1. 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)

2. 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

3. 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.

4. 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)

5. 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

6. 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 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.

7. 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.

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..)

9. 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 or letter

10. 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

11. 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

12. 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

13. Numbers of patients and physicians at each site

14. Results
289 patients underwent skin-cancer screening

15. 199 patients (69% of the participants) had 390 suspicious lesions identified that generated 412 images

16. Results

17. Results

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

19. 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

20. 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

21. 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.

22. 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.

23. 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

24. 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) .

25. 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

28. Results