Is teleoncology as effective as standard oncology care for the diagnosis of cancer?

From Cancer Guidelines Wiki

Introduction

Cancer diagnosis is based on a combination of careful analysis of tissue by a board certified pathologist, laboratory tests, radiological features and clinical signs and symptoms. Many skin lesions have clinical features that are adequate to diagnose skin cancer without the use of laboratory tests. This makes dermatology the speciality best positioned to utilise teleoncology in the diagnosis of cancer. Both the accuracy and the speed of skin cancer diagnosis is improved when the diagnostic clinician is a dermatologist.[1][2]

Scarce literature exists on the diagnosis of solid organ or haematological cancers using teleoncology. This is most likely due to the increased complexity of these cases and the greater clinical impact of an incorrect cancer diagnosis. The exception is use of telepathology to send images of light microscopy slides to a centralised pathologist.[3]

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Diagnosis of skin cancer

Teledermatology typically involves sending images and/or a clinical history to a centralised dermatologist for diagnostic and management advice. Most of the teledermatology models use an asynchronous or a store-and-forward method whereby the pictures are transmitted after the patient has departed the clinic. This requires good quality cameras and adequate internet access. The feasibility of the asynchronous method has been proven in the USA[4], India[3], Turkey[5] and Cambodia[6]. Dermatological skin cancer diagnoses were compared to the gold standard tissue biopsies. Many of the studies included no or few malignant skin cancer diagnoses thereby diluting the relevance of the results. Despite the small numbers of skin cancers within the studies, the diagnostic accuracy between the in-person dermatologists and teledermatologist was reasonable; 88% in-person compared with 90% teledermatologist.

One health economics concern for teledermatology is a potential increase in the rate of skin biopsies. The Barnard et al study did not see a significant increase in the biopsy rate. Furthermore, the diagnostic accuracy was not greatly improved with the provision of clinical history when added to the digital image.[4]

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Recommendation One

Evidence summary Level References
Teleoncology to diagnose skin cancers is feasible. IV [4], [7], [8], [9], [5]
Evidence-based recommendationQuestion mark transparent.png Grade
In patients with suspected dermatological malignancies the use of asynchronous transmission of skin images to remote dermatologists produces acceptable diagnostic accuracy. In resource scarce health settings more timely diagnoses can be reached using teleoncology.
C


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Diagnosis of non-skin cancers

Few studies are available for the diagnosis of non-skin cancers using teleoncology. A study of patients with head and neck cancers provided encouraging evidence that teleoncology may deliver similar diagnostic accuracies to face-to-face assessments.[10] Another study compared the accuracy of a telephone interview to a trained surgical examination for the diagnosis of breast cancers in Iranian women. The rate of concordance between the two approaches was 62%.[11]

A study in Cambodia assessed the feasibility of reaching a cancer diagnosis in a developing-world community by sending images and clinical data to specialists in the USA. While cancer was correctly identified in all instances, all of the cases were advanced cancers. The utility of this model is therefore limited to developing countries where diagnostic services are scarce.[6]. Another study assessed the concordance of cervical and non-cervical cancer diagnoses between remote pathologists using light microscopy slides compared to remote pathologists using only digitised images of a selection of slides. Complete concordance was seen in 75% of the cases assessed.[3]

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Recommendation Two

Evidence summary Level References
There is insufficient evidence to support teleoncology as a safe alternative to diagnosing non-dermatological malignancies. IV [11], [6], [10], [12]
Evidence-based recommendationQuestion mark transparent.png Grade
In patients with suspected non-dermatological malignancies the use of teleoncology should not replace the standard diagnostic work up algorithm, except in supervised and externally scrutinised trial situations.
D


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References

  1. Ramsay DL, Fox AB. The ability of primary care physicians to recognize the common dermatoses. Arch Dermatol 1981 Oct;117(10):620-2 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7283454.
  2. Cassileth BR, Clark WH Jr, Lusk EJ, Frederick BE, Thompson CJ, Walsh WP. How well do physicians recognize melanoma and other problem lesions? J Am Acad Dermatol 1986 Apr;14(4):555-60 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3958271.
  3. 3.0 3.1 3.2 Desai S, Patil R, Chinoy R, Kothari A, Ghosh TK, Chavan M, et al. Experience with telepathology at a tertiary cancer centre and a rural cancer hospital. Natl Med J India 2004 Jan;17(1):17-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15115226.
  4. 4.0 4.1 4.2 Barnard CM, Goldyne ME. Evaluation of an asynchronous teleconsultation system for diagnosis of skin cancer and other skin diseases. Telemed J E Health 2000;6(4):379-84 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11242545.
  5. 5.0 5.1 Oztas MO, Calikoglu E, Baz K, Birol A, Onder M, Calikoglu T, et al. Reliability of Web-based teledermatology consultations. J Telemed Telecare 2004;10(1):25-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15006212.
  6. 6.0 6.1 6.2 Kvedar J, Heinzelmann PJ, Jacques G. Cancer diagnosis and telemedicine: a case study from Cambodia. Ann Oncol 2006 Jun;17 Suppl 8:viii37-viii42 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16801338.
  7. Ferrara G, Argenziano G, Cerroni L, Cusano F, Di Blasi A, Urso C, et al. A pilot study of a combined dermoscopic-pathological approach to the telediagnosis of melanocytic skin neoplasms. J Telemed Telecare 2004;10(1):34-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15006214.
  8. Mahendran R, Goodfield MJ, Sheehan-Dare RA. An evaluation of the role of a store-and-forward teledermatology system in skin cancer diagnosis and management. Clin Exp Dermatol 2005 May;30(3):209-14 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15807671.
  9. Moreno-Ramirez D, Ferrandiz L, Nieto-Garcia A, Carrasco R, Moreno-Alvarez P, Galdeano R, et al. Store-and-forward teledermatology in skin cancer triage: experience and evaluation of 2009 teleconsultations. Arch Dermatol 2007 Apr;143(4):479-84 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17438180.
  10. 10.0 10.1 Stalfors J, Lundberg C, Westin T. Quality assessment of a multidisciplinary tumour meeting for patients with head and neck cancer. Acta Otolaryngol 2007 Jan;127(1):82-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17364335.
  11. 11.0 11.1 Haghighat S, Yunesian M, Akbari ME, Ansari M, Montazeri A. Telephone and face-to-face consultation in breast cancer diagnosis: a comparative study. Patient Educ Couns 2007 Jul;67(1-2):39-43 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17467949.
  12. Desai S, Patil R, Kothari A, Shet T, Kane S, Borges A, et al. Static telepathology consultation service between Tata Memorial Centre, Mumbai and Nargis Dutt Memorial Charitable Hospital, Barshi, Solapur, Maharashtra: an analysis of the first 100 cases. Indian J Pathol Microbiol 2004 Oct;47(4):480-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16295371.

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Appendices