Application of mobile teledermatology for skin cancer screening

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1 Application of mobile teledermatology for skin cancer screening SoniaA.Lamel,MD, a Kristin M. Haldeman, BS, a Haines Ely, MD, a Carrie L. Kovarik, MD, b Hon Pak, MD, c and April W. Armstrong, MD, MPH a Sacramento, California; Philadelphia, Pennsylvania; and Fort Detrick, Maryland Background: With advancements in mobile technology, cellular phoneebased store-and-forward teledermatology may be applied to skin cancer screening. Objective: We sought to determine diagnostic and management concordance between in-person and teledermatology evaluations for patients at skin cancer screening whose clinical images and history were transmitted through mobile phones. Methods: A total of 86 patients with 137 skin lesions presented to a skin cancer screening event in California. These patients clinical history and skin images were captured by a software-enabled mobile phone. Patients were assessed separately by an in-person dermatologist and a teledermatologist, who evaluated the mobile phoneetransmitted history and images. Diagnostic and management concordance was determined between the in-person and teledermatology evaluations. Results: The primary categorical diagnostic concordance was 82% between the in-person dermatologist and the teledermatologist (95% confidence interval ), with a Kappa coefficient of 0.62 indicating good agreement. The aggregated diagnostic concordance between the in-person dermatologist and the teledermatologist was 62% (95% confidence interval ), with Kappa coefficient of 0.60 indicating good agreement. Management concordance between the in-person dermatologist and the teledermatologist was 81% (95% confidence interval ), with a Kappa coefficient of 0.57, which indicates moderate agreement between the dermatologists. Multivariate analysis showed that older age and presentation of atypical nevus were significantly associated with disagreement in diagnosis between the teledermatologist and in-person dermatologist, after adjusting for other factors. Limitations: Dermatoscopic images were not captured via mobile phones, which might improve diagnostic accuracy. Conclusion: Mobile teledermatology using cellular phones is an innovative and convenient modality of providing dermatologic consultations for skin cancer screening. ( J Am Acad Dermatol 2012;67: ) Key words: mobile teledermatology; skin cancer screening; store-and-forward teledermatology; technology; teledermatology; telemedicine. With more than 2 million skin cancers diagnosed each year in the United States, skin cancers are associated with significant morbidity, mortality, and economic burden. 1-6 Skin cancer screening is important for detecting premalignant and malignant skin lesions at an early stage when they are more amenable to intervention. 7 Although skin cancer screening is From the Department of Dermatology, University of California, Davis, School of Medicine a ; Department of Dermatology, University of Pennsylvania School of Medicine b ; and Telemedicine and Advanced Technology Research Center, Fort Detrick. c Click Diagnostics provided ClickDerm software and assistance with technical support. Conflicts of interest: None declared. Accepted for publication November 21, Reprint requests: April W. Armstrong, MD, MPH, Department of Dermatology, University of California, Davis, 3301 C St, Suite 1400, Sacramento, CA aprilarmstrong@post. harvard.edu. Published online January 16, /$36.00 Ó 2011 by the American Academy of Dermatology, Inc. doi: /j.jaad

2 JAM ACAD DERMATOL VOLUME 67, NUMBER 4 Lamel et al 577 associated with improved health outcomes, 8-10 patients in geographically remote or medically underserved communities may have reduced opportunities for skin cancer surveillance. 11,12 Store-and-forward teledermatology has been used to increase access to dermatology in underserved populations. 13 Traditional store-and-forward teledermatology involves CAPSULE SUMMARY downloading photographs from the camera onto the computer and transmitting these photographs to a dermatologist. 14,15 This process can be time-consuming and requires the use of both a digital camera and a computer, which may not be readily available in some underserved communities. As mobile cellular technology matures, its use in teledermatology has been introduced in limited settings Preliminary studies showed that the use of mobile cellular telephones to capture digital images for clinical diagnosis appeared to be feasible and yielded reasonable diagnostic accuracy However, to our knowledge, the use of mobile cellular technology for skin cancer screening has not been reported in North America. The purpose of this study was to determine whether mobile phoneeenabled technology can be used for diagnosis and management for patients presenting for skin cancer screening. Specifically, we sought to determine diagnostic and management concordance between in-person and teledermatology evaluations for patients at a skin cancer screening event, where clinical images and history were transmitted via mobile phones. METHODS Study procedures This study was approved by the institutional review board at the University of California, Davis. Individuals from the Sacramento, CA, region who participated in a free skin cancer screening event were recruited for participation in this study. Each participant could designate up to 3 lesions of concern to be evaluated. Research staff and medical trainees took digital images of skin lesions using Google Android G1 (HTC Corporation, Taoyuan, Taiwan), a cellular telephone with wireless Internet connectivity and an in-built 3.2-megapixel autofocus camera. d d d The application of mobile teledermatology to increase patient access to dermatologic care is increasing. Mobile teledermatology was used in a volunteer skin cancer screening event with moderate to excellent diagnostic and management agreement between in-person and teledermatology evaluations. With advancements in mobile technology, cellular phoneebased mobile teledermatology will likely evolve into a diagnostically reliable and technologically practical modality for providing dermatologic consultations. The mobile telephone was enabled with ClickDerm (Click Diagnostics, Boston, MA), a mobile-phone application to facilitate remote diagnosis of skin conditions by dermatologists. The mobile platform was configured to ensure encryption and authentication of data and secure transmission in accordance with Health Insurance Portability and Accountability Act (HIPPA) regulations. Two board-certified dermatologists from the University of California, Davis, participated in this study. To ensure that baseline diagnostic concordances were similar between these two dermatologists, diagnostic concordance tests were performed between the two dermatologists for both inperson examinations and teledermatology evaluations before this study. During the study, one dermatologist performed inperson evaluations of participants at the screening event. The other dermatologist evaluated digital images acquired from the mobile phone while being blinded to the evaluations and recommendations from the inperson dermatologist. For each lesion of interest, both dermatologists provided up to 3 differential diagnoses and ranked them in the order of likelihood, and they provided treatment recommendations for lesions of interest. Outcomes measures The primary outcomes measure for this study is management concordance. This measure is defined as agreement between the two dermatologists designated treatment recommendation for a particular skin lesion. Secondary outcomes included aggregated diagnostic concordance and primary categorical diagnostic concordance. Aggregated diagnostic concordance is defined as any agreement between the in-person dermatologist s diagnoses with those of teledermatologist s diagnoses. 25 Primary categorical diagnostic concordance is agreement of the diagnostic category of the lesion of interest. 26 Statistical analysis A mixed-model logistic regression analytical method appropriate for binary outcomes was applied to account for within-person correlation

3 578 Lamel et al JAM ACAD DERMATOL OCTOBER 2012 Table I. Demographic characteristics of patients who underwent skin cancer screening Characteristic N = 86 Age, y (SD) (613.64) Gender, No. (%) Male 36 (41.86) Female 50 (58.14) Race, No. (%) White 73 (84.88) Black 1 (1.16) Asian 10 (11.63) Hawaiian/Pacific Islander 2 (2.33) Marital status, No. (%) Married 27 (31.40) Not married 59 (68.60) Annual income, No. (%) \$25, (34.88) $25,001-$50, (27.91) $50,001-$75, (17.44) $75,001-$100,000 1 (1.16) [$100,000 5 (5.81) Education, No. (%) High school diploma/general Education 39 (45.35) Development (GED) certification College degree 31 (36.05) Graduate degree 16 (18.60) Fig 1. Distribution of diagnoses made through mobile teledermatology at the skin cancer screening event. because one patient may present with more than one lesion of concern. For each outcomes measure, the probability of diagnostic or management concordance was estimated, and confidence intervals (CI) were approximated using a mixed-model logistic regression with repeated measures. Cohen Kappa statistic and Fisher exact test were used to determine whether diagnostic agreement was better than chance alone. McNemar test was performed where appropriate. All statistical analyses were performed using software (SAS, SAS Institute Inc, Cary, NC). RESULTS Prestudy diagnostic concordance tests were conducted between the two study dermatologists to determine internal validity. Before the study, both dermatologists independently evaluated 45 skin lesions in-person and 30 randomly selected storeand-forward images to evaluate diagnostic and management agreement. Diagnostic concordance between the two dermatologists for in-person examination was 91.7% and was 100% for teledermatology evaluations. A total of 86 participants presented with 137 skin lesions for evaluation. The mean number of lesions per patient was 1.59 (SD ). Table I summarizes Fig 2. Pigmented lesion image taken with a mobile telephone during skin cancer screening. This lesion was diagnosed by both the in-person dermatologist and teledermatologist as melanoma, and pathological examination confirmed the diagnosis. characteristics of the study population. Among the participants, 58% of the patients were female, and the average age was years (SD ). Approximately 84% (n = 73) of patients selfreported white as their racial category, and 8% (n = 7) of the patients reported a history of skin cancer. The presenting diagnoses are shown in Figure 1. Of the 137 lesions, 26 lesions (19%) were not transmitted instantaneously, and 4 lesions were deemed inadequate for evaluation by the teledermatologist. An image of a lesion transmitted via mobile telephone for teledermatology evaluation during the screening is shown in Figure 2. Management concordance between the in-person dermatologist and the teledermatologist was high at 81% (95% CI ). The Kappa coefficient was 0.57, which indicates moderate agreement between the dermatologists. The aggregated diagnostic concordance between the in-person dermatologist and the teledermatologist was 62% (95% CI ). The Kappa

4 JAM ACAD DERMATOL VOLUME 67, NUMBER 4 Lamel et al 579 Table II. Concordance measures between inperson and mobile teledermatology evaluation Outcome Aggregated diagnostic concordance Primary categorical diagnostic concordance Management concordance % Concordance N = % CI Cohen Kappa *P \ \ \.001 Values estimated by mixed-model logistic regression to adjust for multiple lesions within person. CI, Confidence interval. *P, P-value. coefficient for aggregated diagnostic concordance was 0.60, indicating good agreement between the dermatologists. Primary categorical diagnostic concordance was high at 82% (95% CI ). The Kappa coefficient for primary categorical concordance was 0.62, indicating good agreement between the dermatologists. All concordance values are listed in Table II. To determine factors that contribute to disagreements in diagnosing premalignant and malignant lesions between in-person and teledermatology evaluations, a multiple variable model was constructed. Factors significant on univariate analyses that entered the multivariate model were age, the presence of atypical nevi, history of actinic keratoses, and number of prior squamous cell carcinomas. Multivariate analysis showed that older age and presentation of atypical nevus were significantly associated with disagreement in diagnosis between the teledermatologist and in-person dermatologist, after adjusting for other factors. Specifically, a 1-year increase in age was associated with an approximate 5% increased odds of diagnostic disagreement for premalignant or malignant lesion (95% CI , P =.006). In addition, presentation of atypical nevi was associated with 30% greater odds of diagnostic disagreement between in-person and teledermatology evaluation (95% CI , P =.047). DISCUSSION Our findings suggest that mobile-phone technology is an innovative and convenient tool that may be used for skin cancer screening in areas without ready access to dermatologists. Specifically, the use of mobile-phone technology yielded high management concordance of 81% between in-person and teledermatology evaluations. This management concordance is comparable with previously reported values that range from 55% to 100% in studies using traditional store-and-forward teledermatology where a digital camera and a computer were used for capturing and transmission of clinical images. 27,28 High management concordance is clinically relevant because management decisions will likely have the highest impact on patients outcomes. Our study also found that the diagnostic concordance from mobile teledermatology was comparable with traditional store-and-forward teledermatology modalities. 13,28-31 Our aggregated diagnostic concordance and primary categorical diagnostic concordance were 62% and 82%, respectively, which suggested moderate to high diagnostic concordance. Importantly, our analyses suggest that extra care needs to be exercised when evaluating pigmented lesions through mobile teledermatology, and novel technologies that integrate dermatoscopy with mobile teledermatology may be applied to increase diagnostic accuracy. To our knowledge, this is the first study that applied mobile cellularephone technology for skin cancer screening in North America. Our findings appear to corroborate those from other studies that applied mobile cellularephone technology in different clinical contexts. The appeal of using mobilephone technology in teledermatology likely includes the following reasons. First, mobile-phone technology offers portability and convenience of being able to capture clinical images and history on a single mobile device and wirelessly transmit the information to the consulting dermatologists. This obviates the need for time required to connect a digital camera to a computer. Second, with the expanding network coverage, wireless mobileephone technology enables secure transmission of clinical information from many places. Third, the ability to capture high-resolution photographs will continue to improve in the near future. This study s findings need to be interpreted in the context of the study design. One limitation of the study is that a number of images were not transmitted instantaneously because of technical difficulties, which were later resolved. We were also not able to capture dermatoscopy images through the mobile phones, which had been found to improve diagnostic accuracy in other studies. 29,32,33 With continued technological advancements, reduction of transmission problems and integration of dermatoscopy with mobile cellularephone technology will likely be forthcoming in the near future. Our study was conducted in the setting of a free skin cancer screening event as a part of a volunteer initiative spearheaded by the American Academy of

5 580 Lamel et al JAM ACAD DERMATOL OCTOBER 2012 Dermatology Teledermatology Task Force. Our findings suggest that dermatology volunteer efforts aimed at serving underserved communities can be facilitated by the use of novel telemedicine technologies. We anticipate that, with the widespread use of cellular telephones and the expansion of wireless networks, meaningful integration of innovative telemedicine technology will be important for increasing access to specialty care and improving patient outcomes. We thank Dr William James for his valuable input in this article and his leadership in the American Academy of Dermatology volunteer teledermatology endeavor. In addition, we thank Cindy Chambers, Kory Parsi, Mary Ann Johnson, Caitlin Harskamp, Lynda Ledo, and the Shifa Community Clinic for their assistance with the skin cancer screening. REFERENCES 1. Seidler AM, Pennie ML, Veledar E, Culler SD, Chen SC. 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