Key Concepts, Gaps in Knowledge Identified in Self-Examination for Those with High Melanoma Risk


A review of randomized clinical trials using the World Health Organization’s framework for clinical adherence to point to key knowledge gaps in self-exam knowledge among those at high risk for skin cancer.

Several key concepts and major gaps in knowledge about patient adherence to self-examination for melanoma were explored in a review of 18 randomized clinical trials, with investigators highlighting the major support strategies and behavioral support tools often used.1

This review adds to the growing body of research on skin cancer prevention, a topic that in the summer months will be particularly important for patients at risk for developing melanoma.

This research was conducted to examine the evidence on self-management practice adherence in those at high risk of developing melanoma, using trial data on practices in self-monitoring. The research was authored by Deonna M. Ackermann, MPH, from the Sydney School of Public Health in the University of Sydney’s Faculty of Medicine and Health.

“We aimed to describe the types of adherence strategies used based on the WHO dimensions of adherence; how adherence was defined, measured, and reported; and any evaluation undertaken,” Ackermann and colleagues wrote.

Background and Findings

The investigators conducted their scoping review and sought to investigate 2 key aspects related to self-management practices in 18 randomized clinical trials involving individuals with a high risk of melanoma. In sum, the review essentially aimed to identify strategies that have been used to improve adherence to self-management practices in such trials.

The team noted that World Health Organization (WHO) states that a patient's adherence to treatment recommendations is influenced by several different factors that all interact with one another.2 These can be divided into 5 dimensions, which include disease-related factors, social and economic factors, therapy-related factors, healthcare team and system-related factors, and patient-related factors.

The research team used a screening process that involved 2 reviewers independently assessing abstracts, titles, and full texts, and resolving any disagreements through discussion or with the involvement of another reviewer.

The team also allowed multiple reports from a single trial to be assessed but only included the trial once, and the most recent report was the primary source of data extraction. Earlier reports were utilized to supplement the relevant information.

After identifying these strategies, the investigators then aimed to examine how adherence data has been measured and reported in these studies. The team’s search was conducted in 4 different databases (MEDLINE, Embase, CENTRAL, and CINAHL) covering the period from the inception of the databases up to July 2022.

Among the 939 records examined by the investigators, 18 randomized clinical trials that used various adherence strategies were found, with participant size ranging from 40 - 724. However, they found insufficient evidence on the effectiveness of these strategies.

The identified strategies included trial design, social and economic support, intervention design, intervention and condition support, and participant support, but there was no mention of strategies for supporting underserved groups, such as socioeconomically disadvantaged people, those with low health literacy, those who do not speak English, or elderly adults. Additionally, very few trials targeted provider adherence

The investigators found that behavioral support tools, such as reminders, priority-setting guidance, and clinician feedback, were used in some trials. Adherence was usually measured by participant self-report.

Additionally, the research team noted that some recent studies involved digital interventions to directly assess patient adherence. The reporting of adherence data was limited, and less than half of the reports discussed adherence.

The eligible studies for inclusion by the investigators in their review were randomized clinical trials that had tested self-monitoring interventions examining the early detection of melanoma in individuals at increased risk due to personal history (melanoma, dysplastic naevus syndrome, transplant ), clinical judgment, an assessment of risk, or history of melanoma in one’s family.

“In this scoping review of 18 RCTs using an adaptation of the WHO framework for clinical adherence, we identified key concepts as well as gaps in the way adherence is approached in design, conduct, and reporting of trials for self-management of melanoma risk,” they wrote. “These findings may support improvements in the design, evaluation, and reporting of adherence strategies for use in research and practice.”


  1. Ackermann DM, Bracken K, Janda M, et al. Strategies to Improve Adherence to Skin Self-examination and Other Self-management Practices in People at High Risk of Melanoma: A Scoping Review of Randomized Clinical Trials. JAMA Dermatol. 2023;159(4):432–440. doi:10.1001/jamadermatol.2022.6478.
  2. World Health Organization. Adherence to long-term therapies: evidence for action. World Health Organization; 2003.
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