Predictive Factor for Emotional Fragility in Early Stage Melanoma Diagnosis

Objective. Melanoma patients remain at risk of disease progression for many years after diagnosis. Psychological distress, depression and anxiety are emotional conditions that negatively inuence both the patients’ quality of life and the clinical course of the disease, laying down for a slow recovery as well as for an increase in comorbidity. Aim of the study was to analyze the psychological needs of young and adult patients diagnosed with early stage melanoma by gender sensitivity. Methods. A sample of 92 patients (age range 18-55 years) with diagnosis of melanoma stage T0-T1a-T1b participated in the study. The examined emotional variables were: psychological distress, depression, stress, anxiety, metacognitions and body self-perception. Results. The results highlighted signicant gender differences: females appeared psychologically more vulnerable than males; another interesting point was no aging depending. Female emotional pattern showed higher anxiety, and psychological distress associated to lower positive self-perception of body image. No signicant difference among cancer staging, as well as no interaction effect and neither signicant covariance by age. Conclusion. an observational study to measure the prevalence of psychological traits (depression, anxiety, distress, and metacognition thinking) in patients diagnosed with early stage of melanoma. Participants of n.92 outpatients outpatients


Introduction
In Europe melanoma is the 3 th type of tumor most widespread in both gender; during 2018, detection data evidenced n.144.209 patients (19.5% of oncological population): death rate 3.7%, and survivorship rate of 79.2% for male, whereas 86.5% for female patients; rates can be lower (50%) in advanced stage of diagnosis [1][2]. However, epidemiological data evidenced the increase of diagnosis and the stabilization of death rate; extensive screening favored higher rate for early diagnosis in early stage of disease and it is related to surgical interventions without adjuvant therapies for better and longer survivorship [3][4].
However, melanoma survivors could experience mental health disorders though diagnosized in early stage of disease and with positive adherence to foreseen follow-ups. Some stidies found 30% of patients might experience psychological distress similarly to oncological patients, anxiety and depression symptoms, affecting the Quality of Life (QoL) over time [5][6][7][8][9][10]. According to researchers, risk factors for mental health disorders are: coping ability, aging, education, affective relations, time from diagnosis, visibility of melanoma area, social support [11][12][13][14][15][16]. The psychological distress in uences negatively cancer patients' QoL and even routine daily living favoring a low psychological adjustment paving the way for less exibility for modelling individual patterns of change over time: frequently patients tend to minimize melanoma diagnosis and no signs for physical impairments could make them less aware about the important role of screening and follow-ups for the prolonged management of their health [17].
High risk for progression of melanoma over the time could impact the psychosocial living of patients: abandoning medical followup, negative body image self-perception, negative thinking, the fear of recurrence 18 . Particularly, psychologycal distress could impact negatilvely the preventive behavior adoption: only 60% of survivors make low use of solar protective cream; 13.7% of survivors is used to self-test for skin, or periodic skin cancer screening [19][20][21]. Moreover, anxiety and fear might in uence the adoption of healthy daily habits as well the fear of recurrence [22]. So far, few reseaches were conducted focused on the QoL in survivorship. Some studies have been conducted on adult population (≥ 50 years old) with advanced stage of melanoma no detecting the effect of emotional traits and the behavioral aspects [23][24][25][26]. The improvement of early screening in Healthcare plans favored the increasing of early diangosis in younger age and this is demanding investigation on wellness and QoL in new target of patients (young).
Our study aimed to investigate the emotional traits of young patients with early melanoma diagnosis analyzing the predictive as well protective factors QoL. We wanted to analyse the aspects of psychological wellness of young patients regard the metacognition thinking (positive/negative thoughts), emotional traits and body self-perception.

Ethical Approval
This study was approved by the Internal Review Board of the University of L'Aquila, Italy (Prot. N° 16372/2019). Informed consent was obtained from each participant, and the study adhered to the Declaration of Helsinki.

Participants
We conducted an observational study to measure the prevalence of psychological traits (depression, anxiety, distress, and metacognition thinking) in patients diagnosed with early stage of melanoma. Participants were composed of n.92 outpatients aged 18-55 years old (mean age 42.2, ±8.4), living in central Italy divided by gender distribution: 1) Female Group (FG, n.55) and 2) Male group (MG, n.37). Participants were outpatients received melanoma diagnosis in mean time 38.8 months (± 38.2) by American Joint Committee on Cancer (AJCC) Cancer Staging Manual (AJCC, 2017): diagnosis of melanoma in stages T0 (no evidence for primary tumor), T1a (tumor thickness measurement: ≤1.0 mm), T1b (tumor thickness measurement: ≤0.8 mm). 26.1% of patients had been diagnosed less than 1 year earlier; 37% between 2 and 3 years and 37% over 5 years before. The regions of the body most often affected were legs (24.9%). The demographic and clinical characteristics of the sample are presented in Table 1.
104 eligible participants were enrolled in the study protocol and then 92 patients were recruited in the research plan: 12 patients refused to be involved in the project no giving written informed consents.

Procedure
Patients were recruited at the UOSD Dermatology, San Salvatore Hospital (ASL1 Abruzzo -Italy). Medical doctor staff enrolled and recruited the eligible participants. Research staff provided a digital form of the test protocol providing mandatory signed informed consent. The time for online form completion was about 20 minutes. The data were collected into a dedicated server, and data scoring was conducted by trained professionals, blinded to the study's objectives.

Psychological measurements
A psychological battery composed of standardized tests for the detection of emotional variables were administered. Demographics were collected through the participants' self-reports. Clinical data were obtained by examining participants' medical records.

Statistical analyses
The data were carefully checked for possible coding errors, attribution of values and updating of missing data before the analysis was conducted. Participants were divided into groups based on gender, age group and disease stage. Descriptive statistical analyzes, multivariate analysis of variance (MANCOVA), LSD test (Post Hoc test) and Linear Regression were performed using SPSS Statistics 22.0. The signi cance level was set at α <0.05.

Results
88.5% (n.92 of n.104) of the eligible patients completed the psychological evaluations, while n.12 refused the participation (they didn't sign the informed consent). The reasons given for not participating included lack of time. Participants were distributed into two groups by gender: Female Group (n.55) and Male Group (n.37); then we divided the sample by median age (43 years old): Young Group (n.46; range age 22-42) and Adult Group (n.46; range age 43-50). Table 2 shows the means value and standard deviations of the raw scores performed to the psychological testing battery. Afterward, we wanted to analyze the performance of patients by cancer stage and gender variables. Participants were divided into 3 groups by (AJCC) Cancer staging: Group T0 composed of n. 24 patients ; Group T1a composed of n. 51 patients, and then Group T1b within n. 17 patients. In Table 3

Discussion And Conclusions
Present study investigated the emotional aspects and body self-perception index after the diagnosis of early stage of melanoma; in particular, focus of the study was to analyze the in uence of diagnosis on QoL, paying the attention on the gender, age and staging effects.
Our results revealed speci c emotional patterns in melanoma patients in the early stages of the disease. First, our nding con rmed the negative impact on emotional pattern of female population regardless to aging [30][31][32][33]. According to Lichtenthal et al. women are more vulnerable to experience dissatisfaction with the appearance of their surgical scar 34 : our study showed that QoL and psychological distress in women are related to the perception of their body, and in particular to the consequences of clinical treatment on the body image; more, their high sensibility to negative believes concerning uncontrollability and danger seemed determine the low level of psychological wellness. On contrary male gender looked more resilient to fragile emotional patterns in early melanoma diagnosis, related to no slight fragility to negative metacognitive thinking.
By psychological perspective, the stage of disease doesn't in uence directly the psychological condition of the patients; ndings showed as patients don't feel the early diagnosis of melanoma as dangerous for them: predictive for negative emotional reaction is related to the gender variable and the melanoma staging isn't perceiped as a protective factor. According to Tesio's conclusions [33], emotional screening is an important step of clinical process but we suggest to integrate the diagnosis procedure by the improvement of patient-centred approach balancing internal and external factors in uencing the mental health of patients and addressing the negative impact of melanoma diagnosis on their QoL: women needs to better cope the diagnosis in term of clinical pathways and signi cance of caring and outcomes in order to be more compliant with effective clinical condition and more adherent making negative beliefs and thoughts less invasive and present. The psychological supports (both asked from patients or proposed in early time) should be based on those emotional aspects making the post-diagnosis to cope better not only by innovative clinical primary treatment, and early screening, but even more adherent to e cient wellness model and QoL.
This study showed the emotional distress can in uence the psychological wellness of patients already in early-stage melanoma diagnosis; more, nding highlighted the gender effect for emotional fragility evidencing women more impacted than men. Psychological distress in melanoma survivors seemed associated to metacognition thinking (negative and maladaptive thoughts), body image perception and surgical scars, and staging.
As melanoma survival has improved in recent years, patient reported outcomes such as Quality of Life have become an important aspect of cancer-speci c research. Several studies are addressing Quality of Life issues [30-34]. However, while there are many studies for cancer sites such as breast, prostate and colorectal cancer, few have focused on the long-term effects of melanoma on patients' wellness. In tumors treated with relatively non-aggressive therapies, with relatively good survival rates, as well in melanoma diagnosis, the living perspective of the patients is very important. In addition to clinical therapy, psychological support might be foreseen in order to manage the positive and higher effects of clinical treatments not only by instrumentals evaluations, but even improving wellness and QoL of patients by the increasing of own health awareness.
The detection of predictive factors for post-diagnosis allows to develop a more suitable and modeled intervention on the speci ccancer pathology. Prevention and intervention protocols must be adapted taking into account gender differences in the adoption of preventive behaviors and compliance with medical recommendations. Last, our nding highlighted the need for regular screening of psychological distress even in patients with early melanoma, and also in the case of long-term follow-up, paying to attention to the personalized and diversi ed psychological support pathways.