10.5826/dpc.1301a18
Introduction The increasing use of teledermatoscopy in clinical practice has led to demands to evaluate the effects of this new technology on traditional healthcare systems.
Objectives To study lead times from first consultation in primary care to diagnostic excision of suspected malignant melanoma lesions in traditional referrals to a tertiary hospital-based dermatology clinic compared with mobile teledermatoscopy referrals.
Methods A retrospective cohort study design was used. Data on sex, age, pathology report, names of caregivers, clinical diagnosis, date for first visit to primary care unit, and date for diagnostic excision were collected from medical records. Patients managed through traditional referral (n=53) were compared with patients managed at primary care units using teledermatoscopy (n=128) regarding lead time from first visit to diagnostic excision.
Results Mean time from date of first visit at primary care unit to diagnostic excision did not differ between the traditional referral and teledermatoscopy groups (16.2 vs. 15.7 days, median 10 vs. 13 days, p=0.657). Lead times from date of referral to diagnostic excision did not significantly differ (15.7 vs. 12.8 days, median 10 vs. 9 days, p=0.464).
Conclusions Our study indicates that lead time to diagnostic excision for patients with suspected malignant melanoma managed by teledermatoscopy was comparable and not inferior to that of the traditional referral pathway. If teledermatoscopy is used at first consultation in primary care, it could potentially be more efficient than traditional referral.
text/xml
2160-9381
2421
en
Emma K Johansson
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
general practitioner
Lead Time From First Suspicion Of Malignant Melanoma In Primary Care To Diagnostic Excision: A Cohort Study Comparing Teledermatoscopy And Traditional Referral To A Dermatology Clinic At A Tertiary Hospital
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-02-25
2023-01-31
2023-02-27
e2023018
Dermatol Pract Concept
Introduction The increasing use of teledermatoscopy in clinical practice has led to demands to evaluate the effects of this new technology on traditional healthcare systems.
Objectives To study lead times from first consultation in primary care to diagnostic excision of suspected malignant melanoma lesions in traditional referrals to a tertiary hospital-based dermatology clinic compared with mobile teledermatoscopy referrals.
Methods A retrospective cohort study design was used. Data on sex, age, pathology report, names of caregivers, clinical diagnosis, date for first visit to primary care unit, and date for diagnostic excision were collected from medical records. Patients managed through traditional referral (n=53) were compared with patients managed at primary care units using teledermatoscopy (n=128) regarding lead time from first visit to diagnostic excision.
Results Mean time from date of first visit at primary care unit to diagnostic excision did not differ between the traditional referral and teledermatoscopy groups (16.2 vs. 15.7 days, median 10 vs. 13 days, p=0.657). Lead times from date of referral to diagnostic excision did not significantly differ (15.7 vs. 12.8 days, median 10 vs. 9 days, p=0.464).
Conclusions Our study indicates that lead time to diagnostic excision for patients with suspected malignant melanoma managed by teledermatoscopy was comparable and not inferior to that of the traditional referral pathway. If teledermatoscopy is used at first consultation in primary care, it could potentially be more efficient than traditional referral.
Emma K Johansson
2023/01/31
10.5826/dpc.1301a18
e2023018
Department of Dermatology, Karolinska University Hospital; Dermatology and Venereology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
2160-9381
general practitioner
en
e2023018
Fee JA, McGrady FP, Rosendahl C, Hart ND. Dermoscopy Use in Primary Care: A Scoping Review. Dermatol Pract Concept. 2019;9(2):98-104. DOI: 10.5826/dpc.0902a04. PMID:31106011.
Lead Time From First Suspicion Of Malignant Melanoma In Primary Care To Diagnostic Excision: A Cohort Study Comparing Teledermatoscopy And Traditional Referral To A Dermatology Clinic At A Tertiary Hospital
https://dpcj.org/index.php/dpc/article/download/2421/1920
    Lead Time from First Suspicion of Malignant
  Melanoma in Primary Care to Diagnostic Excision:
   a Cohort Study Comparing Teledermatoscopy
     and Traditional Referral to a Dermatology
            Clinic at a Tertiary Hospital
                  Karina Schultz1, Lina Ulrika Ivert1,2, Jan Lapins1,2, Karin Sartorius1,3,
                                       Emma Kristin Johansson1,2


1 Department of Dermatology, Karolinska University Hospital, Stockholm, Sweden
2 Dermatology and Venereology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
3 Department of Clinical Science, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden



Key words: teledermatoscopy, dermatoscopy, lead time, malignant melanoma, general practitioner
Citation: Schultz K, Ivert LU, Lapins J, Sartorius K, Johansson EK. Lead Time From First Suspicion Of Malignant Melanoma In Primary
Care To Diagnostic Excision: A Cohort Study Comparing Teledermatoscopy And Traditional Referral To A Dermatology Clinic At
A Tertiary Hospital. Dermatol Pract Concept. 2023;13(1):e2023018. DOI: https://doi.org/10.5826/dpc.1301a18
Accepted: June 8, 2022; Published: January 2023
Copyright: ©2023 Schultz 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: Karina Schultz, Department of Dermatology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
E-mail: karina.schultz@regionstockholm.se




  ABSTRACT             Introduction: The increasing use of teledermatoscopy in clinical practice has led to demands to eval-
                       uate the effects of this new technology on traditional healthcare systems.
                       Objectives: To study lead times from first consultation in primary care to diagnostic excision of sus-
                       pected malignant melanoma lesions in traditional referrals to a tertiary hospital-based dermatology
                       clinic compared with mobile teledermatoscopy referrals.
                       Methods: A retrospective cohort study design was used. Data on sex, age, pathology, caregivers,
                       ­clinical diagnosis, date for first visit to primary care unit, and date for diagnostic excision were
                        ­collected from medical records. Patients managed through traditional referral (n=53) were compared
                         with patients managed at primary care units using teledermatoscopy (n=128) regarding lead time from
                         first visit to diagnostic excision.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023018                                                                        1
                     Results: Mean time from date of first visit at primary care unit to diagnostic excision did not differ be-
                     tween the traditional referral and teledermatoscopy groups (16.2 vs. 15.7 days, median 10 vs. 13 days,
                     p=0.657). Lead times from date of referral to diagnostic excision did not significantly differ (15.7 vs.
                     12.8 days, median 10 vs. 9 days, p=0.464).
                     Conclusions: Our study indicates that lead time to diagnostic excision for patients with suspected
                     malignant melanoma managed by teledermatoscopy was comparable and not inferior to that of the
                     traditional referral pathway. If teledermatoscopy is used at first consultation in primary care, it could
                     potentially be more efficient than traditional referral.




Introduction                                                      SC pathway’s ideal time frame from reasonable suspicion of
                                                                  melanoma to initiation of treatment (diagnostic excision) is
Sweden has one of the highest incidence rates of cutane-          seven days.
ous melanoma in Europe and the incidence is increasing,              In 2015, a mobile TDS pilot project was initiated and
as in most areas with fair-skinned populations, e.g., North       funded by the Stockholm health authorities at the Regional
­America, northern Europe, Australia, and New Zealand [1].        Cancer Center. In the final implementation of the project, the
Diagnosing malignant melanoma at an early stage remains           intention is to include all 200 PCUs in the Stockholm region
the most important predictor of melanoma survival [2].            by 2023.
Most patients have their first consultation in primary care
(PC) and improved management of suspicious pigmented
lesions in this setting is needed. Increasing digitalization in   Objectives
healthcare, including teledermatoscopy (TDS), could be a
                                                                  The aim of this study was to investigate potential differences
promising instrument for skin cancer care [3-5].
                                                                  in lead time from suspicion of malignant melanoma to exci-
    It is well-established that dermatoscopy, in experienced
                                                                  sion when using TDS in PC compared with traditional refer-
hands, increases diagnostic accuracy for both melanocytic
                                                                  ral (TR) to a tertiary dermatology center.
and non-melanocytic lesions [6-13]. Finnane et al. found
in their review that teledermatology consistently reduced
waiting times for assessment and diagnosis, with high pa-         Methods
tient satisfaction [14], and studies indicate that lead times
for patients with suspected malignant melanoma can be re-         Setting
duced if TDS is used for triage [15-18]. Moreover, double         For the present TDS project, PCUs use a dedicated mobile
reading of images has been shown to improve diagnostic            platform (Dermicus, Gnosco AB, Sweden). From 2015, PCUs
performance in telemedicine settings [19-21]. The evolution       in the Stockholm region were recruited. They could partic-
of smartphone-attached dermatoscopes and smartphone ap-           ipate cost-free. The equipment (dermatoscope and phone)
plications makes TDS increasingly convenient to use [22,23].      was free for PCs. In 2019 there were two to four physicians
The role of TDS in managing skin cancer, including the lead       active per PCU, with a total of 230 cases per month. PC
time from the first visit in PC to diagnostic excision, needs     physicians received an introduction to the equipment and a
further exploration [4,14].                                       brief online dermatoscopy course. They chose which lesions
    The region of Stockholm, Sweden, has 2.4 million in-          and the number of lesions to refer without the involvement
habitants, with access to more than 200 primary care units        of a dermatologist. In the clinic, PC physicians take photos
(PCUs). Patients with suspected skin cancer usually visit a       of suspected lesions with a smartphone (iPhone 6S, Apple
PCU, are evaluated by PC physicians, and, if needed, re-          Inc.), attached to a dermatoscope (Heine ic1; Heine Opto-
ferred to a dermatologist at either an out-of-hospital or a       technik, Herrsching, Germany). An overview, a close-up, and
hospital-based dermatology clinic.                                two dermatoscopic images (polarized, unpolarized) are col-
    In 2015, in Sweden, a guideline on urgent cancer refer-       lected and uploaded to a database (Fig. 1,2). The images and
ral pathways (standardized care (SC) pathways) was im-            background information (e.g., patient age and sex, history of
plemented for cancer care, including malignant melanoma           changes and symptoms) are reviewed and dermatoscopic im-
care [24]. In cases reasonably suspicious of malignant mela-      ages analyzed through double reading. A consultation report
noma, a fast-track SC pathway starts and the PC physician         is issued by at least two dermatologists in consensus. The
labels the referral “SC pathway cutaneous melanoma.” The          dermatologists are trained in dermatoscopic diagnosis of



2                                                                     Original Article | Dermatol Pract Concept. 2023;13(1):e2023018
Figure 1. Process of mobile teledermatoscopy as used in the project. The primary care physician examines the patient, takes clinical and
dermatoscopic images (A and B), and fills in clinical information which is then packaged together in the mobile app and sent encrypted to a
database. Photo by Oscar Segerström, Medicinsk bild, Karolinska Hospital.




      Figure 2. Photographs of a teledermatoscopy case. (A) An overview, (B) a close-up, and two dermatoscopic images
      ((C) ­polarized, (D) unpolarized) are collected and uploaded in the mobile application together with background informa-
      tion. Histopathologic diagnosis: Lentiginous malignant melanoma in situ described in pathology report as an extensive atyp-
      ical junction melanocytic proliferation, lentiginous and nested, with frequent rete fusion, multifocal pagetoid upgrowth and
      early involvement of adnexal structures. The lesion focally blends with areas of seborrheic keratosis-like epidermal reaction
      and a small benign intradermal nevus is noted at the periphery of the main lesion.



Original Article | Dermatol Pract Concept. 2023;13(1):e2023018                                                                           3
cutaneous malignancies. The PC physician is provided with               PCUs met the inclusion criteria: the purpose of the refer-
a dermatoscopic description of the lesion with a preferential           ral was a specific suspected melanoma that was considered
diagnosis and a recommendation for management (Fig. 3).                 high-priority by the hospital consultant and planned for an
If the lesion is unequivocally benign, no action beyond in-             in-person visit within two weeks. All referrals in the study
formation to the patient is recommended. In equivocal flat              were sent in electronic format and prioritized by the der-
lesions, a short-term digital dermatoscopic follow-up or ex-            matologist at tertiary DU on the same date as referrals from
cision may be recommended. If melanoma is suspected, the                PCU were sent.
recommendation is an urgent excisional biopsy starting the
SC pathway. The diagnostic excision is performed at the PC              Teledermatoscopy (TDS) Group
clinic or, if necessary, referred to a specialist.                      In the period between 1 January 2016 and 26 March 2019,
                                                                        52 PCUs generated 3,850 individual referrals for TDS. When
Study Design and Study Population                                       searching for lesions labelled as suspected melanoma during
All patients managed on the SC pathway due to suspected                 this period, a total of 200 patients were identified. Fifty-five
malignant melanoma 1) at a tertiary dermatology clinic,                 lesions were excluded based on not being labelled as cases
Södersjukhuset or 2) in the TDS project were recruited to               for the SC pathway, 12 had no available electronic medical
this cohort study. Data were collected from electronic medi-            records, and one was evaluated by only one dermatologist.
cal records. Patients aged 18 years and older were included.            In all, 132 referrals met the criteria in the TDS group: at least
Referrals for specific suspected melanoma lesions that were             two dermatologists in consensus stated that the suspicion of
considered high-priority were selected. Data on sex, age, pa-           malignant melanoma was high and that the SC pathway for
thology, caregivers, clinical diagnosis, date of first PCU visit,       melanoma was recommended.
and date of diagnostic excision, were collected.
                                                                        Primary Outcome
Traditional Referral (TR) Group                                         Lead time (days) from the date of first PCU visit to the date
During the study period from 1 January 2016 to 19 ­December             of diagnostic excision.
2018, 274 patients that were referred to the hospital-based
dermatology unit at Södersjukhuset (tertiary DU) and la-                Secondary Outcome
belled as having suspected melanomas on the SC pathway                  Lead time (days) from date of referral to tertiary DU or TDS
were identified. Of those 274 referrals, 66 from 29 different           to date of diagnostic excision.




        Figure 3. Example of a teledermatoscopy case. The primary care physician fills in clinical information. Two dermatologists
        assess the case independently and provide a detailed description of the dermatoscopic findings, a provisional diagnosis, and
        a consensus recommendation for further diagnostic action.



4                                                                            Original Article | Dermatol Pract Concept. 2023;13(1):e2023018
Statistics                                                       Results
Background characteristics are expressed as percentages
of the total number of individuals or lesions observed, or       A total of 198 patients (one unique lesion per patient) were

mean values and 95% confidence intervals (CIs). Lead times       included in the study, 66 in the TR group and 132 in the TDS

were not normally distributed in the study population and        group (Fig. 4). The background characteristics and a summary

are presented as medians with interquartile ranges (IQRs).       of diagnoses are shown in Tables 1 and 2, respectively. No sig-

P values were calculated with the two-sample Wilcoxon-           nificant differences were observed in age, sex, lesion diameter,

Mann-­Whitney rank-sum test or chi-squared test (dichoto-        or the proportion of histopathologically confirmed melano-

mous variables), and p < 0.05 was considered significant. All    mas. The proportion of invasive melanoma was significantly

statistical calculations were performed with Stata statistical   larger in the TR group than in the TDS group (p=0.028) and

software (StataCorp 2019. Stata Statistical Software: Re-        invasive melanomas were significantly thicker in the TR group

lease 16. College Station, TX: StataCorp LLC).                   (p=0.005). The proportion of melanoma in situ was larger in
                                                                 the TDS group (p=0.036). Among excised lesions, five were of
                                                                 non-melanocytic origin in the TR group and nine in the TDS
Ethics                                                           group (Table 2). In the TR group, five seborrheic keratoses
Ethical approval was obtained from the Swedish ethics com-       were confirmed by partial biopsy, but none were considered
mittee (2019-01290).                                             high-priority (SC pathway) at in-person visits at the tertiary DU.




                 Figure 4. Study flowchart. DU – dermatology unit, PC – primary care, PCU – primary care unit,
                 SU – surgery unit, SC – standardized care, tertiary DU – Södersjukhuset dermatology unit.
                 * SC pathway ends at face-to-face visit.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023018                                                                   5
                                      Table 1. Characteristics of the study population.
                                          Traditional referral (n=66)*              Teledermatoscopy (n=132)**
                                              Mean                95% CI                Mean                 95% CI                 P value
 Age (years)                                    61.0             57.0–64.9               56.1               53.4–58.9               0.054
                                           Proportion             95% CI              Proportion             95% CI
 Female sex (%)                                 42.4             30.3–55.2               53.8               44.9–62.5               0.132
 Proportion of melanoma                         54.5             42.2–68.9               54.5               45.9–63.2               1.000
 Proportion of in situ                          19.7             10.9–31.3               34.1               26.1–42.8               0.036
 melanoma
 Proportion of invasive                         34.8             23.0–46.7               20.5               13.5–27.4               0.028
 melanoma
                                              Mean                 Range                Mean                  Range
 Thickness of invasive                          1.35             0.30–4.50               0.74               0.20–2.15               0.005
 melanoma (mm)
 Max lesion diameter (mm)                   11.4***                2–30                 9.4***                2–30                  0.057
 Lesion localization
                                            Number             Proportion (%)          Number             Proportion (%)
 Head                                           8/66                12.1                10/132                 7.6
 Arms (including shoulders)                   13/66                 19.7                20/132                 15.2
 Legs                                         16/66                 24.2                26/132                 19.7
 Trunk (including neck,                       29/66                 43.9                76/132                 57.6
 gluteus)

CI: confidence interval *Traditional referral: 66 lesions, 36 melanomas (13 in situ, 23 invasive). **Teledermatoscopy: 132 lesions,
72 ­melanomas (45 in situ, 27 invasive). ***There were missing values regarding diameter of the lesion: traditional referral group (n=6), teleder-
matoscopy group (n=3). P values calculated with the chi-squared test (dichotomous variables) or the two-sample Wilcoxon-Mann-Whitney
rank-sum test. Significant differences marked in bold.




               Table 2. Diagnoses of the excised lesions (suspected malignant melanoma at first
                             visit in primary care) among the study participants.
                                             Traditional referral (N=66)                                Teledermatoscopy (N=132)
                                         Partial         Clinical Standard care                               Partial      Clinical
        Diagnosis           Excised      biopsy        evaluation   pathway*             Total    Excised     biopsy     evaluation       Total
 Melanoma invasive             23           0              0                23            23         27          0            2**             29
 Melanoma in situ              13           0              0                13            13         44          1            0               45
 Severe dysplastic               2          0              0                 2              2         7          0            0                7
 nevus
 Melanocytic nevus             10           1              0                10            11         38          0            1               39
 Seborrheic keratosis            3          5              1                 3              9         2          0            0                2
 Squamous cell                   0          0              0                 0              0         0          0            0                0
 carcinoma
 Basal cell carcinoma            1          0              0                 1              1         0          0            0                0
 Spitzoid lesion                 1          0              0                 1              1         3          0            0                3
 Other***                        1          3              2                 3              6         7          0            0                7

* Lesion evaluated as highly suspected malignant melanoma at face-to-face visit at a tertiary dermatology unit (n=53) ** Patient declined
excision. *** Traditional referral group: Epidermal hyperplasia, angioma, lichenoid keratosis, paronychia, subungual bleeding, pseudocyst.
Teledermatoscopy group: Atypical lentiginous lesion, lentigo benigna, lichenoid keratosis, angioma, fibrous histiocytoma, basal melanosis.




6                                                                                Original Article | Dermatol Pract Concept. 2023;13(1):e2023018
TR Group Analysis                                                 (n=87), 7.5 days (IQR 3–19.5, mean 13.2) vs. 13 days (IQR
Of the 66 patients with a referral from PCU, and labelled         8–19, mean 15.2).
high-priority by a dermatology consultant, 56 were assessed
as eligible for the SC pathway at an in-person visit at the       Comparison of TR and TDS Group Lead Times
tertiary DU. In ten cases, the SC pathway was aborted at          Including all excised SC pathway lesions in both cohorts
in-person visits due to the lesion not meeting the criteria of    (n=181), the median lead time from the first visit to diagnos-
suspected melanoma; one was of melanocytic origin (mela-          tic excision was 12 days (IQR 6–19; mean 15.8) and from
nocytic nevus) and was excised, while the rest had other di-      referral to excision 10 days (IQR 6–16; mean 13.6).
agnoses. Three lesions were managed through partial biopsy           Median lead times from first PCU visit to excision
at the first visit and not scheduled for diagnostic excision.     were comparable (p=0.657) between the TR group (n=53,
In the TR group (n=53), median lead time from first visit at      10 days, IQR 6–20; mean 16.2) and the TDS group (n=128,
PCU to diagnostic excision was 10 days (IQR 6–20; mean            13 days, IQR 6–19; mean 15.7). Median lead times from the
16.2). When excluding eight patients that were referred to a      date of referral sent from PCU to time of excision were also
plastic surgery unit (SU), the median lead time was 10 days       comparable (p=0.464): TR 10 days (n=53, IQR 6–20; mean
(IQR 6–14; mean 11.4).                                            15.7) vs. TDS 9 days (n=128, IQR 5–15.5; mean 12.8).
                                                                     When comparing the TR and TDS groups and exclud-
TDS Group Analysis                                                ing the neglected patient (lead time 156 days), times from
Of 132 TDS referrals assessed as suspected melanoma, 128          the first visit to excision had a median of 10 vs. 13 days
were excised (Fig. 4). Excision was performed at PCU in           (p=0.716) and times from referral to excision were not sig-
40 cases. Seventy-seven cases were referred to a dermatol-        nificantly different (median 10 vs. 9 days, p=0.412).
ogy unit (DU) for excision. In seven cases, the PCU chose            For histopathologically confirmed malignant melano-
to refer the patient to a plastic SU due to lesion location       mas, the median lead times from the first visit to excision
and size. Four lesions were referred to a general practice sur-   were comparable (p=0.905) in the TR (n=36) and TDS
geon. Reasons for lesions not being excised (n=4): patients       groups (n=71): 13 days (IQR 6.5–22; mean 19.1) vs. 14 days
declined excision/further treatment (n=2), referral to a DU       (IQR 7–18; mean 16.8), as were the median lead times from
where another dermatologist ended the SC pathway, view-           referral to excision (p=0.166): TR 12.5 days (IQR 6–22;
ing the lesion as benign (n=1), lentigo maligna treated with      mean 18.4) vs. TDS 10 days (IQR 4–15; mean 13.2).
Grenz rays [25] after biopsy instead of excision (n=1).
    Median lead time from the first visit to diagnostic exci-
                                                                  Discussion
sion was 13 days (IQR 6–19; mean 15.7) among all excised
lesions in TDS (n=128). One patient’s referral was neglected,     In this study from Stockholm, patients with suspected ma-
with late management (time to excision 156 days); the case        lignant melanoma identified in PC had a median lead time
was described as an invasive melanoma in the pathology            of 12 days (IQR 6–19; mean 15.8) from first consultation to
report. After exclusion of that case, median lead time was        diagnostic excision. We found that the use of TDS referral
13 days (IQR 6–19; mean 14.6). Some patients were resched-        pathways in PC was at least as efficient regarding lead time
uled at the PCU visit and received a separate appointment for     as TR to a well-organized hospital clinic specialized in cu-
TDS (n=26), which resulted in extended lead time to diagnos-      taneous cancer care. The study identified an organizational
tic excision. Patients who got TDS at their first visit (n=101)   procedure that prolonged the lead time when using TDS. If
had significantly shorter lead time (p<0.001) than those who      TDS were optimized by avoiding internal rescheduling for
were rescheduled: median 10 days (IQR 6–16; mean 12.6)            TDS at the PCU, it could have an even shorter lead time
vs. median 18 days (IQR 13–29; mean 22.3). Patients with          to excision. The impact of TDS on lead time might be of
a difficult site for excision of malignant melanoma were re-      even greater value in rural areas. Furthermore, our findings
ferred to a plastic surgeon (n=7). Median lead time for these     showed that lead time in both cohorts was comparable to
patients was 25 days (IQR 16–43; mean 30.7). Patients with        the standards recommended in international guidelines pre-
excision at other units (DU or general SU, n=80) had com-         sented in the Australian Optimal Care Pathway for people
parable lead times, median 13 days (IQR 8–17; mean 13.9).         with melanoma and the UK Government two-week rule for
The median lead time for patients with surgery performed at       the skin cancer referral pathway [26,27]. The lead times in
a PCU (n=40) was significantly shorter (p=0.013) than for         our study are favorable compared with those in other set-
patients receiving surgery at other units, including plastic SU   tings [16,17]. However, the Swedish SC pathway’s ideal time




Original Article | Dermatol Pract Concept. 2023;13(1):e2023018                                                                7
frame of seven days to excision was not achieved in either        for nodular melanomas: five- and ten-year disease-specific
the TR or the TDS group. The shortest lead times were ob-         survival both decreased by 14.4% in patients treated after
served for patients with surgery performed at a PCU.              a potential delay of 3 months [33]. Radical diagnostic exci-
    In our analyses of histopathologcally confirmed malig-        sion is probably the most important therapeutic intervention
nant melanoma excised at a PCU (n=20), median time from           in a localized disease stage, and studies on time to subse-
referral for TDS to excision was 4 days (range 1–47) and          quent wide excision have reported somewhat contradictory
from first PCU visit to excision 7.5 days (range 1–47). Sim-      outcomes on prognosis [34,35]. The need of improving the
ilarly, Wikström et al. have recently shown that patients in      prevention and outcomes of skin cancer is discussed in the
Stockholm with malignant melanoma had a significantly             summary by Garbe et al. [36]. They highlight that better
shorter median lead time to diagnostic excision when sur-         training of GPs/PC physicians in skin cancer detection and
gery was performed by a general practitioner (GP) (5 days)        better coordination of the patient care pathway from the
when compared with private dermatology/surgery or univer-         GP/PC physician are necessary. The threshold for patients
sity clinics (16 and 12 days, respectively) [28]. Both studies    seeking help for a worrisome skin lesion may be reduced by
indicated that PC in Stockholm was more effective regarding       convenient, easily accessible, well-organized expertise – for
lead time to excision than when patients were referred for        instance through TDS – in PC. We observed that PC physi-
excision. If TDS is used properly, the lead time to excision      cians initially referred banal lesions for TDS evaluation, but
for patients with suspected malignant melanomas could be          this gradually advanced to predominantly complex referrals.
reduced even more. Other studies have shown that lead time        As discussed in the review of Fee et al., one of the barriers to
can be reduced by using TDS [15-18,29]. As pointed out in         the use of dermatoscopy in PC is lack of training [37]. The
the literature review by Finnane et al., actual waiting times     educational value of TDS in PC could be significant and is
vary significantly between different studies [14]. Congalton      not well-studied. Furthermore, TDS is still not included in
et al. demonstrated the ability of TDS to reduce wait times in    European residency programs. To date, some TDS projects
a virtual lesion clinic (VLC), a skin imaging center, in New      were carried out, for training purposes (i.e., early melanoma
Zealand [16]. Patients were referred by a GP to a VLC, where      recognition) and showed that residents/novices reached a
TDS was performed. The median waiting time between re-            higher learning curve and accuracy compared with older/ex-
ferral and VLC assessment was 9 days, compared with 26.5          perts, especially with mobile tools [38,39]. In addition, the
days for standard outpatient assessment by a dermatologist.       covid pandemic has stressed the importance of being able to
VLC patients underwent excision earlier than patients un-         manage TDS tools.
dergoing a standard assessment. Median time to excision of           The use of dermatoscopy by general practitioners in con-
a suspected melanoma was 40 days from VLC assessment. In          junction with the value of TDS could significantly improve
another consecutive study from New Zealand, Sunderland            the early detection of melanoma. It may, in part, explain
et al. showed that a hybrid e-referral system, where an expe-     the detection of a higher proportion of in situ melanomas
rienced surgical oncologist selected the management option        and melanomas with a lower Breslow thickness in the
or referred suspected melanomas for TDS, could reduce the         TDS cohort. Further, there is evidence that melanomas de-
number requiring excision [30]. In a TDS project in Belgium       tected by dermatologists are thinner than those detected by
(Telespot), Damsin et al. found a median delay of 11 days be-     non-dermatologists [40]. An alternative explanation is the
tween TDS diagnosis and treatment of high-priority lesions,       involvement of selection bias where the more obvious mela-
which was seven times shorter than the conventional care          nomas are referred to either a dermatologist or for excision
pathway [17]. Morton et al. set up a photo triage center and      (without TDS consultation), while PCUs use TDS for more
reduced mean waiting times to intervention for melanoma           equivocal lesions. If this is true, then the number needed to
from 39 to 36 days [29]. In both Congleton et al. and Mor-        excise for benign lesions may decrease with TDS.
ton et al., patients were lost to follow-up since they did not       This paper compares two ways of processing patients
show up for the photo session (10% and 22%, respectively).        with suspected melanoma lesions, initially evaluated in PC.
This highlights why TDS at a first visit is important, and        We did not find any significant difference in lead times be-
when TDS is performed at the first PCU visit, the risk of         tween the TR pathway and the TDS pathway. When ana-
no-shows can be eliminated.                                       lyzing teledermatoscopy separately, we could conclude that
    Studies on the timeline from a patient first noticing a le-   there was potential to optimize lead times by using TDS at
sion to consultation and excisional biopsy have not shown         a first appointment, rather than rescheduling specifically for
any impact on Breslow thickness, though they have shown           TDS – and also, when possible, performing diagnostic ex-
that patient delay (pre-presentation time) makes up the larg-     cision in a PCU. In Stockholm, TDS is becoming one of the
est proportion of the delay [31,32]. There are studies indi-      key instruments in PC, with PC physicians enlisting the aid
cating that time to excision can affect the prognosis, at least   of dermatology specialists. Although studies have recognized



8                                                                     Original Article | Dermatol Pract Concept. 2023;13(1):e2023018
that TDS can be an effective tool to improve skin cancer                      a clinical setting. Br J Dermatol. 2008;159(3):669-76. DOI:
care, research has yet to closely investigate its role in varied              10.1111/j.1365-2133.2008.08713.x. PMID:18616769.
                                                                         8.   Rosendahl C, Tschandl P, Cameron A, Kittler H. Diagnostic ac-
settings, such as urban or rural.
                                                                              curacy of dermatoscopy for melanocytic and nonmelanocytic
                                                                              pigmented lesions. J Am Acad Dermatol. 2011;64(6):1068-73.
Strengths and Limitations                                                     DOI: 10.1016/j.jaad.2010.03.039. PMID:21440329.
The major strengths of this study are the cohort design and              9.   Kittler H, Seltenheim M, Pehamberger H, Wolff K, Binder M.
the inclusion of a cohort of patients treated with standard                   Diagnostic informativeness of compressed digital epilumines-
                                                                              cence microscopy images of pigmented skin lesions compared
healthcare (TR group) for comparison of lead times. How-
                                                                              with photographs. Melanoma Res. 1998;8(3):255-60. DOI:
ever, it is a limitation that we included only one tertiary cen-
                                                                              10.1097/00008390-199806000-00008. PMID:9664147.
ter, making it difficult to generalize our findings to healthcare       10.   Piccolo D, Peris K, Chimenti S, Argenziano G, Soyer HP. Jumping
systems in other settings, such as other regions in Sweden,                   into the future using teledermoscopy. Skinmed. 2002;1(1):20-4.
remote or rural areas, or other countries with unstructured                   DOI: 10.1111/j.1540-9740.2002.01830.x. PMID:14673232.
tracking of suspicious cancer. Another limitation is that the           11.   Vestergaard T, Prasad SC, Schuster A, Laurinaviciene R, Andersen
                                                                              MK, Bygum A. Diagnostic accuracy and interobserver concor-
study was conducted at the time of a pilot TDS project, and
                                                                              dance: teledermoscopy of 600 suspicious skin lesions in Southern
therefore not representative of how efficient it will be after
                                                                              Denmark. J Eur Acad Dermatol Venereol. 2020;34(7):1601-
implementation.                                                               1608. DOI: 10.1111/jdv.16275. PMID:32031277.
                                                                        12.   Börve A, Terstappen K, Sandberg C, Paoli J. Mobile
                                                                              ­teledermoscopy-there’s an app for that! Dermatol Pract Concept.
Conclusions                                                                    2013;3(2):41-8. DOI: 10.5826/dpc.0302a05. PMID:23785643.
                                                                        13.    Arzberger E, Curiel-Lewandrowski C, Blum A, et al. Teleder-
Lead time from a first PCU visit to diagnostic excision in a
                                                                              moscopy in High-risk Melanoma Patients: A Comparative
TDS urgent referral pathway in PC was comparable to that                      Study of Face-to-face and Teledermatology Visits. Acta Derm
of a traditional urgent referral pathway to a well-organized                  Venereol. 2016;96(6):779-83. DOI: 10.2340/00015555-2344.
hospital clinic. If TDS is used at the first PC consultation,                 PMID:26776245.
the lead time to diagnostic excision of suspected melanomas             14.   Finnane A, Dallest K, Janda M, Soyer HP. Teledermatology for
                                                                              the Diagnosis and Management of Skin Cancer: A Systematic
could be shorter than it is with the standard referral pathway.
                                                                              Review. JAMA Dermatol. 2017;153(3):319-327. DOI: 10.1001
                                                                              /jamadermatol.2016.4361. PMID:27926766.
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10                                                                           Original Article | Dermatol Pract Concept. 2023;13(1):e2023018
