Prof Anne-Claude Crémieux 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)

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

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. 2Geller AC et al. Cancer 2009;115:1318–27. 3 Grange F. Br J Dermatol. 2012;167:1351–9.

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

Described in 1995 in a remote rural area (Oregon) 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-to-face dermatology Reduced costs (18%)3 1Perednia DA, Brown NA. Bull Med Libr Assoc 1995;83(1):42-47 2Van der Heijden JPJ Telemed Telecare 2013;19:320–5. 3Eminovic N. BMC Health Serv Res 2010;10:251.

TD with or without teledermoscopy (TDS) for cancer screening Mobile/smart phone TDS (i-phone) Limited experience (Australia) Suitable for triage of skin cancers1 High percentage of patients referred for face-to-face examinations or lesion excisions may be lost-to-follow-up with a store-and-forward TD triage system2 Stimulate the evaluation of Real-time TD triage TDS =Microscopic view 1Börve A, Acta Derm Venereol 2015;95:186–90. 2Massone C J Eur Acad Dermatol Venereol 2014;28:1103–8.

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..)

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

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) Teleplatform Bagnolet (Dermatologists) Diagnosis and decision-making No 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 When skin lesions were suspicious, clinical and dermoscopy images were obtained and transferred immediately Low quality images were retaken

Numbers of patients and physicians at each site

Results 289 patients underwent skin-cancer screening

199 patients (69% of the participants) had 390 suspicious lesions identified that generated 412 images

Results

Results

Results Actinic keratosis (3 patients) Atypical nevi (2 patients)

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

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

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.

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.

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-to- face 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

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) .

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

Results