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APP REVIEWS

Skin Cancer

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Dr. Matthew Cruickshank
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There are more than 80,000 new skin cancers diagnosed each year in Canada, with more than 5,000 of them being melanoma1. Skin self-examination and reduction of UV exposure are two important ways to reduce the impact of skin cancer in Canada. Cancer Care Ontario recommends that patients who are at high risk for melanoma be identified by their primary care provider, counseled about skin self-examination and monitored yearly by a provider trained in screening for skin cancer 2. The Canadian Task Force on Preventive Health Care has appraised and is in support of the Australia and New Zealand melanoma guidelines which emphasize skin cancer prevention in all individuals and self-monitoring in high-risk individuals3. Can apps help us with these important tasks?

When I started this review, I was naively hopeful that I would find an app that could help patients and primary care providers assess a lesion and determine whether it needed further evaluation through dermoscopy or biopsy. There have, in fact, been apps developed to assess lesions but unfortunately they have not yet achieved this goal. Experts generally view digital interpretation of moles critically4. Wolf et al studied several of these apps in 2013 and came to the conclusion that reliance on detection applications that have a high false negative rate and are not subject to regulatory approval can delay the diagnosis of melanoma and harm users5. The Federal Trade Commission in the United States has in fact brought cases against several mole-detecting apps for false advertising of their capabilities to detect skin cancers, and these apps are no longer commercially available6.This is perhaps the reason why one of the more internationally popular apps, SkinVision, is not yet available in Canada or the United States4,7. Hopefully these applications will continue to improve their accuracy and be formally evaluated so that they can be used clinically and recommended for patient use. Until then, there are still important roles apps can have for skin cancer. Apps can help with risk factor assessments and education on prevention and screening. They can also provide tools to help users self-examine and monitor their skin. For this review we identified four skin cancer apps that could be recommended for patient use.

Apps Reviewed

Miiskin
3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars
Sunface
3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars
UV-INDEKS
3 stars3 stars3 stars3 stars3 stars
UMSkinCheck
2.5 stars2.5 stars2.5 stars2.5 stars2.5 stars

UMSkinCheck

2.5 stars2.5 stars2.5 stars2.5 stars2.5 stars

UMSkinCheck is a free mobile app developed by the University of Michigan medicine department. It was included in this review as it provides a broader range of features than most mole tracking apps. It is the only app that guides users through creating a full body photographic library which can then be used for later comparison. It also lets users track individual lesions and provides education on skin cancer. Although the app was recently updated, it has an outdated look and feel and would benefit from a more comprehensive update. It also has some important limitations such as not providing a backup tool and not letting users import higher resolution photos which would be especially useful for the full body survey. This app could be useful for patients who require skin self-examination and want to take the extra step in creating a full body photo library. It is available in both the Android and Apple app stores.

Detailed Review View All

Features

+-

This app steps users through creating a 23-image full body photographic library which can be used for later lesion comparison. It allows users to track individual lesions and walks them through full body skin exams. It provides text and image-based educational materials. It unfortunately does not allow users to import higher quality photographs and relies on a phone’s camera. This is especially limiting in creating the full body photo library where each individual photo covers a large skin area. It also does not provide backup functionality and photographs are lost if the app is deleted or the user gets a new phone.

Effectiveness

+-

Skin self-monitoring is recommended for individuals at a high risk for skin cancer and creating a full body photographic library can be a helpful for this. If used as suggested, this app could be effective for self-monitoring. It is, however, limited by its lack of import and backup functions. The app would benefit from a formal evaluation.

Usability

+-

The app has a dated look which makes it feel less professional than other apps. It is well laid out, however, and most users would find it straightforward to use.

Privacy & Security

+-

A privacy policy for the app was easily found online but it is neither comprehensive nor reassuring. The app stores full body naked photos which demands high privacy standards. The policy states the application stores photographs but does not state if these are stored in the app alone or in a company database, or whether they can be shared with third parties or used for research.

Reliability

+-

The app has only received a few updates since its release in 2012 which makes long term availability questionable. With this in mind, users should proceed with caution. The app did not crash during testing.

Accessibility

+-

The app is free and available in both the Android and Apple app stores. Most users would find it straightforward to use. Creating the full body image gallery requires having the help of another person to take pictures which may not be feasible for some users.

UV-INDEKS

3 stars3 stars3 stars3 stars3 stars

UV-INDEKS is an app developed in Denmark in collaboration with the Danish Cancer Society, among other organizations. It is available as a free download from the Apple and Android app stores. It provides up-to-date UV index information for locations all over the world based on the weather forecast from the Danish Meteorological Institute. It also provides a graphical hourly UV forecast for the day and daily forecast for the week. It allows users to complete a self-assessment of their skin type and offers specific recommendations in light of how they might react to various UV indices. The app can be set up to send users warnings for high UV index days but these warnings are only issued once a day instead of in real time. This app provides useful information for those trying to reduce their UV exposure. The information it provides is also integrated into comprehensive weather applications that many smartphone users already use.

Detailed Review View All

Features

+-

This app provides up-to-date UV index information for locations all over the world based on the weather forecast from the Danish Meteorological Institute. It provides a graphical hourly UV forecast for the day and daily forecast for the week. It helps users identify their skin type and personal UV risk by comparing their skin colour to colour palates on the app and answering some basic questions. It does not include very dark skin types; an easy fix would make the app more inclusive. The app can be set up to send users warnings for high UV index days but only does this once a day instead of in real time.

Effectiveness

+-

This app provides users with tools to help them reduce their UV exposure which can reduce skin cancer risk. It is not clear, however, if the way the information is provided is effective. For example, the app can provide users a single notification of the UV forecast for the day but cannot provide real-time updates, notifications or suggestions to help users modify their behaviour.

Usability

+-

The app has a clean interface and is intuitive to use. Most users would be able to get started without difficulty.

Privacy & Security

+-

The app uses location data but does not collect any other personal user data. I could not find a privacy policy in the app itself or online. Although the app likely poses very little risk to users, a privacy policy outlining the processing of location data would be appreciated.

Reliability

+-

The app has been updated a few times a year since its release. No bugs or crashes were identified during testing.

Accessibility

+-

The app is free and available in both the Android and Apple app stores. The app is clear and accessible for most users.

Miiskin

3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars

This app’s website explains that the wife of the developer had many moles removed and required regular skin self-examinations. She asked her husband to help her with this and he became increasingly frustrated by the task, finding it very difficult to notice subtle changes in moles. He developed Miiskin as a simple tool to document and organize photos of moles for comparison over time. The app is user friendly and easy to get started with. The app offers a subscription for $4.49 U.S. per month or $30.99 U.S. per year to back up photos on a secure cloud. This would not be required for many users as the app also lets users export photos. For patients who require skin self-examination, this app is a useful tool. The app is available as a free download from the Apple and Android app stores.

Detailed Review View All

Features

+-

This app lets users take serial photos of their moles, organized on a body map. A reminder can be set for when to take new pictures. The app lets users back up their photos by exporting them or by uploading them to a cloud storage which requires a subscription fee. The app does not allow users to import photos into the app which would be useful for users who have access to higher quality cameras and lenses.

Effectiveness

+-

Skin self-monitoring is recommended for individuals who are at high risk for skin cancer. This app could help these individuals monitor their moles more effectively. It unfortunately has not been clinically evaluated so it is unclear if it is actually helpful in changing mole monitoring behaviour or the effectiveness of the monitoring. I hope to see this app formally evaluated as part of its ongoing refinement.

Usability

+-

The app has a clean and intuitive interface that is simple to use. It unfortunately does not integrate the education readings and videos that are available on its website, such as a how-to video about performing a full body skin check. Some users may miss out on these resources because they are not easily accessible.

Privacy & Security

+-

A privacy policy was easily found on the app website. It speaks of safeguards in place for storing and using personal registration data such as user email addresses. It does not, however, comment on storage or security of user-generated photos uploaded for users of their backup service. The privacy policy should be updated to reflect storage and use of photographs.

Reliability

+-

The app has had frequent updates since its launch in 2017. It worked very well during testing with no crashes and no bugs identified. Customer support responded to an email within 24 hours

Accessibility

+-

The app is free and available in both the Android and Apple app stores. The app is simple and accessible for most users.

Sunface

3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars

Sunface is an app that offers a novel tool for skin cancer education and prevention that takes advantage of our vanity. Sunface allows users to take a selfie of their face and morph it through five to 25 years of aging with and without sun protection and from weekly tanning. Allowing users to see what UV damage will do to their appearance motivates users to modify their behaviour and protect themselves from UV radiation. The app was piloted in two secondary schools and after using the app the majority of students reported that they were motivated to reduce UV exposure and avoid using tanning beds8. This app could act as a fun and accessible tool that may help modify behaviour for skin cancer prevention.

Detailed Review View All

Features

+-

The app allows users to take a selfie of their face and morph it through five to 25 years of aging with and without sun protection and from weekly tanning. It then animates the result with blinking and head movements. The app provides social media sharing links which could increase its impact. It also provides information on the ABCDEs of melanoma and basics of sun protection.

Effectiveness

+-

The app was piloted in two secondary schools and after using the app the majority of students reported that they were motivated to reduce UV exposure and avoid using tanning beds. More research is required to see if this extends to other groups and whether it can help motivate individuals to make sustainable behavioural changes.

Usability

+-

This app has a simple and clean user interface. It’s easy to get started and within less then a minute of using the app users are able to see themselves 25 years older and sun damaged!

Privacy & Security

+-

A privacy policy clearly states that no user data is collected or saved by the company. This app presents very little risk to users.

Reliability

+-

This is a new app and has only had one update since its release. It performed well during testing with no bugs or crashes identified.

Accessibility

+-

The app is free and available in both the Android and Apple app stores. The app is simple and accessible for most users.

References

  1. “About Skin Cancer.” Canadian Skin Cancer Foundation, 2018, http://www.canadianskincancerfoundation.com/about-skin-cancer.html.
  2. From, L., et al. “Screening for Skin Cancer.” Cancer Care Ontario, 19 June 2009, http://www.cancercareontario.ca/en/file/3336/download?token=3yAI2HKV.
  3. Cancer Council Australia, et al. “Melanoma.” Canadian Task Force on Preventive Health Care, 2008, https://canadiantaskforce.ca/portfolios/melanoma/.
  4. Maier, T., et al. “Accuracy of a Smartphone Application Using Fractal Image Analysis of Pigmented Moles Compared to Clinical Diagnosis and Histological Result.” Journal of the European Academy of Dermatology and Venereology, vol. 29, no. 4, 2014, pp. 663–667., doi:10.1111/jdv.12648.
  5. Wolf, Joel A., and Laura K. Ferris. “Diagnostic Inaccuracy of Smartphone Applications for Melanoma Detection Reply.” JAMA Dermatology, vol. 149, no. 7, 2013, p. 885., doi:10.1001/jamadermatol.2013.4337.
  6. Healio. “FTC Announces Settlements against Marketers of Apps Claiming Utility in Early Melanoma Detection.” Cancer Commons, 25 Feb. 2015, http://www.cancercommons.org/tag/melapp/.
  7. “SkinVision.” SkinVision – Skin Cancer Melanoma Detection App, 2018, https://www.skinvision.com/.
  8. Brinker, Titus Josef, et al. “Photoaging Mobile Apps in School-Based Melanoma Prevention: Pilot Study.” Journal of Medical Internet Research, vol. 19, no. 9, 2017, doi:10.2196/jmir.8661.
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