Sian Gibson, 51 (pictured), consulted her GP about an unusual freckle she found on her ankle . As a redhead, 51-year-old Sian Gibson was used to having freckles — they’d covered her arms, face and chest since childhood. But in 2008, she noticed a new freckle, darker than usual and larger — the size of a small fingernail — on her ankle. ‘I don’t have many freckles on my legs, so I noticed it straight away,’ says Sian, a mother of three and grandmother of five. ‘My GP told me it was nothing and not to worry about it. But, of course, I did. At the time, there was a campaign about the importance of early detection of skin cancer. Every time I caught sight of the freckle, I would be reminded of how much I wanted to be around for my family.’ However, instead of returning to her GP to ask for a hospital appointment, Sian, from Boston, Lincolnshire, turned to her mobile phone for medical advice. ‘I’d recently got an iPhone and was downloading the apps that were just becoming available,’ she says. ‘One evening, I searched online for “large freckle” and found my way to a free app that claimed to be a mole evaluator that would identify at-risk moles. I thought: “Why not? What have I got to lose?” ’ Sian was ahead of the times. Apps, short for applications — programs that can be downloaded to run on a smartphone — were few and far between in 2008. Today, they’ve become essential to most people’s lives. With 100,000 health apps available in Britain and more launching every week, the medical sector is a market leader — with apps to track calories consumed and kilometres jogged, give first aid advice, provide cognitive behavioural therapy for phobias and remind people to take medication. One in five health apps claims to support a diagnosis, as with Sian’s mole app. One program turns your mobile phone into an electrocardiogram, tracking heart rhythms and emailing the results to a doctor, while others allow patients to record blood pressure or blood sugar. In 2013, the global market for health apps was worth $2.4 billion, according to market research firm research2guidance — and this is predicted to rise to $26 billion by 2017. The NHS has launched the Health and Symptom Checker, and the use of apps in the health service is only set to increase. Last week, it emerged that the NHS is now helping to launch apps to help people cope with depression. ‘We know people are more likely to make healthy choices if they can set their own goals,’ says Bradford GP Dr Shahid Ali, professor of digital health at Salford University. ‘And there’s evidence that with health apps, people are able to have a more grown-up relationship with their doctors and nurses.’ A handful of GPs have welcomed the technology to their practices. Dr Jagdeesh Dhaliwal, a GP in Walsall, West Midlands, says three or four of the 40 or so patients he sees a day bring along their phones to provide information from an app. ‘They might have diabetes or high blood pressure, and we’ll use the app to look at an updated graph of their latest tests to see how well they’re managing the condition.’ But critics say apps need regulation before we encourage doctors — and patients — to use them. There are no rules to regulate health apps. And Sian Gibson’s experience shows why this needs urgent attention. Sian later downloaded a health app that said it would be able to identify at-risk moles (file image) The app Sian had downloaded consisted of several pages of photos of abnormal moles. ‘I remember scrolling through them with a growing feeling of panic,’ she says. ‘But when there was nothing that looked remotely like my freckle, I thought I was off the hook. The app confirmed what the doctor had told me, and I stopped worrying.’ Two years later, though, in summer 2010, Sian scratched her ankle on her staircase and the freckle started to bleed. Yet still she didn’t worry. ‘Even when the scratch didn’t heal properly, I didn’t get alarmed. I thought it must be psoriasis, which I suffer from occasionally,’ she says. A couple of months later, Sian’s new GP caught sight of the messy spot, by then double the size, when she made a routine surgery visit. ‘He said, “That’s rather unsightly, why don’t I remove it?” He made an appointment for me the same week, and later told me he knew straight away it was a skin cancer.’ Tests showed Sian’s ‘freckle’ was the most dangerous form of skin cancer — a malignant melanoma, which was at a stage where the cancer is liable to spread to the rest of the body. ‘I owe my life to that doctor and the fact that he noticed the spot while I was in his consulting room,’ says Sian. She was referred to hospital and, in January 2011, had surgery to remove the tumour. ‘Thankfully, there was no spread. The cancer had been caught, probably just in time. Now, I have a slightly bumpy ankle and a 3 in scar.’ Sian says that there may have been a warning on the health app to check with a doctor — ‘but I didn’t see it and, in the circumstances, I don’t think I would have taken any notice’. Newer versions of mole-checking apps are more sophisticated, allowing users to photograph a mole and using mathematical formulas to check for skin cancer symptoms, such as asymmetry, irregular borders or varied colour. But they still miss two out of three melanomas, according to dermatologists at the University of Pittsburgh Medical Centre in a study published in 2013 in the journal JAMA Dermatology. The researchers reported this can give users ‘a false sense of security’. ‘This is very dangerous when a lesion can grow deeper and spread to other organs within a matter of months,’ says lead researcher and skin cancer specialist Dr Laura Ferris. And the fact that mole apps have been singled out in this way does not mean they are the only ones causing concern, says Dr Claudia Pagliari, director of the eHealth Interdisciplinary Research Group at Edinburgh University. It wasn't until two years later that Sian (pictured) discovered that the mole was in fact the most dangerous form of skin cancer . ‘Reports of actual harm to consumers are still rare, but this could simply mean the potential for harm hasn’t yet translated into an actual event,’ she says. But attempts by regulators in the U.S. to impose stricter controls have been unsuccessful. So while the manufacturers of Mole Detective, an app that claims to be able to ‘help to detect skin cancer earlier’ (and is downloadable in Britain) has been fined by the U.S. Federal Trade Commission for making misleading claims in its advertising, the app is still doing business as normal. So, how can you know which apps you should use? There are guides that can be helpful, says Dr Dhaliwal. He recommends the NHS Health Apps Library (apps.nhs.uk) — though it is limited to less than 100, with a basic rating system. He also recommends myhealthapps.net, an independent website that lists hundreds of apps, with a ‘five heart’ rating system based on reviews by patient groups, consumers and carers globally. NHS England is to unveil a system of awarding kitemarks to trusted health apps later this year. But this will be a tricky enterprise, says Charles Lowe, chair of the Royal Society of Medicine telemedicine and e-health section. Proportion of GPs who use the internet to diagnose patients. ‘Online commerce has found ways of approving apps very quickly as they come on the market,’ he says. ‘Health apps will have to be approved with the same urgency — in days or weeks, rather than months or years, as with new drugs. But there mustn’t be any compromise to safety or efficacy.’ Whether British doctors will welcome the e-health revolution — and their patients brandishing mobile phones in the consulting room — still remains to be seen. A recent survey of family doctors found eight in ten reported patients becoming more anxious as a result of using apps. Dr Martin Scurr, Good Health’s GP, says apps ‘will never be a substitute for an appointment with the doctor’. ‘Patients sometimes email me photographs, asking for an opinion,’ he says. ‘It doesn’t work. They have to come into the surgery and be examined properly.’ Certainly, Sian Gibson has been put off health apps. ‘Obviously, my first GP got it wrong when he told me not to worry about my freckle,’ she says. ‘But on top of that, the app gave me a false sense of security. ‘Thank goodness I now have a good doctor. Thanks to him, all should be well at my five-year check-up next month. But it was a close call.’
In 2008, Sian Gibson noticed a new, larger and darker freckle on her ankle . She consulted her GP but was told it was nothing to worry about . She downloaded a health app that also suggested nothing was wrong . Two years later, Sian found out that the freckle was actually skin cancer .