Key Points
Question
What are the lived experiences and fear of cancer recurrence among survivors of localized cutaneous melanoma?
Findings
In this qualitative and survey-based study of 51 patients with a history of localized cutaneous melanoma (stage 0-IIA), most respondents reported high levels of fear of cancer recurrence. Survivors also described negative emotions surrounding follow-up appointments, intensity of melanoma surveillance, lifestyle changes associated with sun exposure, and thoughts about life and death.
Meaning
These findings suggest that despite having excellent prognoses, survivors of localized melanoma have high rates of fear of cancer recurrence, and express intense negative survivorship experiences that could affect psychological well-being.
Abstract
Importance
Most of the rapid increase in cutaneous melanoma incidence in the US has been localized disease that is treated surgically and is associated with high survival rates. However, little is known about the psychological well-being of survivors in the US.
Objective
To explore the lived experiences and fear of cancer recurrence among survivors of localized cutaneous melanoma.
Design, Setting, and Participants
This was a qualitative and survey-based study that used semistructured interviews and the Fear of Cancer Recurrence Inventory short form (FCRI-SF) survey tool with participants recruited from an academic dermatology practice affiliated with the University of Texas, Austin. Interviews were completed via telephone or in person from August 2021 to September 2022. Each of the 9 items in the FCRI-SF was rated on a 5-point Likert scale, scored from 0 to 4, with a maximum possible score of 36 points. Data analyses were performed from February 2022 to June 2023.
Main Outcomes and Measures
Semistructured interviews were analyzed for themes and subthemes associated with the lived experiences of survivors of cutaneous melanoma. The FCRI-SF scores were tabulated, with scores of 13 or greater identifying potential cases of clinically significant fear of cancer recurrence.
Results
In all, 51 participants (mean [SD] age, 49.5 [11.7] years; 34 [67%] female and 17 [33%] male) with a history of localized melanoma (stage 0-IIA) completed the interview and survey. Among them, 17 (33%) had survived a diagnosis of stage 0 melanoma, and the remainder, at least 1 invasive melanoma diagnosis (stage I-IIA). Semistructured interviews revealed several themes: (1) emotions surrounding follow-up appointments, (2) intensity of melanoma surveillance, (3) lifestyle changes regarding sun exposure, and (4) thoughts about life and death. Thirty-eight of 51 participants had an FCRI-SF score above the threshold for clinical fear of cancer recurrence.
Conclusions and Relevance
This qualitative and survey-based study found that despite having an excellent prognosis, some survivors of localized melanoma, even those who had stage 0, have high rates of fear of cancer recurrence and intense survivorship experiences that affect their psychological well-being.
This qualitative and survey-based study uses interviews and surveys to understand the psychological well-being of survivors of localized cutaneous melanoma.
Introduction
Melanoma is the fifth most common cancer in the US, and its incidence continues to increase. Most melanomas are detected at early stages and have good prognoses; however, a small proportion will progress and be fatal. In 2023, an estimated 8000 deaths in the US will be attributable to melanoma.1 The lethality of melanoma is highly dependent on the stage at which it is detected—lower stage at diagnosis is associated with much lower risk of death. Nearly 80% of invasive melanomas are diagnosed at the localized stage, which has a 5-year survival of 99.6%.2
Furthermore, half of all melanomas diagnosed in the US are stage 0, also referred to as melanoma in situ (MIS).3 Patients diagnosed with MIS or early invasive melanoma (stage I) have a relative survival rate of greater than 100%, meaning their survival rate from all causes is higher than age-, sex-, and race-matched controls without melanoma.4,5 Despite a good prognosis, patients can experience recurrence or, more commonly, develop subsequent primary melanomas, and therefore, they undergo frequent follow-up screening and examinations.5
Many studies have documented the psychological and physical repercussions of a melanoma diagnosis.6,7 However, despite the increasing incidence and prevalence of lower-stage melanomas, particularly MIS, fewer studies have used qualitative methods to understand how a melanoma diagnosis affects the lived experiences of this patient population. Notably, few studies have assessed the fear of cancer recurrence among survivors of early-stage melanoma, and to our knowledge, no related research has been conducted in the US.8 Thus, our research objective was to perform a qualitative and survey-based study to understand the lived experiences and fear of cancer recurrence among survivors of stage 0 to IIA localized cutaneous melanoma.
Methods
The institutional review board of the Dell Medical School at The University of Texas in Austin reviewed and approved this study. Before the interview, participants provided written informed consent, agreeing to a recorded interview and allowing their deidentified data to be used for research. Participants were compensated with a gift card of $50. This study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline.9
Setting, Population, and Recruitment
Participants were recruited by convenience sampling. Eligibility criteria included being at least 18 years old, being able and willing to provide informed consent in English, and having a history of at least 1 localized melanoma (MIS or stage I-IIA). Recruitment occurred within a small academic dermatology practice affiliated with the University of Texas in Austin. After a scheduled clinic visit, patients who met the inclusion criteria were invited to participate in the study.
Semistructured interviews (30-75 minutes) were conducted from August 2021 to September 2022 via a 1-on-1 telephone conversation, with the exception of 1 interview that was conducted in-person. Sixty-one patients met inclusion criteria and were approached to participate.
Interview Guide Development and Survey
The semistructured interview guide was developed by 4 of the study team members (J.L., A.S.A., E.A.J., J.T.) through a consensus process involving several iterations. It was then pilot-tested with survivors who met the inclusion criteria but who were later excluded from the final study analyses. The interview guide was adjusted according to the feedback from the pilot group. The final interview guide was composed of open-ended questions to collect information on the patient’s experiences after surviving a melanoma diagnosis and treatment.
In addition, a validated quantitative measure, the Fear of Cancer Recurrence Inventory-short form (FCRI-SF),10 was used to assess clinically significant fear of cancer recurrence among the participants. Clinically significant was defined as fear that could be considered maladaptive and associated with significant psychological distress or disability.10 After obtaining permission from its developer, we adapted the FCRI-SF to include melanoma-specific language.
The FCRI-SF is a shorter version of the FCRI, which comprises 7 subscales: triggers, severity, psychological distress, coping strategies, functioning impairments, insight, and reassurance.11 The FCRI-SF assesses only the severity subscale because it most closely measures clinical fear of cancer recurrence.10 Each FCRI-SF item is rated on a 5-point Likert scale from 0 to 4, with a maximum possible score of 36 points. FCRI-SF item 5, “I believe that I am cured and that the melanoma will not come back” was the only item that had to be reverse-coded to be melanoma-specific. A score of 13 or greater to less than 16 had high sensitivity (88%) and specificity (75%) for clinical fear of cancer recurrence; however, at 16 or greater, the specificity increased to 97% but the sensitivity dropped to 67%.
Data Collection
One member of our team conducted the interviews (J.L.). She is a research coordinator and identifies as female. She was trained in best practices and techniques for qualitative interview methods. The interviews were audio-recorded, deidentified, and transcribed verbatim using Datagain (Datagain Transcription Services). Transcripts were loaded into Dedoose qualitative coding software, version 9.0.86 2022 (SocioCultural Research Consultants, LLC). Our research team reviewed the transcripts for accuracy and removed identifying information. Recruitment ended when thematic saturation was achieved, as indicated by data redundancy.
Participants completed an electronic survey that collected demographic information including age, sex, race and ethnicity, employment status, education level, health insurance, household income, marital status, and melanoma stage (all self-reported). The stage of each melanoma was corroborated using results of prior pathology testing available in the patient’s electronic health record. Participants were grouped by melanoma stage; those with more than 1 melanoma were categorized by the highest stage of melanoma.
The FCRI-SF survey was also sent electronically, via REDCap (Research Electronic Data Capture; Vanderbilt University), and 75% of participants had completed it before the interview. Survey data were managed using REDCap, version 13.5.4.
Statistical Analysis
Semistructured Interviews
Given limited information about the lived experience of patients with localized melanoma, we used a grounded theory framework to inductively develop the codebook and iteratively refine themes elucidated from data collection.12 The codebook was developed by 4 team members (J.L., A.N.M., C.N.H., A.S.A.) who independently coded the first 10 transcripts and generated an initial list of codes with definitions. These codes were discussed, and a consensus was reached. The codebook was used by 3 team members (J.L., A.N.M., C.N.H.) to independently code subsequent transcripts. The codebook was iteratively updated with novel codes through the data collection process, with discrepancies resolved through discussion. Intercoder agreement was assessed via the interrater agreement function in Dedoose, with a κ statistic for agreement of 0.79.
After the codebook was finalized, our team (J.L., A.N.M., C.N.H., A.S.A.) performed thematic analysis at regular meetings where themes and subthemes were discussed, and consensus was reached. Data saturation was achieved after no new themes emerged in the final interviews.
FCRI-SF Survey
Patients’ demographic information and FCRI-SF scores were analyzed using descriptive statistics (means, medians, and ranges). The proportion of participants with an FCRI-SF score of 13 or higher was calculated because it is the recommended threshold for screening for clinical fear of cancer diagnosis. The proportion of participants with a score of 16 or higher was also calculated due to the high specificity at this threshold.
Statistical tests were not performed; only descriptive statistics were used. The analysis was performed from February 2022 to June 2023, using Excel, 16.80 (Microsoft).
Results
In all, 51 patients (mean [SD] age, 49.5 [11.7] years; 34 [67%] female and 17 [33%] male; 51 [100%] were not Hispanic, 50 [98%] were White, and 1 individual [2%] identified as multiracial) provided consent, completed the study requirements, and were included in the analyses (eFigure in Supplement 1). Forty-four participants (86%) reported having a college degree or higher level of education and 43 (84%) reported a household income greater than $100 000 annually. Forty-five participants (88%) reported having private health insurance and 5 (10%) had more than 1 type of insurance. Regarding melanoma stage, 17 participants (33%) had survived MIS; 31 (61%), stage I; and 3 (6%) stage IIA (Table 1).
Table 1. Demographic Characteristics of Participants.
| Characteristic | Participants, No. (%) |
|---|---|
| Total participants, No. | 51 |
| Age, y | |
| 30-39 | 12 (23) |
| 40-49 | 15 (29) |
| 50-59 | 11 (22) |
| 60-69 | 10 (20) |
| 70-79 | 3 (6) |
| Sex | |
| Female | 34 (67) |
| Male | 17 (33) |
| Race and ethnicity | |
| Hispanic | 0 |
| Multiracial | 1 (2) |
| White | 50 (98) |
| Education level, degree | |
| High school | 3 (6) |
| Partial college or associate | 4 (8) |
| Bachelor’s | 17 (33) |
| Master’s | 19 (37) |
| Doctorate | 8 (16) |
| Employment status | |
| Employed | 38 (74) |
| Retired | 11 (22) |
| Unemployed | 2 (4) |
| Health insurance type | |
| Medicare | 1 (2) |
| Medicaid | 0 (0) |
| Private insurance | 45 (88) |
| >1 Insurance type | 5 (10) |
| Household income, $ | |
| ≤24 999 | 1 (2) |
| 25 000-49 999 | 2 (4) |
| 50 000-74 999 | 2 (4) |
| 75 000-99 999 | 3 (6) |
| ≥$100 000 | 43 (84) |
| Marital status | |
| Never married | 4 (8) |
| Cohabiting with partner | 4 (8) |
| Married | 40 (78) |
| Divorced | 2 (4) |
| Widowed | 1 (2) |
| Melanoma stage | |
| 0 (Melanoma in situ) | 17 (33) |
| I (Breslow thickness <0.8 mm) | 31 (61) |
| IIA (Breslow thickness >1.0-2.0 mm) | 3 (6) |
Interview Results
Four main themes and 10 subthemes (Table 2) arose regarding the survivorship experiences of participants with a history of localized cutaneous melanoma. Representative quotes from the answers to the interview questions can be found in eTable in Supplement 1.
Table 2. Themes and Subthemes Among Survey Responses From Survivors of Localized Cutaneous Melanoma.
| Theme | Subtheme |
|---|---|
| 1. Emotions surrounding follow-up appointments | Anxiety leading up to appointments |
| Anxiety undergoing skin examination | |
| Relief after normal examination | |
| 2. Intensity of melanoma surveillance | Biopsy procedure frequency |
| Worries about family risk for melanoma | |
| 3. Lifestyle changes regarding sun exposure | Increase in sun protection practices |
| Fear of the sun | |
| Diminished enjoyment of outdoor activities | |
| 4. Thoughts about life and death | Increased thoughts and guilt about their mortality |
| New perspectives about the future |
Theme 1: Emotions Surrounding Follow-Up Appointments
Anxiety Leading Up to Appointments
When describing their emotions, as follow-up appointments for melanoma surveillance approached, many participants reported heightened anxiety. Participants noted that they dreaded appointments because the clinic visits prompted worry about various moles on their bodies and whether they were developing new melanomas. Multiple participants mentioned that these emotions sometimes occurred daily for weeks to months leading up to follow-up visits. Participant 40 (stage MIS) shared,
I’m anxious at the appointment…I usually have a biopsy…so, I prepare myself mentally that that’s [sic] likely to happen and then waiting the week…it’s like a low-grade fever, like nagging in the back of my mind.
Anxiety Undergoing Skin Examination
Undergoing skin examination provoked anxiety for patients mostly due to fear of melanoma recurrence or that a new primary melanoma would be diagnosed. Participants expressed concerns that additional biopsy procedures would be performed, and these thoughts developed into further exacerbation of already high-anxiety levels. Participant 50 (stage MIS) described the experience as,
It’s high anxiety for me…when I have an appointment…I just get very anxious about it and mainly because I’m thinking, ‘Maybe this time…everything will be fine…There won’t be anything on my body that needs to be removed.’
Relief After Normal Findings
Some participants expressed relief after skin examination, specifically when no new concerning lesions were found. This was described by participant 52 (stage IA) as,
You sort of feel like you have the weight of the world lifted off your shoulders…I get to the appointment and I’m scared that they’re going to say something and when they don’t and I’m like, oh thank you…I feel like just like I don’t have to worry about this now for the next couple of months.
A sense of relief made patients feel positive after skin examinations.
Theme 2: Intensity of Melanoma Surveillance
Biopsy Procedure Frequency
Participants reported undergoing biopsy procedures routinely during their follow-up visits given their history of melanoma. Some were anxious about having additional biopsy procedures, with participant 68 (stage IA) describing, …like a ticking time bomb, all of my moles, biopsy everything. Take them all off.” Other participants reported having stoic feelings, accepting that this was a necessary consequence of their melanoma history.
There were also participants who were grateful for additional biopsy procedures because of the improved likelihood of diagnosing another melanoma early. In fact, some participants desired more biopsy procedures than their treating dermatologist thought necessary. Although these participants understood that more biopsy procedures may not be useful or could cause permanent scarring, they believed that the potential benefits outweighed potential risks.
Worries Regarding Family Risk of Melanoma
Receiving a melanoma diagnosis had made many participants concerned about their family members’ risk of melanoma, especially for their children and siblings. Participant 36 (stage MIS) highlighted the importance of advising family members to see a dermatologist for melanoma screening, stating, “One of the recommendations that they made was to tell them to go get a mole check just in case they were also at higher risk.” Several participants mentioned that, because of their diagnosis, they sought genetic testing for themselves and family members.
Theme 3: Lifestyle Changes Related to Sun Exposure
Increase in Sun Protection Practices
Most participants reported changes in sun protection practices after their localized melanoma diagnosis, including more frequent sunscreen use, seeking shaded areas, and wearing sun-protective clothing. For most, sun protection became a bigger priority to prevent a subsequent melanoma.
Participants remarked that some behavior changes were uncomfortable (eg, wearing more sun-protective clothing), yet worthwhile because these behaviors eased anxiety about the risks of sun exposure. Overall, participants viewed sun exposure behavior changes as a balance between having an acceptable quality-of-life and still reducing their melanoma risk through behavior changes.
Fear of the Sun
Many patients expressed fear of sun exposure. Participant 42 (stage MIS) noted having “sun paranoia,” which he elaborated on as, “I would even be like nervous about having my arm exposed in the car.” Participant 48 (stage IIA) even characterized the sun as “the devil” and explained,
I am an outside person…and now I hide from the sun…I am always in the shade. I always have a chair that has a shade thing on it. I stay away from the sun as much as I can sadly.
This type of sun exposure fear altered many participants’ behavior, although some expressed that given the ubiquity of the sun, it was difficult to avoid completely.
Diminished Enjoyment of Outdoor Activities
There were psychological consequences of sun avoidance reported by some participants. This included avoiding certain outdoor activities from which they had previously derived pleasure and a heightened concern about sun exposure. For example, participant 28 (stage MIS) expressed,
I like to kayak and canoe, but that can be tough if you’re out on a lake or a river because there’s no shade…if I know I want to be out there all day, I probably would do [it] if I hadn’t been diagnosed with melanoma.
Theme 4: Thoughts About Life and Death
Increased Thoughts and Guilt About Mortality
Participants noted that having localized melanoma had led to increased thoughts about their own mortality; some reported thinking about mortality almost every day. These thoughts were especially acute whenever they looked at their moles. Regret about choices made in the past regarding risky behavior and consequences, such as sun burns, made some feel as the possibility of death from melanoma was their fault. Participant 56 (stage IA) shared,
It has made me feel, I mean more aware of my own mortality and regrets more, again choices I made in younger years, even knowing there are risks and consequences…I don’t know why I wasn’t more wise.
Many participants expressed not only a fear of melanoma recurrence, but a new fear about mortality associated with other types of cancer.
New Perspectives About the Future
Some participants expressed that receiving a melanoma diagnosis gave them a new perspective on life, altering how they planned for the future. These participants described changing overall health habits for the better and renewing commitments to accomplishing life goals. For example, participant 73 (stage IA) decided to marry their partner:
I had another…a mole removed, that I was convinced was melanoma…I was dating my now husband…neither one of us was particularly interested in getting married…I said to my husband, ‘Look…if this is melanoma…we need to be able to be there for each other, so I want to get married.’ So, I would say it kind of affected me because now I’m married, I suppose that’s in a good way. But yeah, put my mortality on, at kind of the forefront.
Fear of Recurrence Inventory Short Form
The mean (SD) score on the FCRI-SF survey was 18.0 (6.5) points (Figure). Thirty-eight participants (75%) met the threshold for having a clinical fear of cancer recurrence (score ≥13 points). At a more specific threshold of (score ≥16 points), 34 (67%) met the cutoff for screening for clinical fear of cancer recurrence. The mean (SD) scores for stage 0 (MIS) and stage I-IIA were similar: 18.6 (6.3) and 17.7 (6.7), respectively. The average (median [range]) time between most recent melanoma diagnosis and survey completion was 49 (25 [1-371]) months.
Figure. Score Distribution on the Fear of Cancer Recurrence (FCR) Inventory−Short Form (N = 51).
The yellow area shows participants who reached a threshold of 13 or greater (high sensitivity) and the beige area shows participants who reached a threshold of 16 or greater (high specificity).
Discussion
In this qualitative and survey-based study of people with a history of localized cutaneous melanoma, participants recounted aspects of their lived experiences after diagnosis and their perspectives on cancer survivorship. Consistent themes and subthemes brought up by participants included anxiety associated with follow-up skin examinations, frequent biopsy procedures due to screening intensity, fear of the sun, changes in sun exposure behavior, and increasing thoughts about death. Many of these experiences profoundly affected participants’ lives, despite the favorable prognosis for this group. Nearly 75% of participants had FCRI-SF scores above the threshold for defining a clinically important level of fear of cancer recurrence. These qualitative and quantitative findings underscore the psychological repercussion of a localized melanoma diagnosis.
Previous studies have attempted to quantify the psychological well-being of individuals with a history of melanoma. A systematic review of 44 studies (mostly performed outside of the US)7 found that approximately 30% of patients with melanoma reported clinically relevant levels of psychological distress. Many of these studies used validated measures such as the Beck Depression Inventory, Brief Symptom Inventory, and the Hospital Anxiety and Depression Scale, that consistently demonstrated that patients with a melanoma, regardless of stage, have increased anxiety and depression levels when compared with unaffected populations.13,14,15 A more recent study16 that was not included in the review investigated psychological distress among patients in Italy with early-stage melanoma, and found that at long-term follow-up, 25% and 44% endorsed anxiety and emotional distress symptoms, respectively. Furthermore, the investigators found no difference between patients diagnosed with stage 0 to IA compared with stage IB to II melanoma. Many study participants expressed similar feelings at follow-up appointments, even years after their initial diagnosis.
In our study, we measured fear of cancer recurrence because it is an important concern for many patients with a cancer diagnosis, including melanoma. Our findings, using the FCRI-SF questionnaire, are similar to those of a study conducted in Australia8 that focused on fear of recurrence among patients diagnosed with localized primary or recurrent melanoma. In that cross-sectional study, 77% scored at the proposed threshold (FCRI-SF score, ≥13 points) to screen further for clinically important levels of fear of recurrence, finding that are similar to those of our study (74.5%). These investigators used the FCRI-SF as the primary outcome and found that the mean (SD) score was 15.0 (6.9) for patients with a stage 0 to II melanoma, with no recurrence or new primary melanoma, and 19.0 (8.0) for patients with a recurrence or new primary melanoma.8 These findings are consistent with our cohort. Notably, FCRI-SF scores in our study findings were higher than those of other studies of other early cancers, including breast, 15.8 (8.4); prostate, 11.9 (6.8); colorectal, 13.5 (7.7); and lung 14.0 (9.3) cancer.8,17
Patients with localized cutaneous melanoma often undergo only surgical treatment and are spared from the potentially debilitating long-term physical consequences of systemic therapy. However, our study suggests that fear of cancer recurrence substantially affects patients’ anxiety during survivorship. Anxiety, worry, and fear were commonly expressed emotions in the interviews, and were underscored by the FCRI-SF survey results. A quality of life study of patients with localized melanoma in Germany showed that nearly half reported not being asked by a physician had about how they were coping.18 Given the crucial role that dermatologists play in diagnosing melanomas, there may be an opportunity to provide reassurance and support for patients to mitigate the psychological consequences of the diagnosis, by emphasizing the excellent life expectancy at a localized stage, particularly at stage 0.4 In addition, a referral to a mental health practitioner could be placed for patients with higher levels of anxiety and fear of recurrence.
Our study findings may have implications for cancer screening efforts. Recently the US Preventive Services Task Force concluded that there was insufficient evidence for or against screening for melanoma, citing in their evidence review sparse information on harms.19,20 Our findings highlight some of the potential psychological harms of diagnosing melanoma, which should be considered when assessing the net benefit of screening, particularly given that many or most screening-detected early-stage melanomas will not progress.21,22
Limitations
Our study has several limitations including the use of convenience sampling. All of our study participants were insured, most were not Hispanic; they were White, wealthier than average, and well educated; and the study was conducted at an academic medical practice. Although melanoma, particularly early-stage melanoma, is associated with this demographic profile,23,24,25,26,27 we may not have captured themes and experiences of individuals from other backgrounds. Recall bias and social desirability bias may have affected responses about follow-up care and sun-exposure behavior. Our cohort was younger than the average age for melanoma diagnosis. Further research is warranted with a larger and more diverse study population.
Conclusions
The findings of this qualitative and survey-based study suggest that despite having an excellent prognosis, patients with localized cutaneous melanoma, even those with stage 0, have high rates of fear of cancer recurrence and anxiety that produces restrictive behaviors, both of which negatively affect psychological well-being. These findings underscore the importance of addressing the psychological well-being of patients with early melanoma and potentially implementing supportive interventions.
eFigure. CONSORT Diagram
eTable. Illustrative Representative Quotes Organized by Theme
Data Sharing Statement
References
- 1.Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin. 2023;73(1):17-48. doi: 10.3322/caac.21763 [DOI] [PubMed] [Google Scholar]
- 2.Cancer Stat Facts . Melanoma of the Skin. Accessed May 15, 2023. https://seer.cancer.gov/statfacts/html/melan.html
- 3.Welch HG, Mazer BL, Adamson AS. The rapid rise in cutaneous melanoma diagnoses. N Engl J Med. 2021;384(1):72-79. doi: 10.1056/NEJMsb2019760 [DOI] [PubMed] [Google Scholar]
- 4.Marcadis AR, Marti JL, Ehdaie B, Hakimi AA, Davies L, Morris LGT. Characterizing relative and disease-specific survival in early-stage cancers. JAMA Intern Med. 2020;180(3):461-463. doi: 10.1001/jamainternmed.2019.6120 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Patel VR, Roberson ML, Pignone MP, Adamson AS. Risk of mortality after a diagnosis of melanoma in situ. JAMA Dermatol. 2023;159(7):703-710. doi: 10.1001/jamadermatol.2023.1494 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Rychetnik L, McCaffery K, Morton R, Irwig L. Psychosocial aspects of post-treatment follow-up for stage I/II melanoma: a systematic review of the literature. Psychooncology. 2013;22(4):721-736. doi: 10.1002/pon.3060 [DOI] [PubMed] [Google Scholar]
- 7.Kasparian NA, McLoone JK, Butow PN. Psychological responses and coping strategies among patients with malignant melanoma: a systematic review of the literature. Arch Dermatol. 2009;145(12):1415-1427. doi: 10.1001/archdermatol.2009.308 [DOI] [PubMed] [Google Scholar]
- 8.Bell KJL, Mehta Y, Turner RM, et al. Fear of new or recurrent melanoma after treatment for localised melanoma. Psychooncology. 2017;26(11):1784-1791. doi: 10.1002/pon.4366 [DOI] [PubMed] [Google Scholar]
- 9.Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. doi: 10.1093/intqhc/mzm042 [DOI] [PubMed] [Google Scholar]
- 10.Simard S, Savard J. Screening and comorbidity of clinical levels of fear of cancer recurrence. J Cancer Surviv. 2015;9(3):481-491. doi: 10.1007/s11764-015-0424-4 [DOI] [PubMed] [Google Scholar]
- 11.Simard S, Savard J. Fear of Cancer Recurrence Inventory: development and initial validation of a multidimensional measure of fear of cancer recurrence. Support Care Cancer. 2009;17(3):241-251. doi: 10.1007/s00520-008-0444-y [DOI] [PubMed] [Google Scholar]
- 12.Foley G, Timonen V. Using grounded theory method to capture and analyze health care experiences. Health Serv Res. 2015;50(4):1195-1210. doi: 10.1111/1475-6773.12275 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Brandberg Y, Månsson-Brahme E, Ringborg U, Sjödén PO. Psychological reactions in patients with malignant melanoma. Eur J Cancer. 1995;31A(2):157-162. doi: 10.1016/0959-8049(94)00333-Z [DOI] [PubMed] [Google Scholar]
- 14.Gibertini M, Reintgen DS, Baile WF. Psychosocial aspects of melanoma. Ann Plast Surg. 1992;28(1):17-21. doi: 10.1097/00000637-199201000-00007 [DOI] [PubMed] [Google Scholar]
- 15.Kelly B, Raphael B, Smithers M, et al. Psychological responses to malignant melanoma: an investigation of traumatic stress reactions to life-threatening illness. Gen Hosp Psychiatry. 1995;17(2):126-134. doi: 10.1016/0163-8343(94)00098-X [DOI] [PubMed] [Google Scholar]
- 16.Tesio V, Ribero S, Castelli L, et al. Psychological characteristics of early-stage melanoma patients: a cross-sectional study on 204 patients. Melanoma Res. 2017;27(3):277-280. doi: 10.1097/CMR.0000000000000348 [DOI] [PubMed] [Google Scholar]
- 17.Lebel S, Simard S, Harris C, et al. Empirical validation of the English version of the Fear of Cancer Recurrence Inventory. Qual Life Res. 2016;25(2):311-321. doi: 10.1007/s11136-015-1088-2 [DOI] [PubMed] [Google Scholar]
- 18.Schlesinger-Raab A, Schubert-Fritschle G, Hein R, et al. Quality of life in localised malignant melanoma. Ann Oncol. 2010;21(12):2428-2435. doi: 10.1093/annonc/mdq255 [DOI] [PubMed] [Google Scholar]
- 19.Mangione CM, Barry MJ, Nicholson WK, et al. ; US Preventive Services Task Force . Screening for skin cancer: US Preventive Services Task Force recommendation statement. JAMA. 2023;329(15):1290-1295. doi: 10.1001/jama.2023.4342 [DOI] [PubMed] [Google Scholar]
- 20.Adamson AS. The USPSTF I statement on skin cancer screening: not a disappointment but an opportunity. JAMA Dermatol. 2023;159(6):579-581. doi: 10.1001/jamadermatol.2023.0706 [DOI] [PubMed] [Google Scholar]
- 21.Elder DE. Obligate and potential precursors of melanoma. J Natl Cancer Inst. 2022;114(10):1320-1322. doi: 10.1093/jnci/djac139 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Eguchi MM, Elder DE, Barnhill RL, et al. Prognostic modeling of cutaneous melanoma stage I patients using cancer registry data identifies subsets with very-low melanoma mortality. Cancer. 2023;129(1):89-97. doi: 10.1002/cncr.34490 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Welch HG, Fisher ES. Income and cancer overdiagnosis: when too much care is harmful. N Engl J Med. 2017;376(23):2208-2209. doi: 10.1056/NEJMp1615069 [DOI] [PubMed] [Google Scholar]
- 24.Idorn LW, Wulf HC. Socioeconomic status and cutaneous malignant melanoma in Northern Europe. Br J Dermatol. 2014;170(4):787-793. doi: 10.1111/bjd.12800 [DOI] [PubMed] [Google Scholar]
- 25.Pion IA, Rigel DS, Garfinkel L, Silverman MK, Kopf AW. Occupation and the risk of malignant melanoma. Cancer. 1995;75(2)(suppl):637-644. doi: 10.1002/1097-0142(19950115)75:2+<637::AID-CNCR2820751404>3.0.CO;2-# [DOI] [PubMed] [Google Scholar]
- 26.Pukkala E, Martinsen JI, Lynge E, et al. Occupation and cancer: follow-up of 15 million people in five Nordic countries. Acta Oncol. 2009;48(5):646-790. doi: 10.1080/02841860902913546 [DOI] [PubMed] [Google Scholar]
- 27.Adamson AS, Welch H, Welch HG. Association of UV radiation exposure, diagnostic scrutiny, and melanoma incidence in US counties. JAMA Intern Med. 2022;182(11):1181-1189. doi: 10.1001/jamainternmed.2022.4342 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eFigure. CONSORT Diagram
eTable. Illustrative Representative Quotes Organized by Theme
Data Sharing Statement
