Patient understanding of moles and skin cancer, and factors influencing presentation in primary care: a qualitative study

Abstract

BackgroundMelanoma incidence in the UK has doubled over two decades, yet there is conflicting evidence about factors which prompt or delay patients seeking advice. Aim: To explore patient understanding of pigmented skin lesions (moles) and skin cancer, and factors which influence seeking help in primary care.MethodSemi-structured interviews with forty MoleMate Trial participants, analysed using the theoretical framework of the Safer-Andersen model of Total Patient Delay.ResultsPatient understanding and awareness was influenced by personal, family and friends' experiences of moles, skin cancer and other cancers, knowledge of risk factors, and the lay media. The route to consulting was complex and often iterative. For lesions that people could see, detecting and appraising change was influenced by comparisons with a normal mole on themselves, a family member, friend or image. Inferring illness came about with recognition of changes (particularly size) as serious, and associated 'internal' symptoms such as pain. For lesions that people could not see, family, friends and health professionals detected and appraised changes. Deciding to seek help was often prompted by another person or triggered by rapid or multiple changes in a mole. Three of four people subsequently diagnosed with melanoma did not seek help; instead, their GP opportunistically noticed the lesion.ConclusionsChanging moles are often perceived as trivial and not signifying possible skin cancer. This study contributes to current national strategies to improve patient awareness and earlier diagnosis of cancer by highlighting factors that can trigger or act as barriers to seeking help.(ISRCTN79932379)

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“…Walter et al (2010) reported that cancer risk assessment of skin moles was heavily influenced by the nonmedical literature and experiences of family and friends, and was not congruent with medical opinion. The importance of informal knowledge about illness in individuals' health beliefs and decisions was also reported by Cytryn et al (2009) in relation to myocardial infarction.…”

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“…Some patients have perceived themselves to be “low-risk” [11] and have reported a lack of general malaise, which might have contributed to delay [12]. Patients have also noted that they worry about attending their general practitioner (GP) for fear of creating a “fuss” [13].…”

“…ICD-10 coding was used as an indicator for body site but this method of grouping included a combination of different histological subtypes within the same code. Patients with early melanoma tend to feel well and, as a result, may not heed the initial symptoms [12]. …”

“…Patient factors, however, crucially influence the timing of presentation [3–11]. It has previously been shown that changing moles may not cause patient concern or even be recognised as a feature of skin cancer [12] and the reasons for delay are complex, including a lack of recognition of the symptoms as significant and not wanting to “waste” the doctor’s time [8, 10, 11, 13]. It is critical to better understand the reasons for patient delay in order to effect change and to overcome obstacles to early detection.…”

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“…Schmid-Wendtner and colleagues 31 similarly found that longer time to biopsy was not associated with greater tumor thickness, while fairer skin type, lower education level, and lack of knowledge about melanoma were associated with greater tumor thickness. Walter and colleagues 32 found that patient lack of concern regarding a changing nevus was a significant barrier to early detection. In this study, we have identified several additional factors associated with delayed melanoma diagnosis, including location on trunk and extremities, new patient status, patient concern before biopsy, and physician suspicion of NMSC.…”