10.5826/dpc.1304a199
text/xml
2160-9381
3132
en
Shari R Lipner
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Anxiety
Yet Another Reason to Examine the Nails: Substantial Cancer-Related Worry and Anxiety in Patients with Melanonychia in a Survey-Based Study
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Letter to the Editor
2023-10-31
2023-01-03
2023-10-31
2024-01-15
e2023199
Dermatol Pract Concept
Shari R Lipner
2023/10/31
10.5826/dpc.1304a199
e2023199
Weill Cornell Medicine, Department of Dermatology, New York, USA
2160-9381
Anxiety
en
e2023199
Kang R, Lipner S. Assessment of internet sources on subungual melanoma. Melanoma Res. 2020;30(4):416-419. doi:10.1097/CMR.0000000000000508
Yet Another Reason to Examine the Nails: Substantial Cancer-Related Worry and Anxiety in Patients with Melanonychia in a Survey-Based Study
https://dpcj.org/index.php/dpc/article/download/3132/2402
              Yet Another Reason to Examine the Nails:
                Substantial Cancer-Related Worry and
               Anxiety in Patients With Melanonychia
                      in a Survey-Based Study
                                           Jose William Ricardo1, Shari Lipner1


1 Weill Cornell Medicine, Department of Dermatology, New York, USA



Citation: Ricardo JW, Lipner SR. Yet Another Reason to Examine the Nails: Substantial Cancer-Related Worry and Anxiety in Patients
With Melanonychia in a Survey-Based Study. Dermatol Pract Concept. 2023;13(4):e2023199. DOI: https://doi.org/10.5826/dpc.1304a199
Accepted: March 23, 2023; Published: October 2023
Copyright: ©2023 Ricardo et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Shari R. Lipner MD, PhD, 1305 York Avenue, NY, NY 10021. Phone: 646-962-3376 Fax: 646-962-0033 E-mail:
shl9032@med.cornell.edu
Patient Consent: All patients gave consent for their medical information to be published in print and online, with the understanding that
this information may be publicly available.




To the Editor,                                                           STAI-6 scores were 10/17 and 47/80, respectively (Table 1).
                                                                         Post-consultation, mean MWS and STAI-6 scores decreased
Longitudinal melanonychia (LM) is a common sign of nail                  by 4.6 and 16.3 points, respectively (P < 0.001 all), for pa-
unit melanoma (NUM), often eliciting anxiety and cancer-­                tients for whom biopsy was not recommended (N = 30)
related worry. We aimed to quantify levels and determine                 (Table 2). Median baseline RIES scores for avoidance and
predictors of melanoma-related worry in LM patients.                     intrusion subscales were 4/40 and 3/35, respectively. Internet
    An Institutional Review Board-approved survey con-                   searches (β=1, P=0.01), personal history of psychiatric ill-
taining demographics, Melanoma Worry Scale (MWS),                        ness (β=1.1, P=0.02), personal history of melanoma (β=1.6,
State-trait Anxiety Inventory (STAI-6), and Revised Impact               P=0.02), and higher STAI-6 scores (β=0.1, P<0.001) inde-
of Event Survey (RIES) (Supplementary material), was ad-                 pendently predicted baseline MWS scores on multivariate
ministered 12/25/20-03/1/22, to patients >18 years present-              analysis.
ing with LM, pre- and post-nail consultation. Univariate                      Univariate analysis of change in MWS scores in the
analysis determined factors affecting baseline MWS scores.               no-biopsy group showed that female sex, seeing dermatol-
Multivariate analysis determined independent predictors of               ogist versus other clinician, internet searching, personal his-
baseline MWS scores (α = 0.05).                                          tory of psychiatric illness, and higher baseline STAI-6 scores
    Forty-eight patients (82%) completed surveys; mean                   were associated with greater decrease in MWS scores post-­
age 51 years and 71% women. Mean baseline MWS and                        consultation (P<0.05 all).




Letter to the Editor | Dermatol Pract Concept. 2023;13(4):e2023199                                                                          1
Table 1. Correlation of baseline melanoma-related worry (MWS scores) with sociodemographic
characteristics, baseline State-trait Anxiety Inventory (STAI-6) and Revised Impact of Event Survey
(RIES) scores.
                                                                     N (%) and mean± SD /           MWS score,
Variables                                                               median (Range)              mean ± SD          P-value
Age, year                                                                   51.1 ± 15.4                                 0.94
Sex                                    Female                                34 (70.8)                10.6 ± 2.8        0.02a
                                       Male                                  14 (29.2)                 8.2 ± 3.1
                                       White                                 30 (62.5)                 10 ± 3.1         0.69b
                                       Black                                  8 (16.7)                 8.9 ± 2.4
Race
                                       Asian                                  6 (12.5)                10.8 ± 2.6
                                       Other                                   4 (8.3)                  10 ± 5
                                       Hispanic/Latino(a)                     5 (10.4)                  9 ± 4.5         0.38b
Ethnicity                              Not Hispanic/Latino(a)                41 (85.4)                10.2 ± 2.9
                                       Prefer not to answer                    2 (4.2)                 7.5 ± 0.7
                                       Yes                                   26 (54.2)                 10 ± 2.8         0.95a
Do you have children?
                                       No                                    22 (45.8)                 10 ± 3.4
                                       Married                               30 (62.5)                 9.9 ± 2.9        0.47b
                                       Single                                 12 (25)                  9.3 ± 3.4
Marital status
                                       Divorced                               5 (10.4)                11.6 ± 2.7
                                       Widowed                                 1 (2.1)                    12
                                       Any college or higher                 42 (87.5)                10.4 ± 2.9        0.001a
                                       degree
Education
                                       Less than a college                    6 (12.5)                  7 ± 2.1
                                       degree
                                       Employed                              35 (72.9)                 10.1 ± 3         0.53a
Employment
                                       Unemployed                            13 (27.1)                 9.5 ± 3.2
                                       <$10,000                                1 (2.1)                     4            0.37b
                                       $10,000-$49,999                         1 (2.1)                    10
Household income, yearly               $50,000-$74,999                        5 (10.4)                10.8 ± 2.9
(United States Dollar)                 $75,000-$100,000                       5 (10.4)                 10 ± 3.9
                                       >$100,000                             29 (60.4)                 9.7 ± 2.9
                                       I prefer not to answer                 7 (14.6)                 11.1 ± 3
Have you ever seen a physician for     Yes                                   42 (87.5)                  9.7 ± 3         0.16a
this?                                  No                                     6 (12.5)                11.7 ± 2.8
What kind of clinician? (N = 42)       Dermatologist                         35 (83.3)                 10.1 ± 3         0.01a
                                       Other type of clinician                7 (16.7)                 7.6 ± 1.9
Have you searched the internet for     Yes                                   38 (79.2)                10.7 ± 2.8       <0.001a
melanonychia-related information?      No                                    10 (20.8)                 7.1 ± 2.3
Did you diagnose yourself using         Yes                                   9 (23.7)                 10.1 ± 3         0.52a
information from the internet? (N = 38) No                                   29 (76.3)                10.9 ± 2.7
Have you ever been diagnosed with a    Yes                                    6 (12.5)                12.2 ± 1.3        0.003a
psychiatric condition?                 No                                    42 (87.5)                 9.6 ± 3.1
Have you ever been diagnosed with      Yes                                    3 (6.25)                  15 ± 2          0.03a
melanoma?                              No                                    45 (93.75)                9.6 ± 2.8




2                                                               Letter to the Editor | Dermatol Pract Concept. 2023;13(4):e2023199
 Do you have a family history of                Yes                                     7 (14.6)             10.6 ± 5      0.71a
 melanoma?                                      No                                      41 (85.4)            9.8 ± 2.7
 STAI-6                                                                             46.6 ± 14.9                           <0.001
                                                                                               c
 RIES                                         Avoidance subscale                    4 (0-26) )c                            0.31
                                                                                        c
                                              Intrusion subscale             3 (0-21)                                       .16
ANOVA = analysis of variance; MWS = Melanoma Worry Scale; RIES = Revised Impact of Event Survey; SD = standard deviation;
STAI-6 = State-trait Anxiety Inventory.
a
  Two sample t-test
b
  ANOVA test
c
  Median (range)


                                   Table 2. Pre- and post-consultation survey results
                                                           Mean/Median score (Range)
                            Pre-test        Pre-consultation                      Post-consultation
                                       Biopsy not        Biopsy     Biopsy not                 Biopsy
                               All   recommended recommended recommended                   recommended
      Survey                (N = 48)    (N = 30)        (N = 18)     (N = 30)     P-value     (N = 18)  P-valuea
                                   c      c               c             c                       c
MWS (range, 4-17)             9.9      10 (4-15)       9.8 (5-17)   5.4 (4-10)    <0.0001    9.9 (5-15)   0.89
                             (4-17)
How much do you              3 (1-5)     3 (1-5)         3 (1-5)      1 (1-5)                  3 (1-5)
worry about getting
nail melanoma?
(range, 1-5)
How much does                2 (1-4)        2 (1-4)             2 (1-4)           1 (1-3)                     2 (1-4)
worrying about
developing nail
melanoma impact your
mood? (range, 1-4)
How much does                2 (1-4)        2 (1-4)             1 (1-4)           1 (1-3)                     2 (1-4)
worrying about
developing nail
melanoma impact.
Your daily activities?
(range, 1-4)
What is your current         3 (1-4)        3 (1-4)             3 (1-4)           1 (1-4)                     4 (1-4)
level of anxiety about
the results of your nail
examination?
(range, 1-4)
STAI-6 (range, 20-80)         46.6 c      47 c (20-77)      45.9 c (20-77)    30.7 c (20-56.6) <0.0001   48.1 c (12-70)    0.6
                             (20-77)
I feel calm (range, 1-4)     3 (1-4)        3 (1-4)             2 (1-4)           1 (1-4)                     3 (1-4)
I am tense (range, 1-4)      2 (1-4)        2 (1-4)             2 (1-4)           1 (1-4)                     2 (1-3)
I feel upset (range, 1-4     1 (1-4)        2 (1-4)             1 (1-3)           1 (1-4)                     1 (1-3)
I am relaxed                 3 (1-4)        3 (1-4)             3 (1-4)           1 (1-4)                     3 (1-4)
(range, 1-4)
I feel content               3 (1-4)        3 (1-4)           2.5 (1-4)           1 (1-4)                     3 (1-4)
(range, 1-4)
I am worried                 2 (1-4)        2 (1-4)             2 (1-4)           1 (1-4)                     3 (1-4)
(range, 1-4)
RIES
Avoidance subscale          4 (0-26)        3 (0-26)          6.5 (0-22)
(range, 0-40)
Intrusion subscale          3 (0-21)        2 (0-21)          4.5 (0-10)
(range, 0-35)
MWS = Melanoma Worry Scale; STAI-6 = State-trait Anxiety Inventory. RIES = revised Impact of Event Survey.
c
 Mean
a
  P-value obtained from paired t-test.



Letter to the Editor | Dermatol Pract Concept. 2023;13(4):e2023199                                                                 3
    Our study showed that LM patients experience substan-            To our knowledge, this is the first study assessing psy-
tial levels of baseline melanoma-related worry and anxiety,       chological distress in LM patients. We show benefit of nail
with internet searching, psychiatric illness, personal history    evaluation on patients psychological wellbeing. We hope
of melanoma, and higher baseline STAI-6 scores predicting         our study will spur dermatologists to regularly perform
higher baseline worry levels. Similar MWS scores (median          nail examinations data and encourage community efforts
8/17) were reported in a survey-based study of 138 p
                                                   ­ atients      to improve accuracy and readability of NUM educational
with atypical mole syndrome undergoing total-body digital         materials.
photography [1]. In a survey-based study of 324 ­patients
with pigmented lesions, mean STAI-6 scores for those
­needing skin biopsy vs. not were 13/26 and 11/26, respec-        References
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MWS or STAI-6 levels between biopsy/no-biopsy groups,                tal photography on cancer worry in patients with atypical mole
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