CC BY
29MEDICAL SCIENCES
CAUSES OF LATE DETECTION OF SKIN CANCER
Vizdoaga V.
Master in Health Management, Chief doctor, doctor dermatologist Clinic "Alter - MED" Chisinau municipality, Republic of Moldova Lozan O.
Doctor habilitat in sciences, university professor Director of the School of Management in Public Health,
Republic of Moldova Betiu M.
Doctor of medical sciences, head of the USMF "Nicolae Testimitanu " dermatovenerology department, Republic of Moldova
Abstract
Skin cancer is a major public health problem both at the global and national level. In the general structure of mortality worldwide, as well as in the Republic of Moldova (RM), malignant tumours occupy the second place, after cerebrovascular diseases. In the Republic of Moldova, it is determined a late addressability of patients with skin tumours. Cancer mortality causes a considerable increase in the costs of treatment of this disease and other social costs associated with the malady: exclusion of person from socio-economic activity, care, time and resources from other family members, transportation, etc. [1].
Patients in the Republic of Moldova do not have sufficient access to modern diagnostic and treatment services. Despite the high incidence and mortality, in the regions of the Republic of Moldova there is only one institution, the Oncological Institute, which offers the specialized treatment to persons with skin cancer that produces enormous additional social costs borne by the patients and their families (transport) and does not ensure the realization of the principle of services closer to the persons who need them [5]. The financing of services provided to persons with cancer is ensured through the funds of the compulsory health insurance [2]. A barrier in the provision of cancer control services in the Republic of Moldova is the insufficiency of the specialized medical personnel and the limited access of specialists in the field to the trainings on the application of modern technologies.
Keywords: skin cancer, Non-Melanoma cancer, Malignant Melanoma, screening, national cancer programs.
INTRODUCTION
The information system in the cancer control is provided by the Cancer Register within the Public Medical-Sanitary Institution, Oncological Institute (IMSP OI) [5], created in 1980. At present it has a system of the collection and storage of data that is done in the paper registers and by the use of MS Excel. The capacity of the analysis of data from the Cancer Register is very limited. The existing regulation on the mandatory reporting of all cases of cancer diagnosed by all providers of medical services is outdated and does not establish clearly the responsibilities. Many medical institutions that provide the services of the diagnosis and treatment of skin cancers at the primary level do not report new cases of cancer, so Non-Melanoma Cancer (Non-Melanoma Cr.) at the level of the Republic of Moldova lacks accurate statistical data [4].
The problems in the route of the cancer patient in the Republic of Moldova are because of the lack of a standardized mechanism as the time of passing of the stages from the first address up to the initiation of treatment. Thus, the Government, the Ministry of Health, the National Medical Insurance Company initiated the elaboration and subsequent implementation of the National Cancer Control Program for 2016-2025, which
aims to reduce the burden of this malady on the society in general and on the individual in particular, but the problem of skin cancer as an oncological pathology is less found as a public health problem [11]. The fact that in the Republic of Moldova the incidence of the malignant neoplasms is much lower compared to the developed countries of Europe, on the one hand, and the mortality rate is higher, indicates that the actions of the early detection and treatment are less effective or underdeveloped [15]. The more advanced the stage of cancer detection, the more unfavourable the outcome of treatment and prognosis, and the chance of the survival of patient is by five and more years lower [13]. At the moment there is a National Clinical Protocol "Skin Malignant Melanoma", elaborated in 2012, but its update is missing, contemporary methods of the diagnosis and treatment are not found [10,12].
From the diagram below (Fig.1) [3] we find that Non-Melanoma Cr. ranks the 2nd among the most frequent cancers in the Republic of Moldova. Malignant Melanoma (MM) ranks the 19th, the official data from the National Cancer Register for 2019. This indicates that every 3rd patient is diagnosed with skin cancer and registered in the National Cancer Register.
Colorectal cr. 38,2
Skin cr. (non-melanoma) 34,5
Prostate cr. (b) 33,6
Mammary gland cr. 33,2
Lung cr. 23,5
Uterine body cr. (f) 21,8
Hemoblastosis Cervix cr. (f) Oral cavity cr.
Stomach cr. Ovarian cr. (f) Thyroid cr. Pancreas cr. Bladder cr. Kidneys and renal pelvis cr.
Liver cr.
Of brain and other parts of CNS Of oral cavity Skin melanoma Mesothelial and soft tissues
0,0 5,0 10,0 15,0 20,0 25,0 30,0 35,0 40,0 45,0
Fig. 1 Incidence of skin cancers for 2019 in the Republic of Moldova %000 [National Cancer Register Data]
For 2020, Non-Melanoma Cr. decreases to the 4th place, while the incidence of MM is increasing with the placement at the 18th place. (Fig. 2) [3].
Colorectal cr. Mammary gland cr. Prostate cr. (b) Skin cr. (non-melanoma) Lung cr. Cervix cr. (f) Uterine body cr. (f) Hemoblastosis Oral cavity cr.
Stomach cr. Ovarian cr. (f) Pancreas cr. Bladder cr. Kidneys and renal pelvis cr.
Liver cr. Thyroid cr. Of brain and other parts of CNS Skin melanoma Of larynx Mesothelial and soft tissues
31,8
28,7 28,5
■ 22,2 20,5
17,7 17,4
14,9
12,4
9,4
7,9 7,1 6,9 6,3 6,2 5,0 3,8 3,7 3,4 3,0
0,0 5,0 10,0 15,0 20,0 25,0 30,0 35,0
Fig. 2 Incidence of skin cancers for 2020 in the Republic of Moldova %000 [National Cancer Register Data]
The pandemic situation influenced the addressability of the patients with skin cancer to the specialist doctor, and doctors conducted many consultations by telephone. The lack of the legislation on telemedicine in the Republic of Moldova camouflaged the incidence of the cases and influenced the statistical data [6,7,8,9].
The addressing of the patients with MM in the Republic of Moldova takes place in the late stages, respectively the survival rate over 5 years is comparatively decreasing by 38,4% for 2020 (Fig. 3).
■ Melanoma ■ Other skin tumours
Fig. 3 Survival for more than 5 years of the patients with skin cancer, 2017-2020, %
Proceeding from the presented situation, we were interested in the determination and analysis of the causes that lead to the late detection of skin cancer in the Republic of Moldova. Identification of the factors associated with the late detection will allow the elaboration of the interventions for the improvement of the prevention measures.
The intended goal consists in the determination of knowledge, attitudes and practices of the patients diagnosed with skin cancer and identification of the path of the patient with skin cancer in the local health system. Evaluation of the opinion of family doctors, doctors dermatologists, oncologists on the late detection of skin cancer.
PATIENTS AND METHODS:
In order to determine the burden of skin cancer in the Republic of Moldova, a selective transversal study was performed on 405 patients diagnosed with skin cancer during the period of February-May 2021, within the PMSI Oncological Institute - the centralized institution in the provision of oncological service in the Republic of Moldova. The criteria for the selection of the target sample were: age over 18 years old; confirmed diagnosis of skin cancer; the agreement of the subjects participating in the study.
On the basis of the studied material, a questionnaire was elaborated with the demographic elements, detailing the path of patient from the appearance of the first symptoms of the disease up to the first interaction with the medical system and subsequent interactions
with specialists who communicated the diagnosis and initiated the specific treatment.
Through in-depth interviews with the application of the open-ended questions, we set the task to find out the opinion of family doctors, dermatologists and oncologists on the causes of the late detection of skin cancer.
In order to improve the quality of the research, the data taken from the medical documents of the patients were used: outpatient or inpatient medical card, form of Referral-extract, Report of statement in patient of the advanced form of malignant tumour, data from the National Cancer Register and data of the National Bureau of Statistics.
STATISTICAL ANALYSIS
The primary data were collected in the spreadsheet program Microsoft Excel 2010, the obtained results were processed by the SPSS program and presented by different types of tables, graphs and diagrams.
RESULTS
Out of 405 patients eligible for the study, 149 were women (49,01%) and 155 were men (50,99%). Most of the respondents were over 65 years old (58%) and the place of residence of 226 patients (55,8%) was urban.
The health system of the Republic of Moldova provides free provision of oncological service for the patients having the insurance policy. Thus, the majority of the respondents 95,8% benefited from free oncological service, being insured by the state, and another 4,2% paid for the treatment. Approximately 92,1% of the study participants opted for a public institution.
Table 1.
General characteristics of sample (N=405)
Sex Frequency Percent %
f 149 49,01
m 155 50,99
Age
16-29 years old 2 0,5
30-54 years old 76 18,8
55-64 years old 92 22,7
>65 years old 235 58
Place of residence rural 179 44,2
urban 226 55 ,8
Insurance policy yes 388 95,8
no 17 4,2
What type of medical institutions did you address for the first time Public institution 373 92,1
Private institution 32 7, 9
Following the analysis of the study group, 305 (75,30%) patients had the established diagnosis of Non-Melanoma Cancer, and 100 patients (24,7%) were confirmed with the diagnosis of Malignant Melanoma. Out of whom 283 patients are diagnosed with basal cell cancer (BCC), 20 patients are registered with squamous cell cancer (SCC) and 2 respondents are diagnosed with keratoacanthoma.
Most patients with Non-Melanoma Cr. (N = 305), in the proportion of 50,5% had the formations localized in the Head-Throat area, 49,2% on areas exposed to ultraviolet rays such as: upper limbs, lower limbs and trunk. Only in one of the patients (0,3%), the formations were found on the hidden area of the body (male genital organs) (Table 2).
In case of Malignant Melanoma, the location of the skin formations was detected on the areas of trunk and upper and lower limbs (98%), and only 2% - with unspecified localization.
Within the group of 305 respondents diagnosed with skin cancer, other oncological diseases were detected simultaneously. 9 persons had simultaneously confirmed the diagnosis of: lung cancer, breast cancer, prostate cancer, oral cancer, haematological disease, cancer of reproductive organs. One respondent out of those interviewed was tested positive for HIV (Table 2).
Table 2.
Localization of formations (N=405)
NM 305 75,30% MM 100 24,70%
C44.1 4 1,30% Eyes/eyelid C43.5 56 56% Trunk
C44.2 4 1,30% Ear pavilion C43.6 18 18% Upper limbs
C44.3 130 42,60% Head/throat C43.7 24 24% Lower limbs
C44.4 16 5,30% Skin part of scalp C43.8 1 1% Without concrete localization (other than those indicated above)
C44.5 90 29,50% Trunk C43.9 1 1% Unspecified
C44.6 31 10.2% Skin of upper limbs
C44.7 29 9,5 Skin of lower limbs
C63.2 1 0,30% Male genital organs (scrotum)
The primary interaction of the patient with the medical system took place through the family doctor in 65,9% of cases, in the proportion of 21,2% of cases the first address was to the doctor dermatologist, 6% to the
doctor oncologist of the OI, 2% of the respondents addressed to the doctor oncologist at the level of the ambulatory specialized medical assistance (ASMA), 3% to the doctor surgeon, 2% to the ophthalmologist (Table 3).
Table 3.
Primary interaction of patients with skin cancer (N=405)
Primary interaction Percentage Frequency
family doctor 65,90% 269
doctor dermatologist 21,20% 84
doctor oncologist of the OI, 6% 24
doctor surgeon 3% 12
doctor oncologist ASMA 2% 8
doctor ophthalmologist 2% 8
Total 100% 405
The vast majority of the respondents 75,1% did 16,3% did self-treatment and only 8,6% addressed to not give importance to the first signs of the disease, the doctor (Table 4).
Table 4.
Actions of patient at the appearance of the first signs of skin cancer (N=405)
Actions of patient at the appearance of the first signs of disease Percentage Frequency
denied the first signs of disease 75,10% 304
did self-treatment 16,30% 66
addressed to doctor 8,60% 35
Total 100% 405
54,3% of patients did not give importance to the injuries on the body and addressed to doctor lately between 1-5 years since the appearance of the first signs of disease. 23,7% addressed to doctor between 1-6 months, 11,6% between 7-12 months, 9,9% addressed
to doctor up to 1 month since the appearance of the first signs of disease, and 0,5% addressed to doctor after more than 5 years since the appearance of the first signs of disease (Table 5).
Table 5.
Time since the appearance of the first signs of disease up to the interaction with the medical system
(N=405)
Time since the appearance of the first signs of disease up to the interaction with the medical system NM /MM Percentage Frequency
between 1-5 years 54,30% 220
between 1-6 months 23,70% 97
7-12 months 11,60% 47
> 5 years 9,90% 41
Total 100% 405
There is a significant difference between the route passed by patients, 75,6% of the respondents for the first time addressed to the primary medicine (family doctor), after the first visit 48,9% of them are redirected to the OI, but can be redirected also to the consultation
of doctor dermatologist 29,9%, doctor oncologist ASMA 14,8%, and since the 3rd or the fourth address, the patient reaches the PMSI OI that is considered the centralized institution in the provision of the oncological service in the Republic of Moldova, (Table 6).
Table 6.
Route passed by patients with skin cancer, % (N=405)
1st address 2nd address 3rd address 4th address P
Primary medicine (Family doctor) 75,6 3,5 - 0,2 /2=806,0, gl=9, p<0,001
Doctor oncologist ASMA 1,7 14,8 6,7 -
Doctor dermatologist 19,8 29,9 0,5 -
Doctor oncologist OI 3,0 48,9 40,7 7,4
According to the interviewed respondents, the causes of the late detection of skin cancer were divided into causes dependent on the medical system and causes dependent on the patient. Indifference to own health (27,15%), insufficient knowledge about disease (18,16%), fear of expensive treatment (15,60%) were
the most frequent causes dependent on the patients. Lack of rural testing (15,80%), lack of doctors in rural localities (15,40%), failure to inform the population about the risks (7,88%) were the causes designated as dependent on the gaps in the medical system.
Table 7.
Opinion of respondents on the causes of the late detection of skin cancer (N=405)
Opinion of respondents on the causes of the late detection Percentage Frequency
indifference to own health 27,15% 110
insufficient knowledge about disease 18,16% 74
fear of expensive treatment 15,60% 63
lack of rural testing 15,80% 64
lack of doctors in rural localities 15,40% 62
failure to inform the population about the risks 7,88% 32
Total 100% 405
In the qualitative part of the study, we found out also the opinion of doctors on the causes of the late detection of skin cancer. The interviewed family doctors reported that many patients avoid the visits to doctors because of a fear to address to an institution with the oncological profile, the fear of the recognition of the existence of an oncological disease. Specialists within the primary medicine reported on the existence of long waiting lists for the appointment to the consultation of doctor oncologist. At the same time, they mentioned the lack of the informative material and diagnostic tools, at the level of primary medical institutions. And at the level of primary medical personnel, a cause is the short time reserved for the prophylactic examination of the patients with skin cancer that makes the consultation a superficial one without the detailed examination of the skin surfaces.
In the opinion of doctors dermatologists, many patients with Non-Melanoma cancer do not perceive the personal risk, avoid the visits to doctor or pass the self-treatment. At the same time, the dermatological offices are equipped insufficiently, and doctors are less trained in the diagnosis of skin cancer.
Doctors oncologists state that the lack of the contemporary diagnostic methods and long waiting lists for surgical treatments within a single institution centralized in the provision of the oncological services nationwide, makes it difficult the path of the patients with skin cancer. Other causes appearing on the way of the patient with skin cancer are the absence of an informational database and the lack of a population screening of the identification of persons being in the risk group.
DISCUSSIONS
Skin cancer is a visible disease and can be identified in the initial stages, however the patients avoid the first signs of the disease. Early detection of the disease would prolong the lives of the patients and would increase their chances of survival. The causes of the late detection of skin cancer are multifactorial and include both the patient-dependent causes and gaps in the medical system.
According to the specialized literature, the factors with major risk of the development of skin cancer have a cumulative and dangerous effect over time. Thus, the majority of respondents are people over 65 years old (58%), followed by the number of those aged between 55 and 64 years (22,7%) and those aged between 30 and 54 years (18,8%). The migration of the young population and the lack of prophylactic control of which they are not conscious, justifies the presence in the study of
a low proportion (0,5%) of cases in people aged be-tween16-29 years.
Depending on the area of residence, 55,8% of the respondents were from the urban area and, respectively, another 44,2% from the rural area. The presence of the centralized oncological service, on the one hand, favours the high accessibility of the respondents from the urban area, and on the other hand, the distance and travel costs of the patients of the suburbs of the country decreases the level of the accessibility of the population to the oncological service.
The medical institutions in the territory lack the specialized medical personnel (family doctors, dermatologists, oncologists, surgeons, etc.) and lack the tools for the diagnosis of skin cancer (dermatoscopes, magnifying lenses, histopathological examination, etc.).
Because of the fact that in 75% of cases, the patients did not give importance to the first signs of disease, the duration of the interval of the addressability to a specialized medical service is between 1 to 5 years for most of them (54,3%). Patients also provide an explanation of the causes of the late detection of skin cancer, where 27,15% believe that indifference to their own health and insufficient knowledge about the disease (18,16%) are the main reasons dependent on the patients.
In 65,9% of cases, the first interaction of patient with medical system takes place through the primary medical assistance. The medical personnel here are facing the difficulties connected with the busy schedule, which does not always allow for the extensive primary consultation. At the level of the primary medical institutions, there is the lack of informative materials on the subject of skin cancer, there is the lack of modern diagnostic tools, and the absence of a common information base in the country affects the process of the redirection of the patients suspected of skin cancer and does not allow their information monitoring in dynamics. The lack of the standardization of the path of the patient with skin cancer contributes to the prolongation of the time since the primary interaction of patient with medical system up to the initiation of the treatment itself. Thus, only since the second and the third visit to doctor, patients manage to contact the doctor oncologist who initiates the specific treatment.
CONCLUSIONS
1. In the Republic of Moldova, the route of the patient with skin cancer is not standardized and there is no conduct guide for Non-Melanoma Cancer.
2. Lack of awareness regarding the symptoms of cancer and low perception of personal risk, delay of the request of medical assistance are the most frequent causes dependent on the patient.
3. The primary interaction of the patient with skin cancer takes place with the family doctor (65,9%), who refers to the doctor dermatologist or oncologist.
4. The role of the doctor dermatologist is to perform the observational screening and to redirect the patients to the doctor oncologist.
5. Insufficient information of the population about skin cancer, lack of medical personnel, lack of equipment with diagnostic tools and long duration of the route of the patient with skin cancer are causes dependent on the national medical system.
6. The opinion of patients and doctors coincides on the main causes of the late detection: indifference to own health and insufficient knowledge of the population about the disease.
7. In the opinion of patients and doctors, widespread information of the population about risk factors of skin cancer, elaboration of a national screening program, training of family doctors, doctors dermatologists on the measures of the diagnosis and prophylaxis of skin cancer could reduce the incidence by this form of cancer on the territory of the Republic of Moldova
ABBREVIATIONS
PMA - Primary Medical Assistance;
ASMA - Ambulatory Specialized Medical Assistance;
BCC - Basal Cell Cancer;
Cr - Cancer;
Non-Melanoma Cr. -Non-Melanoma Cancer;
SCC - Squamous Cell Cancer;
PMSI - Public Medical-Sanitary Institution
MM - Malignant Melanoma;
MS Excel - Micro Soft Excel;
MH - Ministry of Health
RM - Republic of Moldova
REFERENCES:
1. Avram A.M., Dr. Dinu V., Dr. Clontia L., Compararea ghidului national de diagnostic §i trata-ment al melanomului cu ghidurile international. University of Medicine and Pharmacy "Carol Davila", Bucharest, 2015
2. National Medical Insurance Company, Chis-inau, 2021 http://www.cnam.md/?cx=015839770510556218192 %3 Ab3augosbi4m&cof=FORID%3 A10&ie=UTF-8&q=can-
cer&sa.x=0&sa.y=0&find=&siteurl=www.cnam.md% 2F
3. Melanoma of skin/ Number of new cases in 2020, both sexes, all ages, Globocan 2020 https://gco.iarc.fr/today/data/factsheets/cancers/16-
Melanoma-of-skin-fact-sheet.pdf [accessed on July 11th, 2021]
4. Mereuta I., Iacovlev I., Jurcan S., Tratamentul chirurgical contemporan al melanomului malign cu-tanat, Chisinau, 2009
5. Ministry of Health, Labour and Social Protection of the Republic of Moldova, Decentralization of chemotherapeutic and radiological treatment within hospital medical assistance. 2012, p. 7, 11
6. Ministry of Health, Labour and Social Protection of the Republic of Moldova ANNUAL SOCIAL REPORT 2017 Chisinau, 2018 https://msmps.gov.md/wp-content/up-loads/2020/10/RAPORT-SOCIAL-ANUAL-2017.pdf
7. Ministry of Health, Labour and Social Protection of the Republic of Moldova ANNUAL SOCIAL REPORT 2018 Chisinau, 2019 https://msmps.gov.md/wp-content/up-loads/2020/10/RAPORT-SOCIAL-ANUAL-2018.pdf
8. Ministry of Health, Labour and Social Protection of the Republic of Moldova ANNUAL SOCIAL REPORT 2019 Chisinau, 2020 https://msmps.gov.md/wp-content/up-
loads/2021/05/RAPORT-SOCIAL-ANUAL_2019.pdf
9. Order of the Ministry of Health on the approval of the National Clinical Protocol "Malignant skin melanoma" https://msmps.gov.md/wp-content/up-loads/2021/01/ord.-844.pdf
10. Order of the Ministry of Health No. 828 of October 31st, 2011 on the approval of primary medical record forms/Report in case of statement in patient of advanced form of malignant tumour (clinical group IV) p. 4
11. National Cancer Control Program for 20162025, Annex No. 1 to the Government Decision No. 1291 of December 02nd, 2016, Chisinau;
12. National clinical protocol: Malignant Skin Melanoma, PCN-161 Chisinau 2012 http://e-dermatol-ogie. md/chestiute/uploads/2017/07/Protocol-Melanom - malig - cutanat - PDF. pdf [accessed on April 12th, 2021]
13. Standardized clinical protocol for family doctors Malignant Skin Melanoma, available URL: http://89.32.227.76/_files/14354-6.pdf [accessed on December 20th, 2020]
14. ACTIVITY REPORT of the Ministry of Health, Labour and Social Protection January-December 2020 https://msmps.gov.md/wp-content/up-loads/2020/12/RAPORT-MSMPS-2020.pdf
15. Skin Cancer Foundation: Destination Healthy Skin https://www.skincancer.org/early-detection/desti-nation-healthy-skin/ [accessed on June 19th, 2021]
16. Feasibility study of PMSI Oncological Institute. Final Report, Chisinau 2010, p. 19 http://old2.ms.gov.md/sites/default/files/proiecte_des-fasurare/studiul_de_fezabilitate_asupra_imsp_instu-tul_oncologic_din_chisinau.pdf [accessed on May 11th, 2021].
