Transcript CREMIEUX_EUMAS sans com.ppsx

Real-time mobile teledermoscopy for skin-cancer
screening targeting an agricultural population:
An experiment on 289 patients in France
Prof Anne-Claude Crémieux
National Physician Advisor of the Agricultural Social Insurance Mutual Benefit Fund (MSA)
www.ccmsa.msanet
Incidence of skin cancer
 Epidemic proportions in fair
skinned populations
 80,000 new skin cancers*
diagnosed each year in France
 Melanoma: 11,176 new cases
and 1,672 deaths* in 2012 in
France (3% of all cancers)
*Source: InVS et INCa
2
Skin-cancer screening

Early diagnosis of melanoma improves
prognoses and decreases mortality 1
• Survival: 88% to 98% at early stage to
<20% at metastatic stage

Physician-based detection via routine
examination may enhance diagnosis of
early-stage melanoma2

Dermatologists’ skills are superior to those
of non-dermatologists3
1 Bartlett
EK. Surg Oncol Clin N Am 2015;24:215–27.
AC et al. Cancer 2009;115:1318–27.
3 Grange F. Br J Dermatol. 2012;167:1351–9.
2Geller
Skin cancers and agricultural populations

Higher incidences of non-melanoma
and melanoma skin cancers vs general
population (GnP)
• Melanoma incidence in farmers: 2  workers

Agricultural cohorts
- AHS (US cohort): Higher risk of melanoma
(incidence, mortality) vs GnP
- AGRICAN (French cohort): higher incidence
in women (+26%) vs GnP

Related to
• Ultraviolet radiation exposition ++++
• Pesticides ?2
1Waggoner
JK, Am J Epidemiol 2011;173:71–83. 2 IInserm 2013, INCa avril 2014)
Access to dermatologists in France
 Limited
by an undersupply of these specialists, which
results in a long wait times+++.
 In
rural areas, this problem is more acute because of
both the rarity of specialists and geographic distances
MSA (EUMASS juin 16)
Teledermatology (TD)
 Described in 1995 in a remote rural area (Oregon)
 Widely implemented for various skin conditions,
to increase access to dermatology and for cost
savings (avoiding face-to face visits)
 Reimbursed by Dutch regular health care
 Results: 37,201 teleconsultations between 2007
and 20132
•Reduced the number of physical referrals (68%)
•TD accuracy and reliability are similar to face-toface dermatology
•Reduced costs (18%)3
1Perednia
DA, Brown NA. Bull Med Libr Assoc 1995;83(1):42-47
der Heijden JPJ Telemed Telecare 2013;19:320–5.
3Eminovic N. BMC Health Serv Res 2010;10:251.
2Van
6
31
In 2014, the Agricultural Social Insurance Mutual Benefit Fund (MSA) offered its
work in agriculture and live in rural areas with reduced access to dermatologis
participate in a one-day teledermoscopic (TDS) screening event.
de la
BRE
O BJECTIVE:
TD with or without teledermoscopy
(TDS)
for cancer screening
M ETHO DS:
This study’s aim was to assess the feasibility of real-time mobile TDS triage of
agricultural workers by trained medical officers and occupational physicians.
15
 Mobile/smart
phone TDS (i-phone)
• Limited experience (Australia)
Fifteen TDS screening centres were located in different areas of France. Individ
years who worked in agriculture and lived in rural area near a TDS screening ce
to participate in a one-day screening event.They were examined by an MSA ge
who had previously been trained on skin cancers by SNDVdermatologists with
dermoscopy. In cases of suspicious skin lesions, clinical and dermoscopic imag
and transferred immediately to four dermatologists who were simultaneously p
platform for diagnosis and decision-making. Low-quality images were retaken.
MOBILE TELEDERMOSCOPY FOR SKIN CANCER SCREENING
TARGETING
RESULTS:
1
• Suitable
skin cancersON 289 PATIENTS IN FRANCE
ULTURAL
POPULAfor
TIOtriage
N: ANofEXPERIMENT
Two-hundred eighty-nine patients underwent skin cancer screening. Among 19
390 suspicious lesions were identified and generated 412 pictures. All lesions w
by dermatologists. For 105 patients (53%), no follow-up was required. Sevente
referred
to local dermatologists
for rapid examination,
including 12 cases of su
1
2
2
1
2
2
2
2
2
1
P. Sall N’Diaye , C. Blanchet-Bardon , L. Sulimovic , F. Pomykala , M. Colomb , M. Baccard , F. Lassau , G. Reuter , F. Keller , C. F
ite2, R. Tlesions.
riller2Among
, A.C.the
Crémieux
melanocytic
12 patients *
with suspected melanoma, face-to
conducted within ten days for 11 of them, and 1 case of melanoma was confirm
ité Sociale Agricole, Direction of Social Politics - 2 Syndicat National des Dermato et Vénéréologues de France
by histopathology.
 High
percentage of patients referred
for face-to-face examinations or lesion
excisions
KGRO
UN D: may be lost-to-follow-up
ce of skin
cancer has
reached
epidemic proportions in the white population
and is
with
a
store-and-forward
TD
triage
y elevated in agricultural populations, who are exposed to ultraviolet radiation during
sional activities.
system2
Agricultural Social Insurance Mutual Benefit Fund (MSA) offered its customers who
evaluation
of Real-time
culture and•liveStimulate
in rural areas withthe
reduced
access to dermatologists
the ability to TD
n a one-day teledermoscopic (TDS) screening event.
triage
ECTIVE:
s aim was to assess the feasibility of real-time mobile TDS triage of a large number of
1Börve A, Acta Derm Venereol 2015;95:186–90.
workers by trained
medical officers and occupational physicians.
2Massone C J Eur Acad Dermatol Venereol 2014;28:1103–8.
CO N CLUSIO N S:
Our study suggests that teledermoscopy performed in the context
to agricultural populations is feasible and could be useful for impro
populations while avoiding face-to-face examinations by a dermat
TDS =Microscopic view
7
MSA: Mutualité Sociale Agricole
 French
social protection organization for the
agricultural populations (farmers and employees: 4
million people)
 Its
missions include the prevention of occupational
and non-occupational health risks
 Innovative
experimentations on the organization of
health services in remote rural areas
(multidisciplinary nursing homes or primary-care
group practices..)
8
MSA: Mutualité Sociale Agricole

In 2014, MSA invited its customers
working in agriculture and living in
rural areas with reduced access to
dermatologists to participate in a
one-day TDS-screening event

Customers were invited to participate
by e-mail or letter
Objective
 To
assess the feasibility of real-time mobile TDS
triage of a large number of agricultural workers by
trained MSA medical officers and occupational
physicians
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TDS screening centers 2014
15 TDS-screening centers located in 12 areas
Manosque (Alpes de H. Provence)
Yssingeaux (Haute Loire)
Sancerre (Cher)
Corbigny (Nièvre)
Nevers (Nièvre)
Marennes (Charente-Maritime)
Saint Lô (Manche)
Valognes (Manche)
Marmande (Lot-et-Garonne)
Nontron (Dordogne)
Bergerac (Dordogne)
Capestang (Hérault)
Felletin (Creuse)
Chateaubriant (Loire-Atlantique)
Tarbes (Haute Pyrénées)
21 MSA physicians
• 12 occupational medicine physicians
 9 medical officers
Scheme of the intervention
TDS-screening centers
(MSA trained Practitioners)
When skin lesions were
suspicious, clinical and
dermoscopy images
were obtained and
transferred
immediately
Low quality images were retaken
Teleplatform Bagnolet
(Dermatologists)
Diagnosis
No
and decision-making
further treatment
Follow-up
at 12-month intervals
Non-emergency
appointment with a
dermatologist
Referral
to a local dermatologist for a
rapid face-to-face examination or excision
Numbers of patients and physicians at each site
289 patients
Results
289 patients underwent skin-cancer screening
MSA 14
199 patients (69% of the participants) had 390 suspicious
lesions identified that generated 412 images
MSA 15
Results
MSA 16
Results
MSA 17
Results
Actinic keratosis (3 patients)
Atypical nevi (2 patients)
MSA 18
Discussion

First study
• To evaluate mobile TD and TDS for skin-cancer screening targeting this
specific high-risk population
• To assess the feasibility of this screening by trained occupational physicians
and medical officers

This study showed that patients can be successfully evaluated and
rapidly referred to local dermatologists when malignant melanoma is
suspected (11/12 patients with suspected malignant melanoma were
seen by a dermatologist in less than 15 days).

Good-quality images were obtained of all suspicious lesions with the
current technological means (smartphones and a dermoscope).

More than 105 (53%) consultations with a specialist were avoided
19
Total costs of the TD and conventional processes (y-axis) for different patient
travel distances to dermatologist or different percentages of consultations avoided
Eminović et al. BMC Health Services Research 2010;10:251.
distance to a dermatologist was
>75 km.
37% of visits were avoided
20
Survey of the MSA physicians
 All
21 participating MSA physicians were satisfied
with the training and methodological tools provided.
 Eighteen
of them were willing to repeat the
experience.
21
Limitations
 This
study was conducted on a single day
 Small
number of patients.
 The
dermatologists present at the platform were
very familiar with dermoscopy.
 The
images were analyzed in real-time by
dermatologists present at the platform.
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Conclusions
 The
results of our study suggest that real-time mobile
TDS targeting agricultural populations is feasible and
could help to improve skin-cancer screening in
increased-risk populations, while avoiding face-toface examinations by a dermatologist for 53% of the
subjects
 They
also underlined the potential role of occupational
medicine in skin-cancer screening for UV-exposed
populations
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Telemedecine in France

The Social Security Financing Act for 2014 :
Has introduced some experimentations of reinbursement
of TM in 9 regions
 Several
initiatives of Telemedecine are supported by MSA
•surveillance of chronic wounds, ulcers (Regions of Lorraine
and Franche Comté )
•geriatric cares in rural setting (Regions of Bourgogne,
Beauce-Cœur de Loire and Limousin) .
MSA (Affichage > En-tête et pied de page) – JJ/MM/AAAA
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Remerciements aux praticiens et aux équipes
administratives des Caisses du Réseau MSA !
Dr Pierre Segura, Alpes Vaucluse
Dr Pascal Fauron, Auvergne
Dr Agnès Desveaux, Beauce-Cœur de Loire
Dr Claude De Rochefort, Beauce-Cœur de Loire
Dr Maurice Jérome, Beauce-Cœur de Loire
Dr Jean-Pierre Kervran, Beauce-Cœur de Loire
Dr Dominique Semeraro, Bourgogne
Dr Michele Billoué, Bourgogne
Dr Odile Humbert, Bourgogne
Dr Jean-Michel Croq, Charentes
Dr Pierre Jude, Charentes
Dr Ingrid Froger, Côtes Normandes
Dr Guillaume Acher, Côtes Normandes
Dr Pierre Dubois, Côtes Normandes
Dr Francis Mora-Dordogne, Lot et Garonne
Dr Hélène Soulez, Dordogne Lot et Garonne
Dr Alain Barriere, Dordogne Lot et Garonne
Dr Gérard Bernadac, Languedoc
Dr Edith Fesquet, Languedoc
Dr Pierre Tresmontan, Limousin
Dr Francis Coudière, Loire-Atlantique-Vendée
Dr Véronique Delagnes, Charasson-Midi-Pyrénées Sud
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MSA (Affichage > En-tête et pied de page) – JJ/MM/AAAA
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Results
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