Patient adherence to skin self-examination

effect of nurse intervention with photographs



      Results from a single case–control study suggest that skin self-examination (SSE) has the potential to reduce mortality from melanoma by 63%. Despite these encouraging results, SSE rates are low. Few prospective studies of interventions to increase SSE in high-risk cohorts have been performed. The purpose of this study was to assess the impact of a brief nurse-delivered intervention using digital photographs on patients' adherence to performing SSE.

      Design setting/participants

      Patients at high risk for melanoma skin cancer (five or more dysplastic nevi) (N=100) were recruited from the outpatient Pigmented Lesion Clinic at Memorial Sloan–Kettering Cancer Center. All participants had baseline whole-body digital photography as part of their clinical evaluation.


      Patients were randomized: Group A (n =49) received a teaching intervention (physician and nurse education module) with a photo book (personal whole-body photographs compiled in the form of a booklet, with nurse instruction on how to use the photographs); and Group B (n =51) received the teaching intervention only without a photo book.

      Main outcome/measures

      Self-administered questionnaires were provided at three intervals: baseline, post-teaching intervention, and at the 4-month post-baseline visit. To assess adherence with SSE, patients were asked, “How many times in the past 4 months did you (or someone else) usually, thoroughly examine your skin?”


      In Group A (teaching intervention with photo book), 10.2% of the patients at baseline reported skin examination three or more times during the past 4 months, while 61.2% reported skin examination three or more times at the 4-month follow-up (p =0.039 for paired comparison). In Group B (teaching intervention only), nearly 20% of the patients at baseline reported skin examination three or more times during the past 4 months, while 37% reported skin examination three or more times at the 4-month follow-up (p =0.63). The increase in reported skin examination was compared between the two groups (>51% v >17.6%, p =0.001).


      The results suggest that a brief nurse-delivered intervention is effective at increasing patient adherence with SSE. Utilizing digital photographs as an adjunct to screening appeared to increase patient adherence to performing SSE.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Jemal A.
        • Murray T.
        • Samuels A.
        • Ghafoor A.
        • Ward E.
        • Thun M.J.
        Cancer statistics, 2003.
        CA Cancer J Clin. 2003; 53: 5-26
        • Breslow A.
        Thickness cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma.
        Ann Surg. 1970; 172: 902-908
        • Margolis D.J.
        • Halpern A.C.
        • Rebbeck T.
        • et al.
        Validation of a melanoma prognostic model.
        Arch Dermatol. 1998; 134: 1597-1601
        • Sahin S.
        • Rao B.
        • Kopf A.W.
        • et al.
        Predicting ten-year survival of patients with primary cutaneous melanoma.
        Cancer. 1997; 80: 1426-1431
        • Breslow A.
        Tumor thickness, level of invasion and node dissection in stage I cutaneous melanoma.
        Ann Surg. 1975; 182: 773-774
        • Koh H.K.
        • Geller A.C.
        • Miller D.R.
        • Lew R.A.
        The early detection of and screening for melanoma. International status.
        Cancer. 1995; 75: 674-683
        • Weinstock M.A.
        Early detection of melanoma.
        JAMA. 2000; 284: 886-889
        • Koh H.K.
        • Miller D.R.
        • Geller A.C.
        • Clapp R.W.
        • Mercer M.B.
        • Lew R.A.
        Who discovers melanoma? Patterns from a population-based survey.
        J Am Acad Dermatol. 1992; 26: 914-919
        • Miller D.R.
        • Geller A.C.
        • Wyatt S.W.
        • et al.
        Melanoma awareness and self-examination practices.
        J Am Acad Dermatol. 1996; 34: 962-970
        • Weinstock M.A.
        • Martin R.A.
        • Risica P.M.
        • et al.
        Thorough skin examination for the early detection of melanoma.
        Am J Prev Med. 1999; 17: 169-175
        • Tucker M.A.
        • Halpern A.
        • Holly E.A.
        • et al.
        Clinically recognized dysplastic nevi. A central risk factor for cutaneous melanoma.
        JAMA. 1997; 277: 1439-1444
        • Swerdlow A.J.
        • English J.
        • MacKie R.M.
        • et al.
        Benign melanocytic naevi as a risk factor for malignant melanoma.
        BMJ. 1986; 292: 1555-1559
        • Garbe C.
        • Buttner P.
        • Weiss J.
        • et al.
        Risk factors for developing cutaneous melanoma and criteria for identifying persons at risk.
        J Invest Dermatol. 1994; 102: 695-699
        • Berwick M.
        • Oliveria S.A.
        • Luo S.
        • Headley A.
        • Bolognia J.L.
        A pilot study using nurse education as an intervention to increase skin self-examination for melanoma.
        J Cancer Educ. 2000; 15: 38-40
        • Edmondson P.C.
        • Curley R.K.
        • Mardsen R.A.
        • Robinson D.
        • Allaway S.L.
        • Willson C.D.
        Screening for malignant melanoma using instant photography.
        J Med Screen. 1999; 6: 42-46
        • Hanrahan P.F.
        • Hersey P.
        • Menzies S.W.
        • Watson A.B.
        • D'Este C.A.
        Examination of the ability of people to identify early changes of melanoma in computer-altered pigmented skin lesions.
        Arch Dermatol. 1997; 133: 301-311
      1. Phelan DL, Oliveria SA, Christos PJ, Dusza SW, Halpern AC. Skin self-examination in patients at high risk for melanoma: a pilot study. Oncol Nurs Forum 2003;30:1029–36

      2. Rosenstock IM SV, Becker MH. Social learning theory and the health belief model. Health Educ Q 1988;15:175–83

        • Walsh J.M.
        • McPhee S.J.
        A systems model of clinical preventive care.
        Health Educ Q. 1992; 19: 157-175
        • Weinrich S.
        • Holdford D.
        • Boyd M.
        • et al.
        Prostate cancer education in African American choices.
        Public Health Nurs. 1998; 15: 188-195
        • Poss J.E.
        Factors associated with participation by Mexican migrant farmworkers.
        Nurs Res. 2000; 49: 20-28
        • McKee J.M.
        Cues to action in prostate cancer screening.
        Oncol Nurs Forum. 1994; 21: 1171-1176
        • Knight R.A.
        • Hay D.A.
        The relevance of the health belief model to Australian smokers.
        Soc Sci Med. 1989; 28: 1311-1314
        • Janz N.K.
        • Champion V.L.
        • Strecher V.J.
        The health belief model.
        in: Glanz K. Rimer B.K. Lewis F.M. Health behavior and health education. Theory, research and practice. 3rd ed. Jossey-Bass, San Francisco CA2002
        • Guibert R.
        • Leduc N.
        • Fournier P.
        • Tetreault H.
        What factors determine whether individuals found to have hypercholesterolaemia at mass screening accept advice to visit their physician.
        Public Health. 1999; 113: 105-110
        • Gallo M.L.
        • Statskin D.R.
        Pelvic floor muscles exercise compliance in women with stress urinary incontinence.
        Neurourol Urodyn. 1997; 16: 167-177
        • Agresti A.
        A survey of models for repeated ordered categorical response data.
        Stat Med. 1989; 8: 1209-1224
        • Berwick M.
        • Begg C.B.
        • Fine J.
        • Roush G.C.
        • Barnhill R.L.
        Screening for cutaneous melanoma by skin self-examination.
        J Natl Cancer Inst. 1996; 88: 17-23