Marilynn Larkin ( Reuters Health Information) has recently published on Medscape Dermatology (December 16, 2016) an interesting article based on the paper published on JAMA by the group of Prof. Peter Soyer, from the University of Queensland.
NEW YORK (Reuters Health) – Teledermatology is associated with shorter waiting times for assessment and diagnosis and high patient satisfaction, but “robust implementation studies are needed” before the technology can be used as an alternative to face-to-face (FTF) consultations for skin cancer, researchers in Australia say.
“The two most common types of teledermatology are: store and forward (SAF), involving transfer of images and clinical information to a dermatologist for review at another time and location; and live interactive, usually videoconferencing, which allows real-time interaction between the clinician and patient,” Dr. Anna Finnane of the University of Queensland in Brisbane and colleagues explain.
Writing in JAMA Dermatology, online December 7, they point out that in a 2011 systematic review, FTF dermatology was more accurate than SAF teledermatology for diagnosing skin conditions. Since then, they say, options for teledermatological devices, software, and systems have grown significantly.
For an updated review of the most recent studies of teledermatology for skin cancer, the team identified all relevant studies published since 2009. In the 21 studies included, the diagnostic accuracy – defined as “agreement with histopathology for excised lesions or clinical diagnosis for nonexcised lesions” – of consultations for skin cancer was higher for FTF overall (67%-85% agreement with reference standard) compared with teledermatology (51%-85% agreement with reference standard).
Specifically with respect to the accuracy of teledermatology, three studies using 133 to 188 clinical images without dermoscopy demonstrated 68% to 85% agreement between teledermatology diagnoses and reference standard, with 98% sensitivity and 30% specificity for detecting melanoma.
Five studies including dermoscopic or microscopic images of 69 to 613 lesions in teledermatology consultations reported agreement between 51% to 92% with the reference standard, with 96% sensitivity and 62% specificity.
One study reported 100% sensitivity and 97% specificity of teledermatology for malignant melanocytic lesions and 97% sensitivity and 92% specificity for malignant nonmelanoctyic lesions for both clinical images and dermoscopy.
Nevertheless, “most studies of diagnostic accuracy and concordance had significant methodological limitations,” according to the authors.
Studies of health service outcomes found teledermatology reduced waiting times and might result in earlier assessment and treatment. Patients reported high satisfaction and were willing to pay out of pocket for access to teledermatological services.
Dr. Finnane and principal author Dr. H. Peter Soyer, also of the University of Queensland, told Reuters Health in a joint email, “We see teledermatology as a potential way of addressing uneven distribution of health services, particularly in rural and remote areas. Rapid developments in technology mean we can now get very high quality images (including dermoscopic images) reviewed by clinicians efficiently.”
“It is very difficult to test the accuracy of teledermatology for diagnosing skin cancers, because of inherent differences in clinician opinions and level of experience between clinicians,” they said. “For example, if the same clinician provides the in-person diagnosis and telediagnosis, even with a period of time between the two, it is possible the clinician recalls their previous diagnosis. This could result in overestimating the accuracy of teledermatology for diagnosing skin cancer.”
“In contrast,” they continued, “if different clinicians are used to test the two diagnostic methods, it is unknown whether the clinicians would have agreed even if both were seeing a patient in person, and this could lead to understating the accuracy of teledermatology.”
“The current research suggests teledermatology is certainly an appropriate referral and/or triage tool, but requires more robust research before we could confidently recommend teledermatology as a substitute for in-person consultation.”
Dr. Kally Papantoniou, a clinical assistant professor of dermatology at The Mount Sinai Medical Center in New York City, told Reuters Health that while teledermatology “will be able to provide patients – especially (those) living in rural areas where it can take many months to get a skin exam – access to a mole evaluation, a concerning limiting factor can be the quality of the images.”
“Some patients have access to dermatoscopes, which if used properly can provide superior images for interpretation,” she said by email.
Dr. Papantoniou added, “Another concern with teledermatology is if the patient only shows the clinician the lesion that concerns (him or her), which may be benign, and then neglects to bring to the doctor’s attention a more concerning growth which may go unnoticed.”