Why don't skin cancer patients listen to me?

Non-adherence to melanoma prevention recommendations

Suephy C. Chen, M.D., M.S. Dept of Dermatology Emory University Div. of Dermatology Atlanta VAMC

What do we want our MM patients to do at home?

• Avoid Sun (Primary Prevention)

• Self skin examination (Secondary Prevention: Early detection)

Wide range of adherence

• Review of 91 studies

• Sunscreen adherence: 7 to 90%

• Yearly SSE rates: 23 to 61%

Kasparian, N.A., J.K. McLoone, and B. Meiser, Skin cancer-related prevention and screening behaviors: a review of the literature. J Behav Med, 2009. 32(5): p. 406-28.

Mediators of Adherence

• Bosworth, H.B., E.Z. Oddone, and M. Weinberger, Patient treatment adherence : concepts, interventions, and measurement. 2006, Mahwah, N.J.: Lawrence Erlbaum Associates, Publishers. xix, 582 p.

Intention

• The reason behind a particular action

• Driven by many factors – Normative pressure

• Attitudes

• Subjective norms

– Positive effect

– Cues to action

– Reinforcement

Intention: Attitudes Common attitudes

• Towards sunscreen (sticky, time consuming)

• Perceived risk of developing skin cancer

• Perceived benefits of sun protection vs sun exposure

Derm response

• Alternative sun protection behaviors

• Talk about individual risk

• Vitamin D comes in supplements

Intention: Subjective norms

Peer pressure • Tan look (“white fat

looks worse than tan fat”)

• Are people around patient using sunscreen?

Response • De-emphasize tan

attractiveness • ? Are self tanners a

good idea?

• Educate re photo-aging

• Increase social norms of sun protection behaviors (rash guards, umbrellas…)

N=382 More likely to use an umbrella • After viewing the collage (P < 0.001) • If recommended by a dermatologist Independent predictors of social acceptability

• Age • Had not lived in another country • Use sun protective clothing use • No sunscreen use

• Skin color, ethnicity & education NOT predictors

Intention: Cues to action

Sunscreen • Spouse reminds • Exit of the home:

put bottle so remember to apply before leaving the house

• Make part of AM habit

• People

• Location

• Timing Self skin exam

• Running/drinking/ breakfast buddy check back

• Computer for photo check

• Same day of the month

Intention: Reinforcement

• Provider provides encouragement at clinic visit (vs. reprimand)

• Provider gives clear, directed instructions – How much (shot glass full)

– When (20 min prior to going out)

– Where (air conditioned area)

• Written action plans (handouts)

Confidence

• Response efficacy: Confidence that the behavior actually works

• Self-efficacy: Confidence in performing a health behavior

Improving Response efficacy

• Confidence that the behavior actually works

• Provide education from literature – Sunscreen usage helps for 10 years hence

– Using total body photos saves on unnecessary biopsies

Improving Self-Efficacy • Confidence in performing a health

behavior

• Providing how-to information – Nurses to educate

– Handouts

– Videos

• Using teachbacks to assess understanding

Improving Self-efficacy: MM apps

• Algorithms to detect worrisome lesions – Skinvision – Doctor Mole – UMSkincheck

• TeleDerm/Tracking – Mole Detect Pro (Mole Detective) – SpotCheck (photo of mole to MD) – FotoSkin – Mole Mapper

Text reminders: RCT

• Weekly informational texts & monthly reminders

• Control: only SSE educational materials at baseline

• Subjects were surveyed on examination of 7 body sites

• Texting group examined sig more body parts at follow-up compared to baseline

Text reminder RCT

Text msg subjects also had greater increase in (vs. no texting) • Cancer awareness and knowledge

• Cancer worry

• Self-efficacy (confidence in ability to perform SSE)

• Response efficacy (confidence that SSE are worthwhile)

Barriers

• Obstacles that prevent an individual from performing an action – Physical

– Logistical

– Social/environmental

• Even if have intention, skills, and confidence to perform that behavior

Removing Barriers

• Using stick/spray sunscreens when hard to use lotion – Public area; sandy beach; kids faces

• Using clothing instead of sunscreen – no need to re-apply

• Being available by phone or email if pt has questions

Removing Barriers

• Being available for spot check of worrisome lesion on SSE – Next day appointment

– TeleDermatology

– TeleDermoscopsy

JAMA Derm 2015 151(5)

489-96

• 29 pts that completed FU • Derm identify 1 lesion of interest • Baseline and 3-4 mo FU visit

– Routine (Nikon) dermoscopic image – iPhone image (DermScope, Canfield)

• Management Decision – Office-based: Routine visit – TeleDerm: both iPhone images

TeleDermoscopy: Results

• Feasibility – 97%: Image pair evaluable

• Diagnostic concordance – 97% agreement – Kappa statistic: 0.87 (ideal >0.7)

• Patient receptiveness – High degree confidence to take image – Shorter wait time & potential for more

frequent monitoring – WTP $20-$500 for mobile dermatoscope

TeleDermoscopy • Patient needs dermoscopy unit

• Secure Cloud to store images

• Process to share/transmit with provider

• Attachments to iPhones – 3Gen DermLite DL1 basic ($300)

– FotoFinder Handyscope ($943)

References

• Kasparian, N.A., J.K. McLoone, and B. Meiser, Skin cancer-related prevention and screening behaviors: a review of the literature. J Behav Med, 2009. 32(5): p. 406-28.

• Manne, S. and S. Lessin, Prevalence and correlates of sun protection and skin self-examination practices among cutaneous malignant melanoma survivors. Journal of behavioral medicine, 2006. 29(5): p. 419-34.

• 60. Garside, R., M. Pearson, and T. Moxham, What influences the uptake of information to prevent skin cancer? A systematic review and synthesis of qualitative research. Health Educ Res, 2010. 25(1): p. 162-82.

References

• Jackson, K.M. and L.S. Aiken, A psychosocial model of sun protection and sunbathing in young women: the impact of health beliefs, attitudes, norms, and self-efficacy for sun protection. Health psychology : official journal of the Division of Health Psychology, American Psychological Association, 2000. 19(5): p. 469-78.

• Skiveren, J., E.L. Mortensen, and M. Haedersdal, Sun protective behaviour in renal transplant recipients. A qualitative study based on individual interviews and the Health Belief Model. The Journal of dermatological treatment, 2010. 21(6): p. 331-6.

• Turner, L.R. and R.J. Mermelstein, Psychosocial characteristics associated with sun protection practices among parents of young children. Journal of behavioral medicine, 2005. 28(1): p. 77-90

References

• Bosworth, H.B., E.Z. Oddone, and M. Weinberger, Patient treatment adherence : concepts, interventions, and measurement. 2006, Mahwah, N.J.: Lawrence Erlbaum Associates, Publishers. xix, 582 p.

• Webb, T.L. and P. Sheeran, Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence. Psychological bulletin, 2006. 132(2): p. 249-68.

• Armitage, C.J. and M. Conner, Efficacy of the Theory of Planned Behaviour: a meta-analytic review. The British journal of social psychology / the British Psychological Society, 2001. 40(Pt 4): p. 471-99.

• Theory at a glance: a guide for health promotion practice. NIH publication. 2005, Bethesda, MD: National Institutes of Health, National Cancer Institute.

• Fishbein, M., et al., Can we explain why some people do and some people do not act on their intentions? Psychology, Health & Medicine, 2003. 8(1).

• Bandura, A., Health promotion by social cognitive means. Health Educ Behav, 2004. 31(2): p. 143-64.

References

• Bodenheimer, T., et al., Patient self-management of chronic disease in primary care. JAMA, 2002. 288(19): p. 2469-75.

• Warsi, A., et al., Self-management education programs in chronic disease: a systematic review and methodological critique of the literature. Archives of internal medicine, 2004. 164(15): p. 1641-9.

• Chisolm, S.S., et al., Written action plans: potential for improving outcomes in children with atopic dermatitis. Journal of the American Academy of Dermatology, 2008. 59(4): p. 677-83.

• Ntuen, E., et al., Physicians' perceptions of an eczema action plan for atopic dermatitis. The Journal of dermatological treatment, 2010. 21(1): p. 28-33.

• Oliveria, S.A., et al., Patient adherence to skin self-examination. effect of nurse intervention with photographs. Am J Prev Med, 2004. 26(2): p. 152-5.