as answering quiz questions in order to with curative intent is possible. e-Health may achieve these progress through the tutorial. Skinsafe, an interactive app ends through various means including serving as diagnostic available for download via the University of Nottingham devices, teaching skin self-exams (SSE) through demon- website, goes through various teaching modules and quizzes stration, explaining the ABCDE diagnostic features of mela- the user on recently presented information [54]. One of these noma through interactive teaching or exposition, and by modules entitled, “Spotting Melanoma,” explains how to offering mole tracking and SSE date reminders to assist users discern moles from freckles and what warning signs may war- in regularly evaluating their moles. rant a clinical consultation. This module finishes with a brief By encouraging greater and more autonomous involve- quiz which challenges the user to determine which moles in a ment in health care, the use of e-Health tools offers oppor- series of photographs show warning signs of melanoma [54]. tunities to providemorecomprehensive patientcareand In a randomized trial, general practitioners and nurses were bolster the relationships between patients and clinicians asked to prescribe Skinsafe to at-risk patients. Patients who [37]. e-Health tools for screening might resolve the gap for received the Skinsafe intervention improved both skin cancer primary care physicians as well, providing easily accessible knowledge and screening behaviors, reporting more skin training on performing clinical skin exams [71](e.g.,bysuch mole checks than did patients without Skinsafe at 6-month websitesaseDerm)[72]. In a survey of primary care physi- followup [73]. cians (PCPs), nearly half of the respondents reported that More sophisticated melanoma programs, such as eDerm, they did not perform skin exams and that a common barrier are targeted to educate medical personnel to better discern to performing exams was a lack of confidence in identifying melanomas [51]. This program includes a lecture on skin skin lesions [41]. e-Health devices may address these issues cancers as well as benign skin lesions and rashes as well as from the physician’s side as they may encourage greater interactive lessons with individualized feedback to increase screening and referral in the primary care setting. the user’s ability to distinguish skin lesions. Practitioners who The increasing availability of e-Health devices might also completed the eDerm training program sent fewer of their benefit patients in remote locations without access to specia- patients to receive unnecessary biopsies [74]. lists, or patients with physical barriers that affect access to care. With an increasingly aging population and limited 3.6. Mole Tracking and Reminder Apps. Mole mapping soft- number of health facilities, e-Health technologies might be ware allows consumers to photograph moles and concur- particularly useful in elderly populations that tend to be rently save the date and time of the mole for future compari- more isolated [46]. While older adults use technology less son of “evolution” (the “E” in ABCDE). Mole tracking [54, 73], studies have indicated that elderly patients trained 6 Journal of Skin Cancer to use certain devices found the technology easy to use and melanoma screening, but all share a common drawback that demonstrated a high level of satisfaction with the delivery of levels of uptake and screening adoption are too low for even e-Health services [51, 55, 74]. Thus there is potential for such an accurate screening method to effectively reduce mortality. tools to improve screening rates in this at-risk population The availability of e-Health tools to a large proportion of the [57]. population with access to mobile devices offers one avenue Conversely, the use of e-Health devices may potentially for improving adoption and uptake of simple screening tools. disrupt collaborative relationships between patients and However, as is the case with any screening method, careful physicians [75] as information is presented within a limited analysis of the accuracy and efficacy of each of these tools is context which may lead to miscomprehension of medical required, and that evaluation should include analysis of the diagnoses. e-Health tools may be used in lieu of clinical visits, potential drawbacks to their use, such as generating a false and patients may overestimate their accuracy. Such overcon- sense of security with a false negative outcome. fidence might lead patients to neglect a physician’s consult While e-Health applications offer much promise for the that may have been essential to discovering a melanoma at a improvement of melanoma screening, current production treatable stage [21, 22, 26]. and evaluation efforts are ad hoc, and most apps have some, Thus, while e-Health tools have tremendous potential but not all, required features. Very few have been formally to diagnose melanomas at an earlier stage, we must also tested, and doing so could be an excellent step forward in consider the potential harms of e-Health tools to screen for widening the scope of effective melanoma screening. melanoma that derive from the limited oversight of their use by professionals. As is the case with any screening approach, Authors’ Contribution we should consider the potential harms of e-Health as a screening method, as well as the potential benefits, and this A. 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