Embracing apps that can catch skin cancer early

Ear­ly detec­tion can make all the dif­fer­ence when treat­ing skin can­cer. Con­se­quent­ly, the num­ber of skin diag­no­sis and mole mon­i­tor­ing apps has mul­ti­plied over the past five years. A 2017 study, for instance, found there had been an 80.8 per cent growth in der­ma­tol­ogy apps since 2014.

But do such telemed­i­cine apps cre­ate more prob­lems than solu­tions? Or can sophis­ti­cat­ed, reg­u­lat­ed tech­nol­o­gy, arti­fi­cial intel­li­gence (AI) and telemed­i­cine prod­ucts stream­line patient path­ways and ease the bur­den of health­care pro­fes­sion­als, detect­ing more cas­es of malig­nant melanoma?

Healthcare professionals overstretched

Skin dis­or­ders are extreme­ly com­mon and the num­ber of peo­ple who devel­op malig­nant melanoma in Britain has risen faster than any oth­er com­mon can­cer. Between 2013–14 and 2017–18 GP refer­rals for der­ma­tol­ogy increased by 15 per cent to 1.16 mil­lion a year, accord­ing to NHS Eng­land.

The coro­n­avirus pan­dem­ic has meant many rou­tine screen­ings, and urgent refer­rals and treat­ments, have been delayed or can­celled, lead­ing to a back­log of patients.

With so many moles referred from pri­ma­ry care, which usu­al­ly require a biop­sy, malig­nant melanoma is noto­ri­ous­ly time inten­sive and chal­leng­ing for doc­tors to diag­nose.

How telemedicine can help

Telemed­i­cine has been hailed as a solu­tion. Skin diag­no­sis and mon­i­tor­ing apps, such as Skin Ana­lyt­ics, Miiskin or Mol­e­Care, present an oppor­tu­ni­ty to clear the back­log of patients cre­at­ed by the pan­dem­ic and could make it pos­si­ble to catch addi­tion­al skin can­cers ear­ly on.

Neil Daly, chief exec­u­tive of Skin Ana­lyt­ics, believes there is “no answer that doesn’t involve tech­nol­o­gy like ours”. He says: “We just don’t have the resources to cope with the num­ber of patients oth­er­wise.”

The rise in com­mer­cial skin diag­no­sis apps could reflect an increased desire for patients to take health­care into their own hands, espe­cial­ly in light of COVID-19. “It’s empow­er­ing for the patient because it enables them to take con­trol of their own health,” says Dr Sharon Wong, der­ma­tol­o­gist based at Lon­don Bridge Hos­pi­tal.

How­ev­er, there are con­cerns about unreg­u­lat­ed com­mer­cial apps diag­nos­ing and treat­ing skin can­cers and skin con­di­tions.

As der­ma­tol­o­gists we will and we should move along with how tech­nol­o­gy devel­ops. AI will be the way for­ward and we do need to adapt our ways accord­ing­ly

John Loder, invest­ment direc­tor for Nes­ta, an inno­va­tion foun­da­tion, is opti­mistic about the poten­tial of sophis­ti­cat­ed telemed­i­cine tech­nol­o­gy, but says it must be prop­er­ly reg­u­lat­ed and test­ed in clin­i­cal set­tings. “The reg­u­la­to­ry envi­ron­ment is not com­plete­ly nailed down,” he says.

A BMJ report released in Feb­ru­ary looked into pub­licly avail­able skin­Scan and Skin­Vi­sion apps, and con­clud­ed algo­rithm-based smart­phone apps had a “poor and vari­able per­for­mance”, say­ing “these apps have not yet shown suf­fi­cient promise to rec­om­mend their use”.

Challenges with app-based healthcare services

If telemed­i­cine solu­tions don’t have a high degree of accu­ra­cy they could cause addi­tion­al prob­lems, such as miss­ing can­cers and offer­ing false reas­sur­ance or fur­ther over­load­ing health­care pro­fes­sion­als.

“If a patient goes to a GP and says this app says this, it’ll be dif­fi­cult for the GP, who is not a skin expert, to dis­agree. So we could get more patients referred to the der­ma­tol­o­gist, which could even increase the work­load,” says Dr Adil Sher­az, con­sul­tant der­ma­tol­o­gist and British Skin Foun­da­tion spokesman.

On top of this, images patients take them­selves on smart­phones might not be clear, so apps could miss prob­lems.

Anoth­er con­cern is that a lot of the images in app data­bas­es are from lighter skin types. “So they could widen the gap we already have in pick­ing up melanomas in dark­er skin types,” says Sher­az. “We have to be care­ful to cater for all dif­fer­ent types of skin can­cers.”

Where it’s used, telemed­i­cine works best along­side health­care pro­fes­sion­als. One rea­son for this is the emo­tion­al ele­ment of diag­nos­ing can­cer and need to reas­sure patients, says Daly at Skin Ana­lyt­ics. “Peo­ple are real­ly com­plex and AI is a blunt tool that you need to tar­get in the right way,” he says.

For exam­ple, Wong says if a patient of hers had a lesion that looked con­cern­ing, she could prime them for the pos­si­bil­i­ty of bad news ear­ly on.

Der­ma­tol­o­gists can also exam­ine patients phys­i­cal­ly. “Ulti­mate­ly humans will pre­fer to have human inter­ac­tion and AI isn’t able to engage in that high­er-lev­el con­ver­sa­tion,” she says. “As a human we can exam­ine not just on a visu­al aspect, but also on a tac­tile aspect. We can touch the skin.”

Health services of the future

Despite the mis­giv­ings, many in pub­lic health­care and dig­i­tal health are excit­ed about the pos­si­bil­i­ty of telemed­i­cine and envi­sion a future where skin diag­no­sis apps work along­side clin­i­cians.

Dig­i­tal solu­tions can reach remote loca­tions and peo­ple unable to access ser­vices due to the coro­n­avirus pan­dem­ic. Both Wong and Sher­az say they believe skin mon­i­tor­ing apps, such as Miiskin, are already help­ful and would like to work with more reg­u­lat­ed, sophis­ti­cat­ed dig­i­tal tools in the future.

“As der­ma­tol­o­gists we will and we should move along with how tech­nol­o­gy devel­ops. AI will be the way for­ward and we do need to adapt our ways accord­ing­ly,” says Sher­az. “I’m real­ly hap­py peo­ple are look­ing at this tech­nol­o­gy.”

Wong agrees. “Dur­ing COVID we’ve used tele­d­er­ma­tol­ogy a lot and it’s only pushed to the fore­front the impor­tance of embrac­ing and work­ing along­side tech­nol­o­gy to improve patient care,” she says.

Telemed­i­cine has the poten­tial to stream­line health­care ser­vices and help der­ma­tol­o­gists to detect skin can­cers. But there are still a num­ber of chal­lenges that must be over­come to ensure the range of skin diag­no­sis apps are reg­u­lat­ed, sophis­ti­cat­ed and safe to use.

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Speeding up skin cancer detection

Sci­en­tists have warned there could be thou­sands of excess deaths in the UK in the com­ing years due to delays in can­cer diag­no­sis and treat­ment dur­ing the coro­n­avirus cri­sis.

To tack­le this, Uni­ver­si­ty Hos­pi­tals Birm­ing­ham (UHB) NHS Foun­da­tion Trust launched a pilot in May with arti­fi­cial intel­li­gence (AI) com­pa­ny Skin Ana­lyt­ics.

Ser­vices were set up away from the hos­pi­tal and the trust’s clin­i­cal pho­tog­ra­phers worked with Skin Ana­lyt­ics to cap­ture an image of the patient’s lesion which was then assessed by the AI. If it was deter­mined to be can­cer­ous, a der­ma­tol­o­gist remote­ly reviewed and placed the patient on the cor­rect treat­ment path­way.

The aim of the pilot was to reduce delays in skin can­cer detec­tion and treat­ment dur­ing the pan­dem­ic by pro­vid­ing a screen­ing pro­gramme using the AI tool.

“It was dri­ven by the demand caused by COVID,” says Neil Daly, chief exec­u­tive of Skin Ana­lyt­ics. “We want­ed to deal with a vol­ume of patients that couldn’t be seen in hos­pi­tal and we were able to see a large num­ber of patients and take some of the pres­sure off.”

Nick Bar­low, direc­tor of applied dig­i­tal health at UHB, says he is “incred­i­bly proud” of the ini­tia­tive. “Iden­ti­fy­ing patients with melanoma [dur­ing the coro­n­avirus pan­dem­ic] and pro­vid­ing treat­ment soon­er will result in sig­nif­i­cant ben­e­fits,” he says. “Man­ag­ing the clin­i­cal risk and find­ing the patients who need treat­ment for melanoma will also be a key focus for hos­pi­tals well beyond the COVID-19 cri­sis.”

The pilot is an exam­ple of how sophis­ti­cat­ed AI-based tools can be used along­side health­care pro­fes­sion­als to help detect skin can­cers, espe­cial­ly in light of the pan­dem­ic.