To the Editor:
Store-and-forward teledermatology relies on primary care providers’ (PCP) ability to detect suspicious lesions. Incidental findings, defined as imaged lesions beyond the reason for consult and undocumented by the referring PCP, have not yet been quantified in teledermatology. While others have studied incidental skin cancers comparing teledermatology to in-person evaluation and found 8/9 incidental malignancies in patients with history of neoplasia,1 none have investigated incidental lesions missed but visible on the consult itself.1,2 We aimed to evaluate clinically significant incidental lesions in teledermatology consults of veterans with a skin cancer history and factors associated with higher likelihood of lesion discovery as evidenced by teledermatologist documentation.
The Emory University IRB and Atlanta Veterans’ Affairs Medical Center approved this retrospective cohort study of 95 teledermatology consults. Implementation of a clinical log tracking incidental lesions began July 21, 2015; 45 and 50 consults were randomly selected from before and after this date, respectively. Inclusion criteria were a personal history of melanoma or keratinocyte carcinoma. The final cohort comprised 11.2% (95/847) of screened consults. Patient, disease, and teledermatology reader characteristics were chosen a priori and summarized descriptively. A board-certified dermatologist blinded to the previous diagnosis and patient characteristics independently reviewed only consult images for clinically significant lesions. Consult characteristics were compared by presence or absence of incidental finding using unpaired t-tests and Fisher’s exact tests in SAS 9.4 (Cary, N.C.) with statistical significance at p<0.05. The same was performed among consults with an incidental finding to determine predictors of lesion discovery.
The majority of participants were white males; mean participant age was 68.3 years. Seventy-seven (81.0%) patients had keratinocyte carcinoma history while 21 (22.1%) had melanoma history. In 26 of 95 consults (27.3%), 27 incidental findings were discovered including 17 with actinic keratoses, 6 neoplasms uncertain behavior, 1 pigmented lesion, 1 melanoma, 1 squamous cell carcinoma, and 1 seborrheic dermatitis. Consults with an incidental finding were often located on the head or neck than other areas (p = 0.0009, Table 1). Implementation of the clinical tracking log, resident training level, and number of images were not significant predictors of documenting an incidental finding on the original consult (Table 2).
Table 1.
Association of Consult Characteristics with Presence of Incidental Finding
| Incidental Lesion Present | p-value | |||
|---|---|---|---|---|
| No (n=69) | Yes (n=26) | |||
| Age | mean 68.3 (std dev 9.6) | mean 68.4 (std dev 12.0) | 0.98 | |
| Race | White | 64 (92.8%) | 25 (96.2%) | 1.0 |
| AA | 1 (1.4%) | 0 | ||
| Unknown | 4 (5.8%) | 1 (3.8%) | ||
| Sex | Male | 66 (95.7%) | 26 (100%) | 0.56 |
| Female | 3 (4.3%) | 0 | ||
| Consult Year | 2012 | 1 (1.4%) | 1 (3.8%) | 0.07 |
| 2013 | 5 (7.2%) | 4 (15.4%) | ||
| 2014 | 11 (15.9%) | 7 (26.9%) | ||
| 2015 | 23 (33.3%) | 3 (11.5%) | ||
| 2016 | 21 (30.4%) | 5 (19.2%) | ||
| 2017 | 8 (11.6%) | 6 (23.1%) | ||
| History of NMSC* | Yes | 54 (78.3%) | 23 (88.5%) | 0.38 |
| No | 15 (21.7%) | 3 (11.5%) | ||
| History of Melanoma* | Yes | 18 (26.1%) | 3 (11.5%) | 0.17 |
| No | 51 (73.9%) | 23 (88.5%) | ||
| Consult Anatomic Location** | Head or Neck | 22 (31.9%) | 20 (76.9%) | 0.0009 |
| Lower Extremity | 9 (13.0%) | 0 | ||
| Upper Extremity | 13 (18.8%) | 4 (15.4%) | ||
| Trunk | 23 (33.3%) | 2 (7.7%) | ||
| Missing | 2 (2.9%) | 0 | ||
| Chief Complaint** | Lesion | 45 (65.2%) | 20 (76.9%) | 0.19 |
| Rash | 13 (18.8%) | 1 (3.9%) | ||
| Other / Missing | 11 (15.9%) | 5 (19.2%) | ||
| Image Quality | Fully Satisfactory | 62 (89.9%) | 24 (92.3%) | 1.0 |
| Satisfactory with Suggestions | 7 (10.1%) | 2 (7.7%) | ||
| Number of Images | mean 13.8 (std dev 12.4) | mean 13.4 (std dev 11.5) | 0.88 | |
Determined via documentation by dermatology, not pathology report
As stated on consult request, collected via chart review
Table 2.
Predictors of Incidental Lesion Discovery During Original Consultation
| Discovered (n=8) |
Not Discovered (n=18) |
p-value | ||
|---|---|---|---|---|
| Age | mean 65.37 (std dev 18.08) | mean 69.72 (std dev 8.51) | 0.53 | |
| Race | White | 8 (100%) | 17 (94.4%) | 1.0 |
| AA | 0 | 0 | ||
| Unknown | 0 | 1 (5.6%) | ||
| Sex | Male | 8 (100%) | 18 (100%) | n/a |
| Female | 0 | 0 | ||
| Consult Year | 2012 | 0 | 1 (5.6%) | 0.46 |
| 2013 | 0 | 4 (22.2%) | ||
| 2014 | 2 (25%) | 5 (27.8%) | ||
| 2015 | 2 (25%) | 1 (5.6%) | ||
| 2016 | 1 (12.5%) | 4 (22.2%) | ||
| 2017 | 3 (37.5%) | 3 (16.7%) | ||
| Clinical Tracking Log Implemented | No | 3 (37.5%) | 11 (61.1%) | 0.40 |
| Yes | 5 (62.5%) | 7 (38.9%) | ||
| History of NMSC* | Yes | 6 (75%) | 17 (94.4%) | 0.21 |
| No | 2 (25%) | 1 (5.6%) | ||
| History of Melanoma* | Yes | 2 (25%) | 1 (5.6%) | 0.22 |
| No | 6 (75%) | 17 (94.4%) | ||
| Consult Anatomic Location** | Head or Neck | 5 (62.5%) | 15 (83.3%) | 0.16 |
| Lower Extremity | 0 | 0 | ||
| Upper Extremity | 1 (12.5%) | 3 (16.7%) | ||
| Trunk | 2 (25%) | 0 | ||
| Chief Complaint** | Lesion | 4 (50%) | 16 (88.9%) | 0.05 |
| Rash | 1 (12.5%) | 0 | ||
| Other / Missing | 3 (37.5%) | 2 (12.5%) | ||
| Resident Level | PGY-2 | 0 | 0 | 0.62 |
| PGY-3 | 4 (50%) | 7 (38.9%) | ||
| PGY-4 | 4 (50%) | 7 (38.9%) | ||
| PA or Attending Only | 0 | 4 (22.2%) | ||
| Image Quality | Fully Satisfactory | 7 (87.5%) | 17 (94.4%) | 0.53 |
| Satisfactory with Suggestions | 1 (12.5%) | 1 (5.6%) | ||
| Number of Images | mean 18.75 (std dev 16.16) | mean 11.06 (std dev 8.32) | 0.24 | |
| Bother/QOL Score**† | mean 2.50 (std dev 1.41) | mean 1.56 (std dev 1.10) | 0.08 |
Determined via documentation by dermatology, not pathology report
As stated on consult request, collected via chart review
Patients were asked either “How much does this problem bother you?” or “How does this problem affect your symptomatic, emotional, and activity quality of life.” Scale was 0-4 with 4 being the most bothersome or affecting.
The high prevalence of incidental findings in this cohort with a skin cancer history represents a vital area for teledermatology quality improvement. Many of the incidental lesions were from consults with a head or neck location. Teledermatologists should be especially vigilant when evaluating these areas. The majority of incidental findings were actinic keratoses; identification and treatment of these pre-cancers is critical to delaying skin cancer.3
Other studies have revealed that referring PCPs may not choose the most important lesion to submit for consultation, even if the lesion is visible.4,5 In our study, lesions were close enough to be imaged, yet still undocumented. Limitations include sample size resulting in low power to detect small differences and information bias in cases referred for clinic follow-up. Further study is warranted to evaluate the benefit of lesion-directed teledermatology with total body skin examination for patients with a skin cancer history.
Funding Sources:
Supported in part by the Dermatology Foundation and the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health under award number UL1TR002378 and KL2TR002381 (H.Y.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Abbreviations and Acronyms
- PCP
Primary Care Provider
Footnotes
Conflict of Interest: The authors have no conflicts of interest relevant to this work to disclose.
IRB Statement: Approval granted by the Emory University and Atlanta Veteran’s Affairs Medical Center (IRB #98805).
Prior Presentation: Presented as an abstract at the American Academy of Dermatology 2019 Annual Meeting on March 2, 2019.
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