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The melanoma incidence and mortality rates in rural and remote communities are exponentially higher than in urban areas. Digital health could be used to close the urban/rural gap for melanoma and improve access to posttreatment and support care services.
The aim of this review was to understand how digital health is currently used for melanoma posttreatment care and determine the benefits for Australian rural and remote areas.
A systematic search of PubMed, Medline, PsycINFO, and Scopus was conducted in March 2018. Findings were clustered per type of intervention and related direct outcomes.
Five studies met the inclusion criteria, but none investigated the benefits of digital health for melanoma posttreatment care in rural and remote areas of Australia. Some empirical studies demonstrated consumers’ acceptance of digital intervention for posttreatment care. The findings did not take into consideration individual, psychological, and socioeconomic factors, even though studies show their significant impacts on melanoma quality of aftercare.
Digital interventions may be used as an adjunct service by clinicians during melanoma posttreatment care, especially in regions that are less-resourced by practitioners and health infrastructure, such as rural and remote Australia. Technology could be used to reduce the disparity in melanoma incidence, mortality rates, and accessibility to posttreatment care management between urban and rural/remote populations.
Australia remains a country with one of the highest levels of melanoma. In 2015, the worldwide average age-standardized incidence rate (ASR) for melanoma was 5 cases for 100,000. However, the rates for Australia and New Zealand are over ten times that level (
Worldwide ranking of the average age-standardized incidence rate for melanoma.
Rank | Country | Age-standardized incidence rate for melanoma (95% CI) |
1 | New Zealand | 54/100,000 (39-73) |
2 | Australia | 54/100,000 (41-78) |
3 | Norway | 26/100,000 (18-32) |
4 | Sweden | 26/100,000 (20-35) |
5 | The Netherlands | 25/100,000 (17-30) |
Cutaneous melanoma (CM) is the fourth most commonly diagnosed cancer in Australia [
Melanoma treatment plans depend on (1) prognostic factors which are primarily defined by the American Joint Committee on Cancer staging system [
In 2017, the Australian Institute of Health and Welfare estimated that 14,000 new melanoma cases would be diagnosed. However, there are only 775 registered dermatologists in Australia (only 260 of which are melanoma specialists), and very few of them are easily accessible to people living in rural and remote areas [
It has been suggested that technology-based training and telehealth could help combat this disparity by bringing health services to rural and remote areas [
In order to structure posttreatment plans, physicians must refer to the clinician guidelines. A recent study [
An area of posttreatment care that is often neglected across all populations is psychosocial support. Psychological distress, including worry, anxiety, and fear of disease recurrences and death, are common for survivors [
Although reviews have evaluated the effectiveness of technology for melanoma early detection, no studies have directly highlighted the benefits of eHealth on melanoma posttreatment care for rural communities. Researchers have qualitatively examined the different forms of treatment and care between rural and urban populations [
It is unclear from the published literature the level and utility of technology support available to patients with melanoma living in remote areas. The primary aim of this systematic review was to (1) examine how technology is currently used and accepted by physicians and patients with melanoma, and (2) to determine if there has been any implementation of such systems in rural and remote areas of Australia. With this focus, the researchers seek to identify areas of weakness and bring to light hypotheses on how technology could be used as an adjunct service during posttreatment care of CM, to aid physicians in designing follow-up care plans for patients with CM based on their needs and personal characteristics.
The overall aim of this systematic review was to investigate digital health acceptance and its current use among people treated for melanoma. Our primary aim was to better understand digital health benefits among rural and remote populations for CM. However, given the impact of CM across all of Australia’s population, literature around digital health and CM that impacted urban and regional areas was incorporated as well. This was done to ensure broad inclusion of digital health practice for CM posttreatment care. The databases selected were searched using keyword combinations related to digital health and melanoma posttreatment care. Specifically, we used the keyword combination “telehealth” OR “telemedicine” OR “teledermatology” OR “online services” OR “ehealth” OR “e-health” OR “eHealth” AND “melanoma.” For the current systematic literature review, 4 databases (PubMed, Medline, PsycINFO, Scopus) were searched in March 2018.
The search was limited to peer-reviewed papers. Search results identified 451 papers which were exported into a Microsoft Excel document. After duplicates were removed, 271 articles remained.
The search strategy involved 2 screening phases. Each article was screened based on exclusion criteria to remove irrelevant articles from the initial selection of 271 articles. For the second phase, only studies that were based on empirical evidence and used a patient-centric approach were retained for the final systematic literature review.
Data was extracted from the relevant papers using the following classification: (1) sources (country, year of study intervention), (2) participant characteristics (gender, residential area, mean ages, patient illness conditions, level of education, and socioeconomic background), (3) study design, (4) study intervention, and (5) research focus (
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of the systematic literature review.
There were 5 studies in total. Two (40%) of the studies were from Scotland, with the other 3 (60%) from the Netherlands, Canada, and the US. All studies were from before 2015 except for one (20%) study from the Netherlands, which was from 2016.
Four of the 5 (80%) studies consisted of patients with melanoma only. The remaining study (20%) recruited patients with a history of melanoma and psoriasis, or collateral cancer. A minority, 2 of the 5 (40%) authors referred to the patient’s illness condition in their sample description. The gender distribution of studies was mostly homogeneous with 47%-60% males and a mean age ranging from 53-66 years. None of the studies used “residential area” as an independent variable. Two (40%) studies used residential area as a patient characteristic but did not mention it in their findings. Also, 2 (40%) studies reported socioeconomic criteria in their findings and 3 (60%) featured level of education.
Prior to the investigation, all published research participants were informed of the objectives of the studies. Three of the 5 (60%) studies [
Distribution of the papers according to the study design and the main focus area. TSSE: total skin self-examination.
Direct outcomes on posttreatment care per type of intervention.
Direct outcomes | Type of intervention | ||||
Provides reassurance to patients [ |
Report sent by phone to clinicians including photographs Self-monitoring supportive tools |
||||
Convenient Avoids in-person clinical visit if not necessary [ |
Report sent by phone to clinicians including photographs |
||||
Reduces the number of people who might forget about total skin self-examination [ |
Reminder sent by text message or email |
||||
Promotes early detection [ |
Report sent by phone to clinicians including photographs |
||||
Behavior change Empowers patients’ confidence to perform total skin self-examination [ |
Self-monitoring supportive tools YouTube videos explaining how to perform a total skin self-examination |
||||
Reinforces total skin self-examination [ |
Self-monitoring supportive tools |
||||
Health care professionals based their opinion on pictures only [ |
Clinicians’ feedback sent by text message or email |
||||
Convenient Reduces travel and saves time [ Quick access to clinicians [ |
Skype or teleconference Store and forward telemedicine |
||||
Patients’ desire to discuss face-to-face with clinicians [ |
Skype or teleconference |
||||
Patients’ skin required to be examined by clinicians [ |
Phone |
||||
Accuracy in the diagnosis [ |
Three-way consultation via a video or Skype link from the general practitioner’s room |
||||
Convenient Time and travel saved [ |
Remote point of contact Nurse specialist’ opinion to be provided via store and forward system |
||||
Not applicable |
Not applicable |
||||
Promotes early detection [ |
Web-based app tailored information delivered about their conditions Skin map |
||||
Reduces patients’ stress [ |
Web-based app tailored information delivered about their conditions Skin map |
||||
Improves patients’ decision-making in treatment [ |
Web-based app tailored information delivered about their conditions |
||||
Ease of communication Content is more adapted to the patients’ level of understanding [ Supporting oral/written information delivered to the patients [ |
Web-based app tailored information delivered about their conditions YouTube videos explaining how to perform a total skin self-examination |
||||
Reduce/control the content load [ |
Web-based app tailored information delivered about their conditions |
||||
Don't want to be associated with other patients Makes them feel sicker than they are [ |
Online peer support (ie, forum, group chat) |
||||
Do not replace the oral and written information provided by clinicians [ |
YouTube videos explaining how to perform a total skin self-examination |
The primary aim of this review was to identify the different use of digital health for melanoma posttreatment care, including its benefits and weaknesses. Patients perceived digital health as an added value to their posttreatment care [
This review found some evidence for the efficacy of digital interventions for melanoma posttreatment care. Key findings identified that clinicians need to take into consideration patients’ characteristics in order to provide personalized follow-up plans, tailored information, and quality of care [
In order to efficiently use personal consumer technology in melanoma posttreatment care, it is crucial to understand patients’ acceptance toward digital intervention. Several of the studies reviewed [
The study by Quereshi and colleagues [
While these findings demonstrated that patients were generally receptive toward digital health for melanoma posttreatment care, no studies to date have focused on rural and remote communities’ views. Nevertheless, a few studies have already highlighted people’s acceptance toward telemedicine in Australian rural and remote communities for cancer more broadly. In their studies, Sebesan and colleagues [
In this systematic review, there was a lack of empirical evidence with regards to the benefits of digital health for support and psychological care services, in order to provide better QoL. These studies mainly focused on early detection, including self-monitoring and TSSE. However, a previous systematic review [
Melanoma early detection reduces the mortality rate and results in simple treatments for lower cost [
Moreover, additional studies [
The comparatively lower cost of delivering support care services via digital health initiatives, in addition to reduced treatment costs associated with promoting early detection [
This systematic literature review presents several limitations. First, most of the studies used small samples (n≥20). It is evident that digital health research regarding melanoma postcare treatment is still in its early stages of investigation. Second, few studies were identified as focusing on the psychosocial and health economic side of post-care treatment, as melanoma studies are primarily focused on early detection, and those that did use a retrospective measurement of consumer attitudes towards telemedicine. Third, melanoma treatment plans depend on individual characteristics, including the disease staging. Only one of the studies used staging as a participant characteristic. Finally, although the authors were primarily interested in rural and remote areas of Australia, the lack of studies conducted in these areas meant that studies for this review were drawn from across the world, and their conclusions may not necessarily generalize to the Australian rural and remote context.
Overall, the current systematic review provides findings of patients’ perceptions toward telemedicine and digital interventions already used by clinicians and patients. However, in order to have a complete review of digital health benefits for melanoma post-treatment care, it would have been necessary to look at HCP’s acceptance of such technological interventions.
The study of digital health has become an area of focus in primary health care, as it can help clinicians in their practice and support patients in improving and monitoring their QoL. While there is research interest in using digital health in early detection of melanoma, there is an urgent need to explore the potential for benefits of digital health in melanoma post-treatment care for specific needs and intervention, particularly for rural and remote populations who are lagging behind regarding postcare treatment quality and availability. This literature review also highlights the importance of considering individual, psychosocial and socioeconomic characteristics in future developments in this area.
Although our findings showed positive outcomes with regards to using technology during post-treatment care, there were also some limitations in using digital health. Patients believe that technology cannot replace the clinician provided written and oral information, follow-up visits, or clinical interventions [
Future research should explore the potential for digital health within rural and remote areas for melanoma posttreatment care in order to reduce the mortality rate disparity in between urban and rural populations. Also, it will be interesting to consider how digital health implementation may transform the patients’ ecosystem and the cost-effectiveness of this solution for both patients and the health care industry.
Interdisciplinary studies in behavioral psychology and health economy can add new insights to the health care industry in term of benefits and services that digital health can bring to melanoma patients care in rural and remote areas.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist.
The consumer-technology relationship and digital interventions for melanoma posttreatment care.
age-standardized rate
cutaneous melanoma
general practitioners
health care professional
information technology
nonmelanoma skin cancer
quality of life
skin self-examination
total skin self-examination
ultraviolet
The authors would like to thank Dr John Turner for his expert advice on research methodology.
None declared.