Jose W. Ricardo

Shari R Lipner

Dermatology Practical & Conceptual

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Letter to the Editor | Dermatol Pract Concept. 2023;13(4):e2023199 1Yet Another Reason to Examine the Nails: Substantial Cancer-Related Worry and Anxiety in Patients With Melanonychia in a Survey-Based StudyJose William Ricardo1, Shari Lipner11 Weill Cornell Medicine, Department of Dermatology, New York, USACitation: Ricardo JW, Lipner SR. Yet Another Reason to Examine the Nails: Substantial Cancer-Related Worry and Anxiety in Patients With Melanonychia in a Survey-Based Study. Dermatol Pract Concept. 2023;13(4):e2023199. DOI: https://doi.org/10.5826/dpc.1304a199Accepted: March 23, 2023; Published: October 2023Copyright: ©2023 Ricardo et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.Funding: None.Competing Interests: None.Authorship: All authors have contributed significantly to this publication.Corresponding Author: Shari R. Lipner MD, PhD, 1305 York Avenue, NY, NY 10021. Phone: 646-962-3376 Fax: 646-962-0033 E-mail: shl9032@med.cornell.eduPatient Consent: All patients gave consent for their medical information to be published in print and online, with the understanding that this information may be publicly available.To the Editor,Longitudinal melanonychia (LM) is a common sign of nail unit melanoma (NUM), often eliciting anxiety and cancer- related worry. We aimed to quantify levels and determine predictors of melanoma-related worry in LM patients.An Institutional Review Board-approved survey con-taining demographics, Melanoma Worry Scale (MWS), State-trait Anxiety Inventory (STAI-6), and Revised Impact of Event Survey (RIES) (Supplementary material), was ad-ministered 12/25/20-03/1/22, to patients >18 years present-ing with LM, pre- and post-nail consultation. Univariate analysis determined factors affecting baseline MWS scores. Multivariate analysis determined independent predictors of baseline MWS scores (α = 0.05).Forty-eight patients (82%) completed surveys; mean age 51 years and 71% women. Mean baseline MWS and STAI-6 scores were 10/17 and 47/80, respectively (Table 1). Post-consultation, mean MWS and STAI-6 scores decreased by 4.6 and 16.3 points, respectively (P < 0.001 all), for pa-tients for whom biopsy was not recommended (N = 30) (Table 2). Median baseline RIES scores for avoidance and intrusion subscales were 4/40 and 3/35, respectively. Internet searches (β=1, P=0.01), personal history of psychiatric ill-ness (β=1.1, P=0.02), personal history of melanoma (β=1.6, P=0.02), and higher STAI-6 scores (β=0.1, P<0.001) inde-pendently predicted baseline MWS scores on multivariate analysis.Univariate analysis of change in MWS scores in the no-biopsy group showed that female sex, seeing dermatol-ogist versus other clinician, internet searching, personal his-tory of psychiatric illness, and higher baseline STAI-6 scores were associated with greater decrease in MWS scores post- consultation (P<0.05 all).2 Letter to the Editor | Dermatol Pract Concept. 2023;13(4):e2023199Table 1. Correlation of baseline melanoma-related worry (MWS scores) with sociodemographic characteristics, baseline State-trait Anxiety Inventory (STAI-6) and Revised Impact of Event Survey (RIES) scores.VariablesN (%) and mean± SD /median (Range)MWS score, mean ± SD P-valueAge, year 51.1 ± 15.4 0.94Sex Female 34 (70.8) 10.6 ± 2.8 0.02aMale 14 (29.2) 8.2 ± 3.1RaceWhite 30 (62.5) 10 ± 3.1  0.69bBlack 8 (16.7) 8.9 ± 2.4Asian 6 (12.5) 10.8 ± 2.6Other 4 (8.3) 10 ± 5EthnicityHispanic/Latino(a) 5 (10.4) 9 ± 4.5 0.38bNot Hispanic/Latino(a) 41 (85.4) 10.2 ± 2.9Prefer not to answer 2 (4.2) 7.5 ± 0.7Do you have children?Yes 26 (54.2) 10 ± 2.8 0.95aNo 22 (45.8) 10 ± 3.4Marital statusMarried 30 (62.5) 9.9 ± 2.9 0.47bSingle 12 (25) 9.3 ± 3.4Divorced 5 (10.4) 11.6 ± 2.7Widowed 1 (2.1) 12EducationAny college or higher degree42 (87.5) 10.4 ± 2.9 0.001aLess than a college degree6 (12.5) 7 ± 2.1EmploymentEmployed 35 (72.9) 10.1 ± 3 0.53aUnemployed 13 (27.1) 9.5 ± 3.2Household income, yearly (United States Dollar)<$10,000 1 (2.1) 4 0.37b$10,000-$49,999 1 (2.1) 10$50,000-$74,999 5 (10.4) 10.8 ± 2.9$75,000-$100,000 5 (10.4) 10 ± 3.9>$100,000 29 (60.4) 9.7 ± 2.9I prefer not to answer 7 (14.6) 11.1 ± 3Have you ever seen a physician for this?Yes 42 (87.5) 9.7 ± 3 0.16aNo 6 (12.5) 11.7 ± 2.8What kind of clinician? (N = 42) Dermatologist 35 (83.3) 10.1 ± 3 0.01aOther type of clinician 7 (16.7) 7.6 ± 1.9Have you searched the internet for melanonychia-related information?Yes 38 (79.2) 10.7 ± 2.8 <0.001aNo 10 (20.8) 7.1 ± 2.3Did you diagnose yourself using information from the internet? (N = 38)Yes 9 (23.7) 10.1 ± 3 0.52aNo 29 (76.3) 10.9 ± 2.7Have you ever been diagnosed with a psychiatric condition?Yes 6 (12.5) 12.2 ± 1.3 0.003aNo 42 (87.5) 9.6 ± 3.1Have you ever been diagnosed with melanoma?Yes 3 (6.25) 15 ± 2 0.03aNo 45 (93.75) 9.6 ± 2.8Letter to the Editor | Dermatol Pract Concept. 2023;13(4):e2023199 3Do you have a family history of melanoma?Yes 7 (14.6) 10.6 ± 5 0.71aNo 41 (85.4) 9.8 ± 2.7STAI-6 46.6 ± 14.9 <0.001RIES Avoidance subscale 4 (0-26)c)c 0.31Intrusion subscale 3 (0-21) c .16ANOVA = analysis of variance; MWS = Melanoma Worry Scale; RIES = Revised Impact of Event Survey; SD = standard deviation; STAI-6 = State-trait Anxiety Inventory.aTwo sample t-testbANOVA testc Median (range)Table 2. Pre- and post-consultation survey resultsMean/Median score (Range)Pre-test Pre-consultation Post-consultationSurveyAll  (N = 48)Biopsy not recommended (N = 30)Biopsy recommended (N = 18)Biopsy not recommended (N = 30) P-valueBiopsy recommended (N = 18) P-valueaMWS (range, 4-17) 9.9 c (4-17)10 c (4-15) 9.8 c (5-17) 5.4 c (4-10) <0.0001 9.9 c (5-15) 0.89How much do you worry about getting nail melanoma?  (range, 1-5)3 (1-5) 3 (1-5) 3 (1-5) 1 (1-5) 3 (1-5)How much does worrying about developing nail melanoma impact your mood? (range, 1-4)2 (1-4) 2 (1-4) 2 (1-4) 1 (1-3) 2 (1-4)How much does worrying about developing nail melanoma impact. Your daily activities? (range, 1-4)2 (1-4) 2 (1-4) 1 (1-4) 1 (1-3) 2 (1-4)What is your current level of anxiety about the results of your nail examination?  (range, 1-4)3 (1-4) 3 (1-4) 3 (1-4) 1 (1-4) 4 (1-4)STAI-6 (range, 20-80) 46.6 c (20-77)47 c (20-77) 45.9 c (20-77) 30.7 c (20-56.6) <0.0001 48.1 c (12-70) 0.6I feel calm (range, 1-4) 3 (1-4) 3 (1-4) 2 (1-4) 1 (1-4) 3 (1-4)I am tense (range, 1-4) 2 (1-4) 2 (1-4) 2 (1-4) 1 (1-4) 2 (1-3)I feel upset (range, 1-4 1 (1-4) 2 (1-4) 1 (1-3) 1 (1-4) 1 (1-3)I am relaxed  (range, 1-4)3 (1-4) 3 (1-4) 3 (1-4) 1 (1-4) 3 (1-4)I feel content  (range, 1-4)3 (1-4) 3 (1-4) 2.5 (1-4) 1 (1-4) 3 (1-4)I am worried  (range, 1-4)2 (1-4) 2 (1-4) 2 (1-4) 1 (1-4) 3 (1-4)RIESAvoidance subscale (range, 0-40)4 (0-26) 3 (0-26) 6.5 (0-22)Intrusion subscale (range, 0-35)3 (0-21) 2 (0-21) 4.5 (0-10)MWS = Melanoma Worry Scale; STAI-6 = State-trait Anxiety Inventory. RIES = revised Impact of Event Survey.cMeanaP-value obtained from paired t-test.4 Letter to the Editor | Dermatol Pract Concept. 2023;13(4):e2023199To our knowledge, this is the first study assessing psy-chological distress in LM patients. We show benefit of nail evaluation on patients psychological wellbeing. We hope our study will spur dermatologists to regularly perform nail examinations data and encourage community efforts to improve accuracy and readability of NUM educational materials.References1. Moye MS, King SM, Rice ZP, et al. Effects of total-body digi-tal photography on cancer worry in patients with atypical mole syndrome. JAMA Dermatol. 2015;151(2):137-143. doi:10.1001 /jamadermatol.2014.2229. PMID: 25389923.2. Al-Shakhli H, Harcourt D, Kenealy J. Psychological distress surrounding diagnosis of malignant and nonmalignant skin le-sions at a pigmented lesion clinic. J Plast Reconstr Aesthet Surg. 2006;59(5):479-486. doi:10.1016/j.bjps.2005.01.010. PMID: 16749193.3. Halteh P, Scher R, Artis A, Lipner SR. A survey-based study of management of longitudinal melanonychia amongst at-tending and resident dermatologists.  J Am Acad Dermatol. 2017;76(5):994-996. doi:10.1016/j.jaad.2016.11.053. PMID: 28411777; PMCID: PMC5912877.4. Hay JL, McCaul KD, Magnan RE. Does worry about breast cancer predict screening behaviors? A meta-analysis of the pro-spective evidence. Prev Med. 2006;42(6):401-408. doi:10.1016/j .ypmed.2006.03.002. Does worry about breast cancer pre-dict screening behaviors? A meta-analysis of the prospec-tive evidence. Prev Med. 2006;42(6):401-408. doi:10.1016/j .ypmed.2006.03.0025. Kang R, Lipner S. Assessment of internet sources on subungual melanoma.  Melanoma Res. 2020;30(4):416-419. doi:10.1097 /CMR.0000000000000508. PMID: 30169432.Our study showed that LM patients experience substan-tial levels of baseline melanoma-related worry and anxiety, with internet searching, psychiatric illness, personal history of melanoma, and higher baseline STAI-6 scores predicting higher baseline worry levels. Similar MWS scores (median 8/17) were reported in a survey-based study of 138  patients with atypical mole syndrome undergoing total-body digital photography [1]. In a survey-based study of 324  patients with pigmented lesions, mean STAI-6 scores for those  needing skin biopsy vs. not were 13/26 and 11/26, respec-tively [2]. We found no significant differences in baseline MWS or STAI-6 levels between biopsy/no-biopsy groups, potentially indicating decreased LM awareness. MWS scores in LM patients with favorable findings were reduced to neg-ligible following consultation. Nail examinations are likely underutilized, with only 18.2% of dermatologists perform-ing them, and 68% of resident dermatologists “not confi-dent” in assessing melanonychia, in a survey-based study of 402 dermatologists [3].Cancer-related worry promotes screening behaviors [4]; however, irrational fear can be detrimental. In a bibliographic analysis of NUM-related online material, reliability was low, with only 22% of websites meeting accepted seventh-grade reading level [5]. Since internet searching correlates with baseline melanoma worry, increased accuracy and readabil-ity of NUM-related online material may improve psycholog-ical outcomes for LM patients.Limitations include small sample size, short follow-up, potential selection bias due to tertiary referral site, report-ing bias, and using an adopted non-melanoma specific worry scale.

Yet Another Reason to Examine the Nails: Substantial Cancer-Related Worry and Anxiety in Patients with Melanonychia in a Survey-Based Study

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Yet Another Reason to Examine the Nails: Substantial Cancer-Related Worry and Anxiety in Patients with Melanonychia in a Survey-Based Study

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