Technology-Enabled Activation of Skin Cancer Screening for Hematopoietic Cell Transplantation Survivors and their Primary Care Providers

总结/摘要 造血细胞移植（HCT）是越来越多的血液病患者的治疗选择， 疾病和恶性肿瘤。然而，HCT相关因素，如用于调节的全身照射， 移植物抗宿主病和长期暴露于免疫抑制治疗，导致非常高的风险， 随后的皮肤癌。与一般人群相比，HCT幸存者也更容易发展为 皮肤癌发生在较年轻的年龄，表现为晚期疾病，并经历多次复发。 尽管负担如此之高，但只有不到20%的长期HCT幸存者报告接受了皮肤癌检查，即使是 尽管>90%的人在前一年被他们的初级保健医生（PCP）看到。在HCT幸存者中， 在他们的随访护理基本上从肿瘤护理过渡到初级护理的时候发展 环境，强调需要制定创新战略，1）为HCT幸存者提供技能， 进行有效的皮肤自我检查，并及时采取行动，从他们的供应商时，令人担忧的病变， 2）让PCP参与基于HCT风险的皮肤癌筛查; 3）确保快速获得皮肤病治疗 考试技术的进步，包括手机的普及和远程皮肤镜检查（远程） 专家评估的照片病变）提供了有希望的机会，以改善早期发现， 皮肤癌的治疗我们提出了一项比较有效性研究，将检查患者的影响， 激活和教育（PAE），单独或与医生定制的策略相结合，对临床 有意义的行为结果。我们将在一个大型、多样化的HCT中心招募720名HCT幸存者，以： 1)确定PAE单独或与医生激活（PAE+Phys）对皮肤癌筛查的影响， 12个月时的预防措施;以及2）在HCT幸存者的PCP中，确定 远程皮肤镜电子学习计划与提供打印材料以识别可疑病变相比。 我们假设，与PAE相比，随机分配至PAE+Phys组的患者将报告更高的彻底性 自我和提供者皮肤检查，可疑病变转诊时间缩短，生活质量提高;比较 单独打印材料，随机接受远程皮肤镜电子学习的医生将更好地认识到 可疑病变和更合适的、具有成本效益的转诊模式。我们的多学科团队将：1） 确定PAE的疗效，以及医生激活的相对受益; 2）告知皮肤癌的实践 使用易于应用于临床环境的创新移动的策略进行筛查;以及3）识别 促进和障碍，以适当提供生存为重点的预防性护理，长期HCT 幸存者从目前的研究中获得的信息可用于制定管理战略， 在初级保健环境中HCT幸存者的其他晚期效应（如心血管、内分泌），并改善 在其他高风险（如辐射照射）癌症幸存者群体中进行皮肤癌筛查。

SUMMARY/ABSTRACT Hematopoietic cell transplantation (HCT) is a curative option for a growing number of patients with hematologic diseases and malignancies. However, HCT-related factors, such as total body irradiation used for conditioning, graft-versus-host disease, and prolonged exposure to immunosuppressive therapy, result in very high risk for subsequent skin cancers. Compared with the general population, HCT survivors are also more likely to develop skin cancers at a younger age, have advanced disease at presentation, and experience multiple recurrences. Despite this high burden, less than 20% of long-term HCT survivors report being examined for skin cancer, even though >90% were seen by their primary care physician (PCPs) in the prior year. In HCT survivors, skin cancers develop at a time when their follow-up care has largely transitioned from oncology care to the primary care setting, emphasizing the need to develop innovative strategies that 1) provide HCT survivors with the skills to conduct effective skin self-examinations, and prompt action from their providers when worrisome lesions are found; 2) engage PCPs in HCT risk-based screening for skin cancer; and 3) ensure rapid access to dermatologic exams. Advances in technology, including widespread availability of cell phones and teledermoscopy (remote expert assessment of a photographed lesion) offer promising opportunities to improve early detection and treatment of skin cancer. We propose a comparative effectiveness study that will examine the impact of patient activation and education (PAE), alone or in combination with physician-tailored strategies, on clinically meaningful behavioral outcomes. We will enroll 720 HCT survivors at a large, diverse HCT center to: 1) Determine the impact of PAE alone or with physician activation (PAE+Phys) on skin cancer screening and prevention practices at 12 months; and 2) Among PCPs of HCT survivors, determine the impact of a teledermoscopy e-learning program compared with provision of print materials for identifying suspect lesions. We hypothesize that compared to PAE, patients randomized to PAE+Phys will report higher rates of thorough self- and provider skin exam, shorter time to referral of suspicious lesions, and improved quality of life; compared to print materials alone, physicians randomized to teledermoscopy e-learning will have greater recognition of suspect lesions and more appropriate, cost-effective referral patterns. Our multi-disciplinary team will: 1) establish the efficacy of PAE, and the relative benefit of physician activation; 2) inform the practice of skin cancer screening using innovative mobile strategies that are readily applicable in the clinical setting; and 3) identify facilitators of and barriers to appropriate delivery of survivorship-focused preventive care for long-term HCT survivors. Information obtained from the current study can be used to develop strategies for management of other late effects (e.g. cardiovascular, endocrine) in HCT survivors in the primary care setting, and to improve skin cancer screening in other high-risk (e.g. radiation-exposed) cancer survivor populations.