The needs and experiences of patients with skin cancer: a qualitative systematic review with metasynthesis

Skin cancer incidence is increasing worldwide. This is an update of a previous review published in 2010 that identified only two studies and found that the needs and experiences of individuals with skin cancer were under‐researched. Our objective was to undertake a qualitative systematic review of the needs and experiences of people with a diagnosis of skin cancer. To update the previous review, the following databases were searched from 2010 to 30 November 2015: CINAHL PsycINFO, Medline and Embase. The methodological quality of the studies was assessed using the Joanna Briggs Institute Qualitative Assessment Review Instrument. The qualitative research findings were synthesized using a pragmatic meta‐aggregative approach. A total of 14 studies (16 papers) were included. Only three studies included patients with keratinocyte carcinoma. Overall, 15 categories were identified and these resulted in four overarching synthesized findings (SFs) from diagnosis (SF1), throughout treatment (SF2) and follow‐up (SF3), and then a fourth SF (SF4) that addressed patients’ satisfaction with their care and their relationship with healthcare professionals. Despite the fact that patients with keratinocyte carcinoma and melanoma can have a very different prognosis, they also share similar needs and concerns especially around the time of diagnosis and follow‐up/surveillance for new lesions. Healthcare professionals working with patients with skin cancer need to understand their psychosocial concerns and their information needs in order to design services appropriately. Future studies need to consider patients with keratinocyte carcinoma in addition to patients with melanoma.


Summary
Skin cancer incidence is increasing worldwide. This is an update of a previous review published in 2010 that identified only two studies and found that the needs and experiences of individuals with skin cancer were under-researched. Our objective was to undertake a qualitative systematic review of the needs and experiences of people with a diagnosis of skin cancer. To update the previous review, the following databases were searched from 2010 to 30 November 2015: CINAHL PsycINFO, Medline and Embase. The methodological quality of the studies was assessed using the Joanna Briggs Institute Qualitative Assessment Review Instrument. The qualitative research findings were synthesized using a pragmatic meta-aggregative approach. A total of 14 studies (16 papers) were included. Only three studies included patients with keratinocyte carcinoma. Overall, 15 categories were identified and these resulted in four overarching synthesized findings (SFs) from diagnosis (SF1), throughout treatment (SF2) and follow-up (SF3), and then a fourth SF (SF4) that addressed patients' satisfaction with their care and their relationship with healthcare professionals. Despite the fact that patients with keratinocyte carcinoma and melanoma can have a very different prognosis, they also share similar needs and concerns especially around the time of diagnosis and follow-up/surveillance for new lesions. Healthcare professionals working with patients with skin cancer need to understand their psychosocial concerns and their information needs in order to design services appropriately. Future studies need to consider patients with keratinocyte carcinoma in addition to patients with melanoma.
What's already known about this topic?
• The incidence of skin cancer is high compared with other malignancies and is increasing.
• Few studies have directly investigated the psychosocial effects of keratinocyte carcinoma and its treatment.
• A previous review included only two studies that looked at the needs and experiences of patients with skin cancer.
What does this study add?
• An additional 12 studies were identified, which focused primarily on melanoma.
• Diagnosis of any type of skin cancer can be distressing and the patient's experience is dependent on its type and severity.
• Patients need emotional support and information tailored to the stage of their particular skin cancer journey. Their experience continues post-treatment, with an ongoing need for information about risk management and skin cancer detection.
Skin cancer is the most common cancer in humans and the incidence is increasing worldwide. 1 There are two main types of skin cancer, namely melanoma and keratinocyte carcinoma. Keratinocyte carcinoma accounts for approximately 97% of skin cancers, which are either basal cell carcinomas (BCCs) or squamous cell carcinomas, along with some rarer types. Currently, 2-3 million keratinocyte carcinomas and 132 000 melanoma skin cancers occur globally each year and one in every three cancers diagnosed is a skin cancer (World Health Organization 2014, http://www.who.int/uv/faq/skincancer/en/ index1.html). Skin cancer affects people from all communities and age groups. Although keratinocyte carcinoma is seen mostly in those aged over 50 years, increasing numbers of younger people are being affected. [2][3][4][5] The large increase in skin cancer incidence, and the fact that keratinocyte carcinoma has high rates of recurrence and subsequent primaries, 6 presents a significant challenge for all healthcare systems.
Patient needs and preferences comprise a core component of evidence-based medicine; 7 however, the support needs and experiences of patients with skin cancer have received limited in-depth attention. This is despite a long-standing recognition that additional research in this area is required (Improving outcomes for people with skin cancer tumours including melanoma, NICE 2006, https://www.nice.org.uk/guidance/ csg8). Qualitative research is ideally suited to provide an indepth picture of the needs and experiences of patients with skin cancer; however, until fairly recently, most empirical research has been quantitative in nature 8,9 and has focused primarily on melanoma. In 2011, one of the authors of this paper (F.B.H.) published a qualitative systematic review and found only two studies that had examined the needs and experiences of people with skin cancer. 10 Qualitative systematic reviews have an important role to play in terms of informing healthcare professionals about the meaningfulness, feasibility and acceptability of healthcare interventions. 11 Recently, there has been increased interest in conducting qualitative research in dermatology 12 and, therefore, an update of the previous review is timely in order to inform practice and improve the patient's experience of having a skin cancer.

Materials and methods
This review adheres to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines 13 and follows the Joanna Briggs Institute (JBI) methodology for qualitative systematic review. 14 This is an update of a previous review. 10 The review considered adults with a diagnosis of either keratinocyte carcinoma or melanoma skin cancer in any setting. The phenomena of interest were the needs and experiences of adults following a diagnosis of skin cancer. All qualitative studies (including, but not limited to, ethnography, phenomenology and grounded theory studies) that met the inclusion criteria were considered. Qualitative elements of mixed-method studies were also included if the qualitative data were presented separately within the publication. The search strategy was designed to be thorough and exhaustive and there was no restriction on language. All relevant studies were considered, irrespective of the date of publication. Relevant keywords appropriate to the review objectives were identified following consultation with information specialists. The following databases were searched from 2010 to 30 November 2015: CINAHL PsycINFO, Medline and Embase. An example of the search strategy for Medline on Ovid is given in Table 1. In accordance with current methodological recommendations, 15 this search strategy was designed to be sensitive rather than specific. The initial search results were exported to EndNote and duplicates were removed automatically. Studies identified from hand searching of reference lists were manually entered into EndNote separately.
The titles and abstracts identified from the search were all independently assessed against the inclusion/exclusion criteria by two reviewers and there were no disagreements between the two reviewers. Full text articles for the relevant studies were obtained and assessed again. There was disagreement between the two reviewers for only one article and this was resolved by involving a third reviewer. Studies meeting the inclusion criteria were then independently assessed by two reviewers for methodological quality using the JBI Qualitative Assessment and Review Instrument (JBI-QARI). 16 There were no disagreements and, therefore, no need to involve a third reviewer.
Data extraction utilized a standardized JBI-QARI tool. Two reviewers read each paper several times to gain an overall understanding of the key findings and to set them in context. One reviewer then extracted the findings from the included studies, which were variously reported as themes, metaphors or categories. Where possible, each extracted finding was supported by a verbatim quote from a research participant to illustrate its meaning. Where this was not possible, the author's narrative was extracted. All findings were assigned a level of credibility (unequivocal, credible and unsupported). These levels were assigned depending on the extent to which supporting quotes, detail and relevant context were available and gave support to the finding's credibility, as per JBI guidelines (JBI handbook). The levels were assigned as follows: • Unequivocal: findings were accompanied by illustrations that were beyond reasonable doubt and, therefore, not open to challenge.
• Credible: findings were accompanied by illustrations that lacked a clear association and were, therefore, open to challenge.
• Unsupported: findings were not supported by data.
Two reviewers independently reviewed the extracted findings and the assigned levels of credibility and reached agreement that the levels of credibility were appropriate for each paper. There were no disagreements regarding level of credibility.
The findings were analysed using JBI's pragmatic metaaggregative approach. 17 Findings from across the studies were reviewed and grouped together based on similarity of concepts/meanings. Categorization involved the aggregation of the findings to generate a set of categories that represent common meanings. The quality of the findings was taken into account by considering their relative importance in shaping the core constructs of the category. Only findings rated unequivocal (U) or credible (C) were used to develop the metasynthesis (Table 2). Categories were then compared, contrasted and synthesized further to produce a set of synthesized findings, defined as an 'overarching description of a group of categorized findings that allow for the generation of recommendations for practice'. 18 The metasynthesis process was led by one reviewer. This was an iterative process, involving a review of the findings/categories/synthesized findings, going back to the original papers for clarification where necessary, and discussion with the whole team until agreement was reached. The ConQual tool was used to establish confidence in the synthesized findings. 19

Results
A total of 317 studies were identified (300 from the database searches and as is commonly reported in qualitative reviews 20 and an additional 17 from references of studies). A total of 54 duplicates were automatically removed from the 300 references. After reviewing the titles and abstracts of 263 studies, the full text of 23 studies was reviewed, of which 16 studies (14 separate research studies) were included (Fig. 1). The characteristics of the included studies can be found in Table 3.
Nine studies were conducted in the U.K., [21][22][23][24][25][26][27][28][29] three in the U.S.A. [30][31][32] and two in Australia. [33][34][35] Only three studies included keratinocyte carcinoma. 21,22,32 Two studies included melanoma that had relapsed, 25 studies included stage I-III melanoma 28,31 and one study included stage III melanoma. 35 In two studies, the stage of melanoma was unknown. 24,26 One study looked at intrafamily risk communication, 30 one study included views on a general practitioner-led follow-up clinic 23 and one study looked at patient satisfaction with follow-up care. 33 The overall quality of the studies was good (Table 4); however, only two studies 25,26 located the research culturally or theoretically and only one 26 reported the influence of the researcher on the research, indicating poor reflexivity overall for the included studies.

Main findings of the review
There were 153 findings, which were either unequivocal or credible. These findings were aggregated into 15 categories. The 15 categories were then meta-aggregated into four synthesized findings. See Table 5 for a summary of the metasynthesis and Table 2 for a full version. Key concepts within their constituent categories are illustrated using representative textual excerpts from selected findings ( Table 6). The synthesized findings emerged from the data and clustered around the natural time points used by the studies to collect data, and also from the representation of study participants.

Synthesized finding 1: the time of diagnosis
Diagnosis is a time of shock and distress, where patients have significant support and information needs, irrespective of the type of skin cancer. For many patients, this diagnosis can come as a severe shock, especially for those who believe that their symptoms are relatively mild and, therefore, nothing to worry about.
Patients particularly remembered the use of the term 'cancer' as causing a significant shock: . . . the consultant just had a look at it and said, 'I think it's a . . . ' and I couldn't even remember the term after I got out of the hospital, but he said 'I think it's a basal cell carcinoma'. Now the only thing I know about the word carcinoma is that it's linked to cancer. And having shortly before lost my brother to cancer, I must admit I did initially go into a bit of a flat spin (panic) . . . (Winterbottom 2004. p229, BCC) Their immediate distress impacted on their ability to listen and to be responsive to information given by the clinician at the time of diagnosis. Patients reported not remembering receiving information at this stage.
I was so upset about the diagnosis that I don't think much information would have penetrated because I was too focused on thinking I've got cancer because you seem to, I went into a, like a shock of my own and switched off I think. (Moore 1996. p60, M) Waiting for biopsy results caused considerable fear and anxiety for many patients. They felt that they were left to guess about their prognosis and the possible seriousness of their skin cancer. However, once the results were known, many patients felt less anxious, regardless of the result and were able to adjust to their condition.    Coping with nodal relapse (U) Trivialization-attempts to rationalize the diagnosis with the good prognosis (C) Adaptation to the diseaseminimizing the experience (C) MM -Adaptation to the diseasechanging behaviours (C) MM Copinginformation seeking-religious faith (C) MM -Making sense of the diseasesocial comparisoncausal attribution (C) Controllability (C) Diagnosiscoping strategies (C) Treatmentcoping strategies (U) Extended survivorshipcoping strategies (C) Professional support helped in coping (C) Support from family and friends helped in coping (U) Thinking strategies helped in coping (U) Concealing distress and 'putting on a brave face' around others (U) Redirecting attention away from the disease (C) Religious beliefs and practices helped in coping (U) Feeling relieved and reassured (C) Reaction to clinical diagnosis (C) Being in limbo: ongoing fear and uncertainty  Increased awareness (U) Self-monitoring Information needs about checking skin (U) Not sure what to look for (U) Participating in my follow-up (U) 'A passing interest'-not much talk about risk (U) 'I trust them to give me knowledge'-wanting accurate and understandable melanoma information (C) Patient perceptions of information received at the HRC (C) Examining myself. . . (U) Receiving melanoma diagnosis elevated the importance of being more vigilant and proactive regarding monitoring one's health and interacting with physicians to obtain good care (U) Survivors became more conscious of sun exposure and expanded use of sun-protection measures following diagnosis (U) Melanoma survivors sought to continue outdoor pursuits but used sun protection (U) A majority of survivors were more likely to engage in regular, consistent sun protection during the summer months (U) The perception that melanoma is not a serious cancer and confidence that dermatologists will identify new melanomas at an early stage both minimized the necessity of establishing consistent sun protection habits for some survivors (U) Survivors regularly visited dermatologists for screening and that seeing a dermatologist is an effective strategy to ensure new melanomas would be identified early (U) Skin self-examination varied significantly across the sample but most did not conduct skin selfexaminations on a regular basis (C) Lack of confidence in ability to identify a suspicious mole was cited as a barrier to conducting skin selfexamination, and some survivors preferred to offload the responsibility to the doctor (U) Fear of the sun (U) Behavioural responses to threat (U) Low confidence in one's ability to detect melanoma (i.e. self-efficacy) (U) An appropriate time for questions (C) Needing to know, not needing to knowambivalence about information needs (U) Changes in behaviour (U) Spreading the word (C) Understanding and communicating risk Awareness and understanding of risk (U) Families facilitate and hinder communication (U) Promoting melanoma prevention and detection in the family (C) An obligation to tell others (U) Survivors were aware their diagnosis increased melanoma risk (genetic susceptibility) and the need for family members to be screened, yet many did not discuss risk reduction with family members (U) (continued)  Patients also expressed a need for emotional support. In some cases, healthcare providers gave patients the impression that skin cancer was less significant than other types of cancer and, therefore, they underestimated or ignored the patients' emotional needs.
. . . And then, I can't say I'm feeling down today or whatever, I'm going to (cancer hospital) on Monday, I feel a bit crap today and all that. But you can't, I mean, if you knew somebody on the phone or you were going to (cancer hospital) and you could have half an hour . . . But there's nothing, you're just out on a limb really. Even though it's a cancer, there's no actual help-type thing. For the time around treatment and immediately afterwards, the experience of having skin cancer varies depending upon the type, stage and treatment. A skin cancer diagnosis can have a significant emotional, physical, social and financial impact, some of which can be long-lasting, and patients and their families may need support in these areas. Patients cope with their experiences in a variety of ways.
The treatment journey was often depicted as stressful and emotional for patients, associated with negative experiences such as the complications of cancer treatments, poor communication with treatment team members, not receiving adequate information and the uncertainty of not knowing whether things would get back to how they were before. For some, there was also the need to travel long distances for treatment. . . . But your managers, you know, like I'd go in and say 'Oh I'm really struggling at the minute, can you take -I can't do this -I need a bit of asome weight taken off me at work' and they'll do it for a short period of time while you're in distress but then it's soon back on you isn't it? (Stamataki 2015 Patients developed a range of mechanisms to cope with their cancer, including avoidance, positive reframing, sticking to routines, seeking social support and solace from religious faith. I have to say I'm a Christian and I believe in healing, and so the whole thing wasn't too much of a problem. I won't say I wasn't concerned, but the faith kept me going and I knew that other people were praying for me. (Winterbottom 2004. p230, M) One study 25 focused particularly on patients who had transitioned from an initial diagnosis of melanoma to nodal relapse. These patients used coping skills learned from their initial diagnosis to help with a diagnosis of nodal relapse.   Physically I was aware of the signs of recurrence and psychologically I found it easier to cope, as opposed to the initial diagnosis which was a major 'shock'. Both patients with keratinocyte carcinoma and patients with melanoma described an ongoing sense of uncertainty and fear (being in limbo) associated with the possibility of recurrence of the skin cancer. This fear was exacerbated by inadequate knowledge regarding risks of recurrence and how and when to seek help.
Well, it's just that, you know, I just hope that it's all gone and that it's not going to flare up again. I mean, I'm touching wood, I don't think it will do because I don't think it was that sort of thing, but there's bound to be doubts, small doubts, you know, even though people do try and reassure you. But hopefully everything will be okay.    For some patients, their experience led to an increased concern for family and community members about their risks of skin cancer. In some cases, patients would actively educate others and encourage treatment-seeking and preventive measures.
One or two people I have spoken to and I've said, I did say look out for dubious looking spots and things that won't go away with ointments and things.    (Moore 1996. p60, M) I went very quiet for the first fortnight afterwards. . . of course I was panicking for 14 days. . . and then when he turned around and said you have got it all (the malignant melanoma was completely excised) but we are going to take a precaution now (and excise a further 1-2 cm) and that was a relief, that first fortnight, every time I had nothing to do I would sit down and start thinking, what if. (Taylor 2009. p33, M) . . .extremely upset, actually, and quite shocked, because I was told that it was very unlikely that it was anything. . . so I was shocked, to say the least. (    Well I've been married to the same person for 42 years, and I love him dearly, but he didn't do well with my diagnosis, which was two years ago. And it was a stage II, and it was a big-it was a fairly big deal. But for some reason he became sick when I got the diagnosis. It was almost as though I was getting more attention than he was, and this became a problem just because I sort of-I guess I'm sort of an insular person, and when this happened I sort of turned inward, and you're trying to steel yourself and get through this, and you just don't want to deal with-I don't want to deal with other people and their problems. I need to focus on this. And it's a selfish thing for me, I know that, but I couldn't deal with him. I never took him with me to the doctor because the first time I did I came out to the waiting room and there he is and he says, 'Oh, I feel awful.' Wait a minute, you know? I'm the guy with cancer, and you feel awful? So this was a problem for probably the first year.   (Winterbottom 2004. p230, KC) I have to say that I'm a Christian and I believe in healing, and so the whole thing wasn't too much of a problem. I won't say I wasn't concerned, but the faith kept me going and I knew that other people were praying for me (Winterbottom 2004. p230, M) There's some things you don't want to ask, some things you don't want to know about. . . you can maintain a more positive outlook if you've got some kind of ignorance. (Tan 2014. p12, M stage I-III) Physically I was aware of the signs of recurrence and psychologically I found it easier to cope, as opposed to the initial diagnosis which was a major 'shock' (Stothers 2015. p34, nodal relapse of melanoma) I (thought) 'I've just got to get up, I've got to start doing anything, I'm wallowing in self-pity here. . .' So I got on to a personal trainer. . . I just thought 'I have to take control of this situation.' (Tan 2014  One or two people I have spoken to and I've said, I did say look out for dubious looking spots and things that won't go away with ointments and things. (Bath-Hextall 2013. p7, BCC) . . .it has raised awareness significantly in our family now, yeah. . . I've been into town today and bought a moisturizer with SPF25 or something or other, so yeah. So I'll wear that constantly now rather than general moisturizers. (Bath-Hextall 2013. p7, BCC) Our friends all know that they can't go anywhere outside with me unless they have put on sunscreen. We (family) are responsible for spreading the word. We owe this to ourselves and to others. (Loescher 2009. p6-7, M) . . .as I say, certain members of my family used to have various bits and pieces like that and so I wondered if to some extent these things were hereditary. (Winterbottom 2004. p229, BCC) When I'm standing at an intersection I sort of find the shadow of a post, believing that even the smallest amount of sun exposure could trigger another melanoma. ( Some patients with melanoma found the clinical settings unsuitable (e.g. overcrowded or lacking in privacy), which impacted on how they interacted with their healthcare providers. Some patients were particularly unhappy about long waiting times and limited consultation periods, which hindered their ability to seek reassurance and information. In some settings, patients objected to frequent follow-up visits as these disrupted everyday life.
[Describing a follow-up at hospital.] At (hospital) it was bedlam, about 30 people in the waiting room. It just seemed like a cattle market, you know, can you understand what I mean? Every few minutes one was coming in and one was coming out. Patients were satisfied with providers whom they perceived to be clinically knowledgeable and who treated them in a holistic manner with compassion and empathy. In cases where either one of these facets was missing, care was perceived to be suboptimal.
[A patient whose dermatologist had misdiagnosed the cancer.] And there's a lot of ignorance around. Doctor says something, you think that's it. I was very ignorant with that first melanoma . . . (Oliveria 2013. p111, M) I don't want the comments anymore, if I have another medical student who says, 'Oh my gosh, you really had five melanomas'. I don't want that anymore. (Loescher 2009. p304, M) Patients with melanoma in a general practitioner (GP)-led follow-up study had less confidence in the GP compared with their hospital doctor and needed reassurance that they had undergone additional training. However, they did feel that they were getting more detailed and comprehensive consultations compared with the hospital appointments.

Categories
Representative quotes The main disadvantage of GP-led follow-up was feeling less reassured, or having less confidence in their GP than in the hospital specialist. There was remarkable agreement among participants that in order for patients to gain maximum reassurance during a GP-led follow-up appointment, the GP needed to be friendly and known, have undergone extra training, appear receptive to questions and familiar with the study protocol and working explicitly to a clear structure. When some of these aspects were lacking, some patients reported feeling unhappy: 'When I went to her she spoke about having all the information, but she kept having to look up bits of paper. I just got the impression she wasn't 100% clued up about what was going on. At the hospital I felt they knew these things as a matter of course.' (Murchie 2010. p230, M) I feel more in control with this system. I know what I'm looking for and if there's a problem or I'm worried, I just need to pick up the phone and I can get seen the same day. I couldn't do that before. (Murchie 2010. p229, M) The GP follow-up consultations were generally viewed as thorough, with many patients believing that they were more detailed and comprehensive than consultations provided in hospital: 'He takes that bit more time. I was given a top-to-toe examination on both occasions and I felt I was getting a better return from him than I got from the hospital.' (Murchie 2010  When I went to her, she spoke about having all the information, but she kept having to look up bits of paper. I just got the impression she wasn't 100% clued up about what was going on. At the hospital I felt they knew these things as a matter of course. (Murchie 2010. p230, M) He takes that bit more time. I was given a top-to-toe examination on both occasions and I felt I was getting a better return from him than I got from the hospital. (Murchie 2010. p229, M)

Discussion
The previous systematic review in 2010 10 highlighted the need for further research into the needs and experiences of patients with skin cancer. Six years later, a further 12 studies have been published; however, only two of these studies exclusively considered keratinocyte carcinoma. 21,32 Despite the high incidence rates of keratinocyte carcinoma worldwide, 1 very few studies have directly investigated the psychosocial effects of this cancer and its treatment. The synthesized findings from this review provide new insights into the complexities and challenges of a patient who is diagnosed and treated for skin cancer; however, there are still very few studies that focus on the most common cancer in humans (keratinocyte carcinoma) and therefore this is an area for further research.
At diagnosis, despite the fact that keratinocyte carcinomas and melanomas can have very different prognoses, healthcare professionals need to be sensitive to, and acknowledge, that having a diagnosis of any type of skin cancer often causes distress. The review shows that all patients require support and understanding, together with tailored information. Studies of other cancer types report similar conclusions. 36 The time around treatment and immediately afterwards can be very different for patients with skin cancer depending on their treatment, type of cancer and stage. This is a time where there is a requirement for clear information that is tailored to the needs of the individual. Patients also need to be followed up by healthcare professionals who are not only clinically knowledgeable but also show compassion and an understanding of the patient's psychosocial needs.
The review has shown that the follow-up period can be experienced as a time of considerable uncertainty and fear especially around prognosis and recurrence. These findings are consistent with issues identified in a systematic review that looked at the unmet support needs of people with cancer. 37 Our findings are also consistent with other studies regarding other cancer types. 38,39 Patients require clear supportive information about surveillance and risk management and this should include information regarding how to identify skin changes, prevent and manage further risknot just for themselves but also for their family. Knowledge about recognizing signs of skin cancer is particularly important as 44% of patients with a keratinocyte carcinoma will develop additional lesions within 3 years 40 and there is a 2Á8% risk of developing a second melanoma after 5 years and a 3Á6% risk after 10 years. 41 Other quantitative studies have also shown that patients with keratinocyte carcinoma experience anxiety and worry about future skin cancers, 42 and have unmet needs regarding the health system and information-related matters. 8 The overall methodological quality of the included studies was good, although there was general poor reflexivity. Providing an overall score for the level of confidence in qualitative review findings is a relatively new development, 19,43 and draws upon the concepts of dependability (established using a set of critical appraisal questions) and credibility (ranked according to the 'goodness of fit' between the author's interpretation and the original data). Therefore, an element of subjectivity will always remain when assigning a level of credibility. The included findings were mainly unequivocal, with fewer equivocal and no unsupported findings. Therefore, the overall dependability and credibility of all synthesized findings were downgraded by one level and the overall ConQual score was medium ( Table 7).
The review included 14 studies representing only four countries; therefore, care must be taken in generalizing the results of this review to other countries. In particular, the category 'financial concerns and consequences' applies only to the U.S.A. and other countries with similar health systems.
Search strategies for qualitative research are less developed compared with quantitative research and, therefore, the main limitation of this review is that the search strategy may not have captured all relevant qualitative studies. 15 This review has shown that, for many patients, having a skin cancer marks the start of a journey. The review shows that specific needs and experiences will vary at each stage depending on the type of cancer and its severity. Crucially, this review highlights how this journey does not end for patients with the cessation of treatment, but continues into an uncertain future requiring ongoing self-monitoring and is often accompanied by fear and uncertainty around the identification of new skin abnormalities.