Psychological factors

Earlier in this section, the phases of reactions to diagnosis of cancer were highlighted (Perkins, 1993); these psychological effects have relevance to behaviour related to self-examination. During psychosocial Phase 1 (existential crisis), acute anxiety is often experienced due to a poor knowledge of melanoma and ‘anticipatory grief’. However, it is argued that some anxiety may cause the individual to act (Redman, 1997) and therefore promote the performance of self- examination. However, extreme anxiety or distress may inhibit patients from ‘seeking’ professional advice and following through with recommendations (Trask et al., 2001). Perkins (1993) suggests that by recognising key psychosocial phases, health professionals may identify the most ‘at risk’ patients and provide the appropriate intervention.

Patients who are well informed about melanoma and their risk of metastases, and therefore, ‘have a concern for their disease or perceive themselves susceptible to developing cancer may be better able to look after themselves and engage in appropriate self care’ (Brown et al., 2000, p. 1148). It has been reported that one of the reasons given by the general public for not performing selfexamination was that they did not believe it to be necessary (Weinstock et al., 1999). Patient’s perceived risk to developing metastases and understanding of melanoma and the purpose of self-examination, particularly Breslow thickness, is not known. In addition, a belief that self-examination is important may also be required (Rosella, 1994). In Phase 2, referred to as accommodation and mitigation, ‘patients feel physically healthy, yet are constantly living with the fear that the disease may return’ (Perkins, 1993, p. 162). Self-examination may assist individuals to keep their fears in check. The emotions experienced by individuals before, during and after self-examination are not known. In both breast cancer (Persson et al., 1995) and testicular cancer (Cook, 2000), it is suggested that patients may experience feelings of fear and anxiety when performing self-examination since it involves trying to find something suspicious (Frank and Mai, 1985; Rutledge and Davis, 1988; Persson et al., 1995). Women described that they would be terrified if they found a lump during breast self-examination (Persson et al., 1995). This may discourage its performance. In contrast, it is speculated that the regular practice of self-examination could reassure individuals and therefore reduce anxiety, if no evidence of metastases were found (Best et al., 1996). Thus the performance of self-examination would be encouraged. Whilst as mentioned, Phases 1 and 2 are relevant to those diagnosed with primary disease, in Phase 3 recurrence of the disease occurs. This can be a time of great anxiety for the patient and their family since there are fewer treatment options available. In Phase 4, there is general deterioration and decline as the disease advances. The goal here is the palliation of symptoms. Teaching of self-examination for metastatic disease Metastases may become apparent in between hospital visit (Basseres et al., 1995) and may occur many years after the initial diagnosis when follow-up visits at the hospital have ceased (Kelly et al., 1985). Patients can find recurrences (Dickers et al., 1999) and therefore it is advised that they should be taught how to examine their own skin. Whilst many patients who have been taught how to perform self-examination do carry out the health professional’s request, often they do not have the necessary knowledge or skills to do so competently as a consequence of current teaching methods (Duncan, 2005). An MDT approach to teaching using innovative aids is suggested (Duncan, 2005). Self-examination should be reinforced at each outpatient appointment and appropriate written materials provided, i.e. ‘How to check your lymph nodes’ (Wessex Cancer Trust, 2004).