Dr. Nishad Sathe, Next Steps Correspondent, interviewed Lily M. Parker, second year medical student at the University of South Florida Morsani College of Medicine, to dig deeper on her research study titled “A mindfulness-based smartphone application intervention to improve the quality of life of patients with cutaneous T-cell lymphoma. A pilot/feasibility study, and an analysis of social determinants of health,” recently presented at the Orlando Dermatology Aesthetic & Clinical (ODAC) Conference in January 2023.
How did this topic pique your interest?
I am originally from Melbourne, FL, and many of my teachers, family, and friends had significant deformities due to skin cancer. This brought me to my work as a technologist in a Mohs laboratory, which fostered my interest in dermatology and skin cancer. A year ago, some other medical students looked at quality of life and social factors in patients with cutaneous T-cell lymphoma (CTCL). They found that earlier disease onset and darker skin tone were associated with lower quality of life in CTCL. It has been well-established that people of non-white races and those with advanced disease have a lower quality of life; however, what is worse is that African-American patients often also present with advanced-stage disease.[1] Much of this is yet unclear, but some theories pose that there is a difference in UV light response in patients of color or that there may be different lab abnormalities across the spectrum; one thing is clear is that CTCL often presents as advanced in African-American patients, and it is thus linked with severe mental health concerns. [2,3] One of my friends and I had talked about how mental health and quality of life were linked in other cancers[4], so we discussed how mindfulness could help other patients with CTCL, especially since research has shown the benefit of individualized treatment plans in patients with CTCL.[5,6] Our group at the Moffitt Cancer Center had done previous studies with a mindfulness app, so this seemed like an appropriate extension in dermatology.[7]
What should clinicians know about using smartphone-based mindfulness applications to improve the quality of life in CTCL patients?
The incidence of mycosis fungoides in the United States is high in African-American patients, with a younger age noted at clinical presentation and a strong association with higher mortality rates.[8] We know that psychiatric diseases and quality of life also intersect with skin of color patients with CTCL. Based on this, we conducted a prospective, interventional study to show the feasibility of using the Headspace meditation-based smartphone application to promote mindfulness for quality of life improvement in CTCL patients. We asked participants to use the Headspace application on their smartphone for 10 minutes daily over four weeks. Then we collected information on pre- and post-trial surveys on many quality-of-life indices. Our study found better quality of life in non-white patients living with CTCL and more mindful attitudes and behaviors in patients with advanced disease who used our application.
The above would suggest that using a mindfulness intervention would be well-tailored for this population. However, one of the challenges we faced was that we had a small sample size, and it was challenging to get buy-in for using the mindfulness application. Based on this, we wanted to emphasize that physicians and dermatologists should work on their interdisciplinary tool set when caring for patients with unique backgrounds or complex disorders like CTCL. Many physicians in other specialties where mindfulness is common—such as psychiatry or family practice—generally have an open mind for things like mindfulness. However, in dermatology, there is a need to expand our horizons to incorporate more mental health-based tools given the many diagnoses like trichotillomania or other psychodermatoses in which this may serve patients well.
What suggestions do you have for people caring for skin-of-color populations when considering their care plans for diseases like CTCL?
Much of the research in CTCL has been done on white patients. It appears that the number is undoubtedly higher when looking at the raw numbers. Still, multiple studies have shown that the incidence of CTCL in patients is younger in African-American patients for unclear reasons.[2,3] We’ve also seen that there is worse quality of life in African-American patients, especially young patients. Therefore, we hope clinicians will note this when considering treatment for this population. From our study, we realized that much of the quality-of-life improvement resulted from understanding or acceptance of the changes to the skin that occur as a consequence of skin cancer. So, having these discussions with patients and recognizing how to treat patients both physically and mentally is essential. For instance, we usually do an excellent job of educating patients who have other chronic diseases, like psoriasis or atopic dermatitis, but we should apply the same educational strategies when taking care of patients with CTCL.
This was an important learning point for me because I realized that what we learn in medical school and often beyond is a more algorithmic approach. But I took away from this research that sometimes we must abandon our rigid routines, which may trap us into a single plan. Instead, it may be essential to take a step back and consider how a patient’s presentation may need an individualized approach. We may also need to think about other areas of their health that may be impacted, such as their mental health. This study taught me the importance of thinking about the impact of a disease process on a patient and being very keenly aware of the interdisciplinary tools to help patients cope and be vigilant of a patient’s holistic health.
What is the future for this focus on mindfulness in CTCL patients and beyond?
The one-year plan is to recruit more patients. We still need to see how the mindfulness application on smartphones will affect our patients over a longer period of time. Until now, we have only studied the patients for four weeks. Yet, getting some patients to use a phone application for their mental health can be challenging, as we found. Some of this is due to their minimal prior technology use or busy lifestyle. However, given the promising success of mindfulness in quality-of-life improvement, I see this going forward in CTCL and other skin diseases, particularly chronic ones like psoriasis or itch. Ultimately, the goal is that this will help any uncomfortable patient, which represents a lot of the dermatology patient population. The future of a mindfulness focus for CTCL patients results in patients feeling better about their disease—both from understanding their condition better and learning to cope with their journey. Mindfulness across a longer span, I think, may help patients build more coping mechanisms and be in a more relaxed state as we work to treat them, which will lead to improved patient care and outcomes.
