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Show Extension of Telemedicine to Treatment Management of Lentigo Maligna with Neoadjuvant Topical Imiquimod Andy Lamb COLLEGE OF NURSING Background PICOT Question ➢ Lentigo maligna is a superficial spreading subtype of melanoma that occurs on chronically sun exposed skin and does not exhibit invasion at the deep margin ➢ Current standard of care is 3 months of neoadjuvant topical imiquimod treatment, followed by a 1-2 month recuperation period, and a definitive staged excision procedure ➢ Topical imiquimod, when used effectively, can reduce tumor burden and required surgical margin, thus reducing cosmetic penalty(1) ➢ Treatment is monitored with monthly in-office follow ups and must be titrated to achieve optimal level of inflammation ➢ Excess inflammation can cause pain, bleeding, oozing, flu-like symptoms, and risk for infection ➢ Inadequate inflammation can compromise efficacy of treatment and lead to a more aggressive definitive surgery Is there an impact on patient experience and understanding of treatment, over a one-month period for patients with an active diagnosis of lentigo maligna, when a call is performed after the first two weeks of treatment with topical imiquimod, in addition to their regularly scheduled follow-up visits, compared with routine follow-ups without a phone call? Figure 1: Example of Excessive Inflammation Associated with Topical Imiquimod ➢ A phone call would be performed by clinic staff after the first 2 weeks of the first month of treatment with topical imiquimod, assessing level of inflammation, performing treatment titration as needed, and addressing any questions. ➢ Patient can send clinic staff a photograph of site via e-mail ➢ Patients have endorsed satisfaction with utility of telephone follow up in other ambulatory settings(3) ➢ Patients in other settings have reported that telephone follow ups show accessibility, personalization, and a sense of relationship with the calling staff member(4), all of which are important qualities in caring for patients in an ambulatory oncology setting Assessment of Efficacy Assessment of efficacy of intervention would be subjective and answer the following questions: ➢ Did the patient require a dosage adjustment? ➢ Did the patient have any questions or concerns? ➢ Did the patient endorse satisfaction with the call? The Gap By the first month follow-up of treatment, it is often determined that patients tend to have difficulty understanding treatment rationale, desired level of inflammation, and when to call and ask for help. Inadequate treatment in the first month can sacrifice one third of their treatment duration. Implementation References 1. 2. 3. Note: From Imiquimod Effect on Forehead [Photograph], by JustinAim, 2010, Wikicommons(2) 4. Donigan, J., Hyde, M., Goldgar, D., Hadley, M., Bowling, M., & Bowen, G. (2018). Rate of recurrence of lentigo maligna treated with off-label neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excision. Journal of American Medical Association Dermatology, 154(8), 885-889. https://doi.org/10.1001/jamadermatol.2018.0530 JustinAim. (2010). Imiquimod effect on forehead [Photograph]. Wikicommons. Retrieved from: https://commons.wikimedia.org/wiki/File:Imiquimod_effect_on_forehead.png Schimpf, M., Fenner, D., Smith, T., Tucker, J., & Berger, M. (2016). Patient satisfaction with nurse-led telephone follow-up in an ambulatory setting. Female Pelvic Medicine and Reconstructive Surgery. 22(6). 430-432. https://doi.org/10.1097/SPV.0000000000000305 Williamson, S., Chalmers, K., & Beaver, K. (2014). Patient experiences of nurse-led telephone follow-up following treatment for colorectal cancer. European Journal of Oncology Nursing. 19(3). 237-243. https://doi.org/10.1016j.ejon.2014.11.006 |
