Public Health Skin Cancer Prevention
by
Karen Glanz
  • LAST REVIEWED: 15 June 2015
  • LAST MODIFIED: 23 February 2011
  • DOI: 10.1093/obo/9780199756797-0056

Introduction

Skin cancer is the most commonly diagnosed cancer in the United States, with more than 1 million Americans diagnosed with it each year. The incidence of skin cancer has increased dramatically worldwide since 2000. Both main types of skin cancer—malignant melanoma and nonmelanoma skin cancer (NMSC)—are now significant public health concerns. Yet even though skin cancer rates are increasing, it is considered one of the most preventable types of cancer. Prevention guidelines include reducing exposure to ultraviolet radiation (UVR); adopting sun protection habits, including the use of sunscreen, hats, shirts, and sunglasses; performing regular skin self-examination; and seeking professional evaluation of suspicious skin changes. Most skin cancer prevention interventions reported in the literature are directed at the general population through school-based curricula, multicomponent community programs, or media campaigns, and some recent trials have targeted people with high sun exposure at work or during outdoor recreation. Children and adolescents are important audiences for skin cancer prevention. This article identifies bibliographic resources related to skin cancer prevention for the general population and groups at increased risk because of genetic traits or environmental exposures. Current and recent books and research articles are included, along with works addressing issues in measurement and methodology for research and evaluation of skin cancer prevention.

General Overviews

Hill, et al. 2004 and Ringborg, et al. 2007 are among the few books focusing specifically on skin cancer prevention. More often, books focus on cancer prevention more generally, or on skin cancer diagnosis and treatment with some coverage of prevention. The two edited volumes cover skin cancer prevention from epidemiological, environmental, and behavioral perspectives. Both books also include chapters written by international authors from a variety of disciplines. They cover epidemiologic, genetic, environmental, and physical and behavioral science perspectives on skin cancer prevention and provide broad background information for both experienced readers and those new to this subject.

  • Hill, David, J. Mark Elwood, and Dallas R. English, eds. 2004. Prevention of skin cancer. Dordrecht, The Netherlands: Kluwer Academic.

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    Covers skin cancer prevention from the etiology and epidemiology of skin cancer and its prevention to the efficacy of interventions. Provides good coverage of environmental issues such as solar and ultraviolet radiation and stratospheric ozone depletion. This book includes a focus on the implications of each chapter for public health.

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    • Ringborg, Ulrik, Yvonne Brandberg, Eckhard W. Breitbart, and Rudiger Greinert, eds. 2007. Skin cancer prevention. New York: Informa Healthcare.

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      This edited volume includes chapters on basic science research on etiology, as well as clinical and public health aspects of skin cancer and its prevention. Importantly, there are different chapters on melanoma and nonmelanoma types of skin cancer, as well as chapters on solaria, sunscreens, vitamin D, the UV Index in international contexts, and health economics aspects of skin cancer prevention.

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      Review Articles and Evidence Reviews

      An extensive evidence review of strategies to prevent skin cancer was undertaken by the Task Force on Community Preventive Services, and the results and recommendations are published in Saraiya, et al. 2004. Glanz, et al. 2007 uses the Task Force review as a starting point for a more extensive review of skin cancer prevention for outdoor workers.

      • Glanz, Karen, D. B. Buller, and Mona Saraiya. 2007. Reducing ultraviolet radiation exposure among outdoor workers: State of the evidence and recommendations. Environmental Health 6: 22.

        DOI: 10.1186/1476-069X-6-22Save Citation »Export Citation »E-mail Citation »

        This paper reviews descriptive data about outdoor workers’ sun exposure and protection and related knowledge, attitudes and policies, and evidence about the effectiveness of skin cancer prevention interventions in outdoor workplaces. Findings show that men are more likely to wear hats and protective clothing and women more likely to use sunscreen. Few data document education and prevention policies.

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        • Saraiya, Mona, Karen Glanz, P. A. Briss, P. Nichols, C. White, D. Das, S. J. Smith, et al. 2004. Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: A systematic review. American Journal of Preventive Medicine 27:422–466.

          DOI: 10.1016/S0749-3797(04)00205-3Save Citation »Export Citation »E-mail Citation »

          This report presents the results of systematic reviews of the effectiveness of interventions to prevent skin cancer by reducing exposure to ultraviolet radiation. The Task Force on Community Preventive Services found that education and policy approaches were effective when implemented in primary schools and in recreational or tourism settings, but found insufficient evidence to determine effectiveness in other settings.

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          Comprehensive Community Programs and Mass Media

          The longest history of comprehensive, multicomponent community skin cancer prevention programs has been in Australia. These programs include integral mass media and communication campaigns. While many reports have been published about these programs, the three citations in this section provide good overviews and unique research on the effects of comprehensive community programs. Montague, et al. 2001 describes the Slip! Slop! Slap! and SunSmart campaigns; Dixon, et al. 2007 reports on the effects of sending weekend ultraviolet (UV) solar forecasts to adults; and Dobbinson, et al. 2008 describes the association of changes in sun protection practices with exposure to SunSmart television advertising.

          • Dixon, H. G., D. J. Hill, D. J. Karoly, D. J. Jolley, and S. M. Aden. 2007. Solar UV forecasts: A randomized trial assessing their impact on adults’ sun-protection behavior. Health Education and Behavior 34:486–502.

            DOI: 10.1177/1090198106294644Save Citation »Export Citation »E-mail Citation »

            This study tested the effectiveness of e-mailing solar UV forecasts and supporting communications to working adults on their protection from excessive weekend sun exposure. while provision of solar UV forecasts in weather forecasts did not promote enhanced sun-protection practices among the adults surveyed, this article can help scholars to consider ways to improve the effects of communication for reducing ultraviolet radiation (UVR) exposure.

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            • Dobbinson, S. J., M. A. Wakefield, K. M. Jamsen, N. L. Herd, M. J. Spittal, J. E. Lipscomb, and D. J. Hill. 2008. Weekend sun protection and sunburn in Australia: Trends (1987–2002) and association with SunSmart television advertising. American Journal of Preventive Medicine 34:94–101.

              DOI: 10.1016/j.amepre.2007.09.024Save Citation »Export Citation »E-mail Citation »

              This article examines trends over fifteen years in behavioral risk factors for skin cancer in an Australian population exposed to the SunSmart program, including SunSmart television advertising. Of particular interest is the finding that higher exposure to SunSmart advertising in the weeks before the interview increased preferences for no tan, hat and sunscreen use, and greater clothing protection.

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              • Montague, Meg, R. Borland, and C. Sinclair. 2001. Slip! Slop! Slap! and SunSmart, 1980–2000: Skin cancer control and 20 years of population-based campaigning. Health Education and Behavior 28:290–305.

                DOI: 10.1177/109019810102800304Save Citation »Export Citation »E-mail Citation »

                In Australia two related sun protection programs have been conducted for more than twenty years: Slip! Slop! Slap! from 1980 to 1988, and SunSmart from 1988 to the present. As described in this article, these programs have played an important role in changing the whole society’s approach to the sun and have resulted in marked reductions in sun exposure.

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                Interventions

                Schools, outdoor worksites, and recreation settings are often-used organizational settings for skin cancer prevention interventions. The prevention programs that fit within these settings are affected by the organizational structures, the populations present in these settings, and the physical aspects of the settings that involve being outdoors and thus exposed to the sun. Opportunities for and limitations of skin cancer prevention in schools, outdoor workplaces, and recreation settings are highlighted in the citations in the following three subsections.

                Schools

                The most frequently studied settings for skin cancer prevention programs are schools, and there is good evidence, as seen in Saraiya, et al. 2004, that educational and policy interventions can be effective in primary schools. Of the many reported studies, a few are particularly well designed and carefully described, have long follow-up periods, and/or use objective outcome measures. The findings of these studies are reported in multiple publications and provide very useful information. Therefore, these reports were selected as important citations for readers. The first study is the Kidskin intervention trial in Western Australia, with a six-year follow-up period. Milne, et al. 2000 reports on the two-year behavioral findings of Kidskin, and Milne, et al. 2001 describes the program’s early impacts on sun exposure and tanning. English, et al. 2005 reports on the six-year outcomes on development of melanocytic nevi. Complementing these findings, Giles-Corti, et al. 2004 discusses the environment and policy interventions. The second study is the Sunny Days, Healthy Ways sun safety curriculum that was implemented and evaluated in primary schools (Buller, et al. 2006a) and middle schools (Buller, et al. 2006b).

                • Buller, D. B., A. M. Taylor, M. K. Buller, P. J. Powers, J. A. Maloy, and B. H. Beach. 2006. Evaluation of the Sunny Days, Healthy Ways sun safety curriculum for children in kindergarten through fifth grade. Pediatric Dermatology 23:321–329.

                  DOI: 10.1111/j.1525-1470.2006.00270.xSave Citation »Export Citation »E-mail Citation »

                  Evaluation of an expanded Sunny Days, Healthy Ways sun safety curriculum was conducted in seventy-seven kindergarten to 5th-grade classes in ten elementary schools. Students received instruction once or twice over two school years or were in a no-treatment control group. A single presentation of the sun safety materials improved sun safety knowledge in students in grades 2–5.

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                  • Buller, D. B., K. D. Reynolds, A. Yaroch, G. R. Cutter, J. M. Hines, C. R. Geno, J. A. Maloy, M. Brown, W. G. Woodall, and J. Grandpre. 2006. Effects of the Sunny Days, Healthy Ways curriculum on students in grades 6 to 8. American Journal of Preventive Medicine 30:13–22.

                    DOI: 10.1016/j.amepre.2005.08.046Save Citation »Export Citation »E-mail Citation »

                    This article reports on development of a sun-safety curriculum for grades 6 to 8, and a test of whether the curriculum increased children’s sun-protection behavior. The six-unit sun-safety curriculum was implemented and evaluated in thirty middle schools in Colorado, New Mexico, and Arizona.

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                    • English, D. R., E. Milne, P. Jacoby, B. Giles-Corti, D. Cross, and R. Johnston. 2005. The effect of a school-based sun protection intervention on the development of melanocytic nevi in children: 6-year follow-up. Cancer Epidemiology Biomarkers and Prevention 14:977–980.

                      DOI: 10.1158/1055-9965.EPI-04-0531Save Citation »Export Citation »E-mail Citation »

                      In this evaluation of the Kidskin trial of a school-based sun protection program in Western Australia, the primary outcome was number of nevi on the back. Compared with the control group, the relative increase in number of nevi on the back was 0.89 for the high intervention group and 0.94 for the moderate group.

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                      • Giles-Corti, B., D. English, C. Costa, E. Milne, D. Cross, and R. Johnston. 2004. Creating SunSmart schools. Health Education Research 19:98–109.

                        DOI: 10.1093/her/cyg003Save Citation »Export Citation »E-mail Citation »

                        Within the Kidskin sun-protection intervention study in thirty-three primary schools in Perth, Western Australia, the moderate and high intervention groups received an environmental intervention aimed at creating SunSmart schools. The program had a positive effect on hat wearing in the playground, especially in the high-intervention groups, but did not change children’s use of shade at lunchtime.

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                        • Milne, Elizabeth, D. R. English, R. Johnston, D. Cross, R. Borland, C. Costa, and B. Giles-Corti. 2000. Improved sun protection behaviour in children after two years of the Kidskin intervention. Australian and New Zealand Journal of Public Health 24:481–487.

                          DOI: 10.1111/j.1467-842X.2000.tb00497.xSave Citation »Export Citation »E-mail Citation »

                          The Kidskin study involved three groups: control, moderate, and high intervention. Results showed that children in the intervention groups, especially the high group, reported less sun exposure and spent less time outdoors in the middle of the day. There was little difference between groups in the wearing of hats or sunscreen.

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                          • Milne, Elizabeth, D. R. English, R. Johnston, D. Cross, R. Borland, B. Giles-Corti, and C. Costa. 2001. Reduced sun exposure and tanning in children after 2 years of a school-based intervention (Australia). Cancer Causes and Control 12:387–393.

                            DOI: 10.1023/A:1011294023498Save Citation »Export Citation »E-mail Citation »

                            This paper presents the results of the evaluation of measured suntan and parent-reported sun exposure in participating children after two years of the Kidskin study in Western Australia. Children in the intervention groups, especially the high group, were less tanned at the end of the summer; this effect was greater for the back than for the forearms.

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                            • Saraiya, Mona, Karen Glanz, P. A. Briss, P. Nichols, C. White, D. Das, S. J. Smith, B. Tannor, A. B. Hutchinson, K. M. Wilson, N. Gandhi, N. C. Lee, B. Rimer, R. C. Coates, J. F. Kerner, R. A. Hiatt, P. Buffler, and P. Rochester. 2004. Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: A systematic review. American Journal of Preventive Medicine 27:422–466.

                              DOI: 10.1016/S0749-3797(04)00205-3Save Citation »Export Citation »E-mail Citation »

                              This report, which reviews the effectiveness of interventions to prevent skin cancer by reducing exposure to ultraviolet radiation (UVR), includes studies in primary and secondary school settings. Findings indicated that education and policy approaches in primary schools were effective, but there was insufficient evidence to determine effectiveness in secondary schools and colleges.

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                              Outdoor Work

                              Outdoor workers receive regular and significant solar ultraviolet radiation (UVR) exposure and thus are at high risk for skin cancer. Interventions to reduce their UVR exposure have been reported in Buller, et al. 2005, a well-designed study with ski instructors, and in another intervention for postal workers reported in Mayer, et al. 2007 and Mayer, et al. 2009. The lifeguard intervention described in Hall, et al. 2008 is exemplary of well-designed research on occupational skin cancer prevention.

                              • Buller, D. B., P. A. Andersen, B. J. Walkosz, M. D. Scott, G. R. Cutter, M. B. Dignan, E. M. Zarlengo, J. H. Voeks, and A. J. Giese. 2005. Randomized trial testing a worksite sun protection program in an outdoor recreation industry. Health Education and Behavior 32:514–535.

                                DOI: 10.1177/1090198105276211Save Citation »Export Citation »E-mail Citation »

                                Go Sun Smart (GSS) is a worksite sun safety program largely based on diffusion-of-innovations theory, which was evaluated in a pair-matched, group-randomized, pretest-posttest controlled design at twenty-six ski areas in western North America. Employees at the intervention ski areas reported less sunburn at posttest than employees at the control areas. Greater program implementation was associated with fewer sunburns among employees.

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                                • Hall, D. M., T. Elliott, E. Nehl, and K. Glanz. 2008. Effectiveness of a targeted, peer-driven skin cancer prevention program for lifeguards. International Journal of Aquatic Research and Education 2:287–297.

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                                  This paper reports on the evaluation of a targeted, peer-driven skin cancer prevention program for lifeguards called Pool Cool Plus. Nine pools received the targeted intervention, and five pools received the standard Pool Cool program. At pools in both study groups, lifeguards increased their sun safety practices and reported more sun-safe pool policies and environments. Sunburns decreased at pools receiving the Pool Cool Plus intervention.

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                                  • Mayer, J. A., D. J. Slymen, E. J. Clapp, L. C. Pichon, L. Eckhardt, L. F. Eichenfield, J. P. Elder, J. F. Sallis, M. A. Weinstock, A. Achter, C. Balderrama, G. R. Galindo, and S. S. Oh. 2007. Promoting sun safety among US Postal Service letter carriers: Impact of a 2-year intervention. American Journal of Public Health 97:559–565.

                                    DOI: 10.2105/AJPH.2005.083907Save Citation »Export Citation »E-mail Citation »

                                    This study examined whether US Postal Service letter carriers who received a sun safety intervention would wear wide-brim hats and sunscreen significantly more often. The two-year sun safety intervention included provision of wide-brim hats, accessible sunscreen, reminders, and six education sessions. Regular sunscreen and hat use were higher among the intervention group than among the control group after three months and at two-year follow-up.

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                                    • Mayer, J. A., D. J. Slymen, E. J. Clapp, L. C. Pichon, J. P. Elder, J. F. Sallis, L. F. Eichenfield, and M. A. Weinstock. 2009. Long-term maintenance of a successful occupational sun safety intervention. Archives of Dermatology 145:88–89.

                                      DOI: 10.1001/archdermatol.2008.544Save Citation »Export Citation »E-mail Citation »

                                      This paper reported on the three-year outcomes of the postal workers’ sun safety intervention. After two years, the intervention sites continued to receive program materials, and they were also given to the control site participants. The intervention group sustained good rates of sunscreen and wide-brim hat use, and sun protection behaviors increased in the control group after they were given the program.

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                                      Recreation

                                      Intense and prolonged sun exposure often occurs during outdoor recreation activities. High ultraviolet radiation (UVR) exposure, often with minimal clothing, tends to occur in beach and swimming pool settings. Other outdoor recreation settings include camps, zoos, and parks. Large and well-designed studies of skin cancer prevention in these locations have been reported. Glanz, et al. 2002 reports on a test of the Pool Cool program at swimming pools in a cluster-randomized trial in two states, and Glanz, et al. 2005 describes how the study was followed up with a large national diffusion trial. Weinstock, et al. 2002 reports on a multicomponent skin cancer prevention trial for beachgoers at northeastern beaches, and Pagoto, et al. 2003 reports on a trial of a multicomponent intervention on midwestern beaches. Mayer, et al. 2001 reports on an intervention for zoo visitors, and Lewis, et al. 2005 reports on a study of different approaches to disseminating the program nationally.

                                      • Glanz, Karen, A. C. Geller, D. Shigaki, J. E. Maddock, and M. R. Isnec. 2002. A randomized trial of skin cancer prevention in aquatics settings: The Pool Cool program. Health Psychology 21:579–587.

                                        DOI: 10.1037/0278-6133.21.6.579Save Citation »Export Citation »E-mail Citation »

                                        This study evaluated the impact of a skin cancer prevention program on sun-protection habits and swimming pool environments in a randomized trial at twenty-eight swimming pools. The intervention included staff training; sun-safety lessons; interactive activities; providing sunscreen, shade, and signage; and promoting sun-safe environments. Results showed significant positive changes in children’s use of sunscreen and shade, overall sun-protection habits, and number of sunburns.

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                                        • Glanz, Karen, A. Steffen, T. Elliott, and D. O’Riordan. 2005. Diffusion of an effective skin cancer prevention program: Design, theoretical foundations, and first-year implementation. Health Psychology 24:477–487.

                                          DOI: 10.1037/0278-6133.24.5.477Save Citation »Export Citation »E-mail Citation »

                                          This article describes the design and theoretical foundations of the Pool Cool Diffusion Trial and reports first-year findings. Aims of the study are to evaluate the effects of two strategies for diffusion of the Pool Cool sun-safety program on implementation, maintenance, and sustainability; environmental supports for sun safety in swimming pools; and sun-protection habits and sunburn among children.

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                                          • Lewis, Elizabeth, J. A. Mayer, D. Slymen, G. Belch, M. Engelberg, K. Walker, H. Kwon, and J. Elder. 2005. Disseminating a sun safety program to zoological parks: The effects of tailoring. Health Psychology 24:456–462.

                                            DOI: 10.1037/0278-6133.24.5.456Save Citation »Export Citation »E-mail Citation »

                                            After previous research found that a sun-safety program for visitors at a zoo increased sun-safety behaviors, this randomized study compared the effects of tailored dissemination materials plus follow-up phone calls versus generic materials on implementation of the program at other zoos. Findings suggest that tailoring did not increase long-term implementation and that generic materials produced a good level of dissemination.

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                                            • Mayer, Joni A., E. C. Lewis, L. Eckhardt, D. Slymen, G. Belch, J. Elder, M. Engelberg, L. Eichenfield, A. Achter, T. Nichols, K. Walker, H. Kwon, M. Talosig, and C. Gearen. 2001. Promoting sun safety among zoo visitors. Preventive Medicine 33:162–169.

                                              DOI: 10.1006/pmed.2001.0875Save Citation »Export Citation »E-mail Citation »

                                              This article reports on a study to evaluate an intervention for reducing UVR exposure during zoo visits. A nonequivalent control group design was used. Intervention consisted of tip sheets, children’s activities, prompts, and discounts on sunscreen and hats. Results showed that in the summer study, sales of both sunscreen and hats increased significantly at the intervention site relative to the control site.

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                                              • Pagoto, Sherry L., D. McChargue, and R. Fuqua. 2003. Effects of a multicomponent intervention on motivation and sun protection behaviors among midwestern beachgoers. Health Psychology 22:429–433.

                                                DOI: 10.1037/0278-6133.22.4.429Save Citation »Export Citation »E-mail Citation »

                                                This study examined the impact of a multicomponent intervention to increase the saliency of skin cancer risk and promote the use of sun protection. Midwestern beachgoers (n = 100) participated in an intervention or a questionnaire-only control group. After two months, the intervention group significantly improved in sun protection use and stage of change, but not sun exposure, compared with the control group.

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                                                • Weinstock, Martin A., J. S. Rossi, C. A. Redding, and J. E. Maddock. 2002. Randomized controlled community trial of the efficacy of a multicomponent stage-matched intervention to increase sun protection among beachgoers. Preventive Medicine 35:584–592.

                                                  DOI: 10.1006/pmed.2002.1114Save Citation »Export Citation »E-mail Citation »

                                                  This article reports on a multicomponent stage-matched intervention for beachgoers and evaluation of its efficacy in a randomized trial. More than two thousand study participants were recruited on beaches in the Northeast. The intervention was effective in increasing self-reported sun-protective behaviors. Similar effects were found across gender and age groups.

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                                                  High-Risk Groups

                                                  Targeting skin cancer prevention to people at high risk may result in greater effects of preventive strategies and an efficient public health strategy. Risk factors for skin cancer include age, sun-sensitive phenotypes, excessive sun exposure, family history, personal history of skin cancer or precancerous lesions, and some other medical conditions. There is a need to develop low-cost, effective interventions to improve skin cancer prevention and early detection behaviors among a broader population of persons at moderate and high risk. Geller, et al. 2006 and Glanz, et al. 2010 describe studies that specifically target individuals at high risk, either siblings of melanoma patients or adults determined to be at moderate or high risk for skin cancer. Aspinwall, et al. 2008 focuses on a group of people who have tested positive in genetic testing for skin cancer–related mutations; this is the first study to explore this emerging approach to identifying skin cancer risk groups.

                                                  • Aspinwall, Lisa G., S. L. Leaf, E. R. Dola, W. Kohlmann, and S. A. Leachman. 2008. CDKN2A/p16 genetic test reporting improves early detection intentions and practices in high-risk melanoma families. Cancer Epidemiology Biomarkers and Prevention 17:1510–1519.

                                                    DOI: 10.1158/1055-9965.EPI-08-0010Save Citation »Export Citation »E-mail Citation »

                                                    A prospective study of melanoma genetic testing for fifty-nine members of Utah CDKN2A/p16 mutation–positive pedigrees was conducted to establish the effect of genetic test reporting on early detection intentions and behaviors (total body skin examination and skin self-examination) in a high-risk population. Participants without a melanoma history who tested positive reported greater intention to obtain total body skin examinations and adherence to skin self-examination recommendations.

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                                                    • Geller, Alan C., K. M. Emmons, D. R. Brooks, C. Powers, Z. Zhang, H. K. Koh, T. Heeren, A. J. Sober, F. Li, and B. A. Gilchrest. 2006. A randomized trial to improve early detection and prevention practices among siblings of melanoma patients. Cancer 107:806–814.

                                                      DOI: 10.1002/cncr.22050Save Citation »Export Citation »E-mail Citation »

                                                      This study tested whether an intervention could lead to improvements in the risk-reduction practices of melanoma patients’ siblings. The intervention consisted of personalized telephone counseling and individually tailored materials for siblings of recently diagnosed melanoma patients, and it was compared to “usual care.” After twelve months, intervention siblings were more likely to examine all moles, including those on the back.

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                                                      • Glanz, Karen, E. R. Schoenfeld, and A. Steffen. 2010. Randomized trial of tailored skin cancer prevention messages for adults: Project SCAPE. American Journal of Public Health 100:735–741.

                                                        DOI: 10.2105/AJPH.2008.155705Save Citation »Export Citation »E-mail Citation »

                                                        This trial evaluated the impact of a mailed, tailored intervention on skin cancer prevention and skin self-examination behaviors of adults at moderate and high risk for skin cancer. Participants from Hawaii and Long Island received either tailored materials, including personalized risk feedback, or general educational materials (control group). The tailored materials had significant effects on sun-protection habits and recent skin self-examination.

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                                                        Screening and Early Detection

                                                        Screening for skin cancer through skin exams by health care providers and skin self-examination has the potential to help detect skin cancers at an earlier stage (i.e., when they are thinner) so that they are more curable and less serious. There has not been a large randomized trial of skin screening in the United States, but an Australian trial reported by Aitken, et al. 2006 and Janda, et al. 2006 provides promising evidence of the impact of skin screening and how it can be successfully implemented. Geller, et al. 2006 shows how American scientists have advocated a national screening program. Another important study is the “Check It Out” trial to promote total skin self-examination (TSSE), and the Weinstock, et al. 2007 and Lee, et al. 2008 reports from the findings of this trial area are included here.

                                                        • Aitken, Joanne F., M. Janda, M. Elwood, P. H. Youl, I. T. Ring, and J. B. Lowe. 2006. Clinical outcomes from skin screening clinics within a community-based melanoma screening program. Journal of the American Academy of Dermatology 54:105–114.

                                                          DOI: 10.1016/j.jaad.2005.08.072Save Citation »Export Citation »E-mail Citation »

                                                          This article describes clinical outcomes of skin screening in a randomized trial in Australia. There, 16,383 whole-body skin examinations resulted in 2,302 referrals for suspected melanomas and nonmelanoma skin cancer (NMSC). The estimated specificity of whole-body skin examinations for melanoma was 86.1 percent. The sensitivity (rate of skin cancer detected per one hundred patients) screened was higher than previously reported.

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                                                          • Geller, Alan C., D. R. Miller, S. M. Swetter, M. F. Demierre, and B. A. Gilchrest. 2006. A call for the development and implementation of a targeted national melanoma screening program. Archives of Dermatology 142:504–507.

                                                            DOI: 10.1001/archderm.142.4.504Save Citation »Export Citation »E-mail Citation »

                                                            The authors advocate for and present the major interrelated components of a national proposal for melanoma screening in the United States. The essence of the strategy is that all white men who are middle age or older should have at least one full-body skin examination. It is proposed that the screening program be achieved by a multipronged approach.

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                                                            • Janda, Monika, J. B. Lowe, M. Elwood, I. T. Ring, P. H. Youl, and J. F. Aitken. 2006. Do centralised skin screening clinics increase participation in melanoma screening (Australia)? Cancer Causes and Control 17:161–168.

                                                              DOI: 10.1007/s10552-005-0419-ySave Citation »Export Citation »E-mail Citation »

                                                              This study analyzed three methods of screening delivery within a randomized community-based trial of population screening for melanoma in Australia. Methods of screening delivery were in day-to-day primary care, in dedicated skin-screening clinics, or organized centrally with participants referred back to their physicians for diagnosis and management. The centrally organized skin-screening clinics significantly increased skin-screening rates.

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                                                              • Lee, K. B., M. A. Weinstock, and P. M. Risica. 2008. Components of a successful intervention for monthly skin self-examination for early detection of melanoma: The “Check It Out” trial. Journal of the American Academy of Dermatology 58:1006–1012.

                                                                DOI: 10.1016/j.jaad.2008.03.008Save Citation »Export Citation »E-mail Citation »

                                                                This article aims to identify the most important Check It Out intervention components for promoting TSSE. Results showed that watching the video, using the hand mirror and shower card, the American Cancer Society brochure, sample photographs, and finding the health educator helpful were associated with performing TSSE at two months, twelve months, or both.

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                                                                • Weinstock, Martin A., P. M. Risica, R. A. Martin, W. Rakowski, C. Dubé, M. Berwick, M. G. Goldstein, S. Acharyya, and T. Lasater. 2007. Melanoma early detection with thorough skin self-examination: The “Check It Out” randomized trial. American Journal of Preventive Medicine 32:517–524.

                                                                  DOI: 10.1016/j.amepre.2007.02.024Save Citation »Export Citation »E-mail Citation »

                                                                  A randomized trial was conducted to determine whether a multicomponent intervention can increase TSSE performance. Participants received instructional materials, a video, a brief counseling session, a brief follow-up phone call, and tailored feedback letters. Results showed that the intervention group increased TSSE performance compared to the control group.

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                                                                  Indoor Tanning and Solaria

                                                                  For several decades, researchers have examined the potential role of indoor tanning and the use of tanning salons and tanning beds (called “solaria”) in increasing risk of skin cancer. These devices are most often used by teenagers and young adults. Also during this period, government and scientific organizations in Australia, Europe, and the United States have considered policies and laws to reduce indoor tanning and to regulate commercial providers of these sources of artificial ultraviolet radiation (UVR). Lazovich, et al. 2010 reports on a well-designed epidemiologic study of indoor tanning and melanoma. Cokkinides, et al. 2009 describes national surveys regarding the use of indoor tanning. This work is complemented by Pichon, et al. 2009 and Mayer, et al. 2008, which investigated the practices of indoor tanning facilities and enforcement of laws in the United States.

                                                                  • Cokkinides, Vilma, M. Weinstock, D. Lazovich, E. Ward, and M. Thun. 2009. Indoor tanning use among adolescents in the US, 1998 to 2004. Cancer 115:190–198.

                                                                    DOI: 10.1002/cncr.24010Save Citation »Export Citation »E-mail Citation »

                                                                    This national assessment of prevalence and trends of indoor tanning use among US adolescents from 1998 to 2004 is based on data from two surveys of youths ages eleven to eighteen years and their parents or guardians. Indoor tanning use by adolescents within the past year changed little from 1998 to 2004 (10 percent to 11 percent).

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                                                                    • Lazovich, DeAnn, R. I. Vogel, M. Berwick, M. A. Weinstock, K. E. Anderson, and E. M. Warshaw. 2010. Indoor tanning and risk of melanoma: A case-control study in a highly exposed population. Cancer Epidemiology Biomarkers and Prevention 19:1557–1568.

                                                                      DOI: 10.1158/1055-9965.EPI-09-1249Save Citation »Export Citation »E-mail Citation »

                                                                      This article reports on a population-based case-control study that examined the association of indoor tanning with melanoma risk. Results showed that among 1,167 cases and 1,101 controls, 62.9 percent of cases and 51.1 percent of controls had tanned indoors. Risk increased with use (years, hours, or sessions), regardless of age when indoor tanning began and what type of device was used.

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                                                                      • Mayer, Joni A., K. D. Hoerster, L. C. Pichon, D. A. Rubio, S. I. Woodruff, and J. L. Forster. 2008. Enforcement of state indoor tanning laws in the United States. Preventing Chronic Disease: Public Health Research, Practice, and Policy 5.4: A125.

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                                                                        This article reports on interviews with key informants in the twenty-eight states with legislation regulating indoor tanning facilities. Results showed that licensure for indoor tanning businesses was required in twenty-two of twenty-eight cities. Slightly fewer than half of the cities gave citations to tanning facilities that violated state law. The relatively low rates of annual inspections and citations are of concern.

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                                                                        • Pichon, Latrice C., J. A. Mayer, K. D. Hoerster, S. I. Woodruff, D. J. Slymen, G. E. Belch, E. J. Clapp, A. L. Hurd, J. L. Forster, and M. A. Weinstock. 2009. Youth access to artificial UV radiation exposure: Practices of 3647 US indoor tanning facilities. Archives of Dermatology 45:997–1002.

                                                                          DOI: 10.1001/archdermatol.2009.85Save Citation »Export Citation »E-mail Citation »

                                                                          This survey assessed indoor tanning facility practices in a sample of facilities in 116 US cities representing all fifty states. Data collectors posed as prospective, fair-skinned, fifteen-year-old female customers who had never tanned before. Approximately 87 percent of the facilities required parental consent, 14 percent required parental accompaniment, and 5 percent said they would not allow the confederate to tan because of her age.

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                                                                          Measurement and Methodology

                                                                          Advances in skin cancer prevention depend on good research and, ideally, on studies of different interventions that can be compared to understand the impact of various strategies. The citations chosen for this section include review and synthesis and original research and are some of the most influential works synthesizing issues in measurement and methods to study skin cancer prevention. Creech and Mayer 2000 reports that most skin cancer prevention studies used verbal reports, or self-reporting, to measure habitual sun exposure and solar protection behaviors. This finding is expanded in Glanz and Mayer 2005. Despite the well-known limitations of verbal reports of behavior, these measures are the most practical for use in both population surveillance and descriptive and intervention research. Therefore, the comparability of assessments across population-based surveys and outcome measures used in intervention research is important, and Glanz, et al. 2008 is an important step in that direction. In addition, because it is important to continue to build a research tool kit for measures other than surveys, including objective biological measures and observational measures, O’Riordan, et al. 2000 and Glanz, et al. 2009 are of particular importance to the field.

                                                                          • Creech, L. L., and J. A. Mayer. 2000. Ultraviolet radiation exposure in children: A review of measurement strategies. Annals of Behavioral Medicine 19:399–407.

                                                                            DOI: 10.1007/BF02895159Save Citation »Export Citation »E-mail Citation »

                                                                            This article reviews ultraviolet radiation (UVR) exposure measurement strategies for application with children. Strategies include verbal report (by self or parent), observation, visual inspection, UV-sensitive film, the Erythema Meter, the spectrophotometer, and the colorimeter. Strategies vary in terms of ease of use, cost, and usefulness for measuring acute and cumulative exposure. There is a need for research to assess the reliability and validity of these measures.

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                                                                            • Glanz, Karen, and J. A. Mayer. 2005. Reducing UVR exposure to prevent skin cancer: Methodology and measurement. American Journal of Preventive Medicine 29:131–142.

                                                                              DOI: 10.1016/j.amepre.2005.04.007Save Citation »Export Citation »E-mail Citation »

                                                                              This article summarizes the state of knowledge about research methodology and measurement in studies of the effectiveness of interventions to prevent skin cancer. Conclusions include the following: verbal reports are the most widely used measures of solar protection behavior; there should be more efforts to complement verbal data with objective measures; and measures of environments and policies should incorporate observations, documentation, and direct measures of ultraviolet radiation (UVR).

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                                                                              • Glanz, Karen, A. L. Yaroch, M. Dancel, M. Saraiya, L. A. Crane, D. B. Buller, S. Manne, D. L. O’Riordan, C. J. Heckman, J. Hay, and J. K. Robinson. 2008. Measures of sun exposure and sun protection practices for behavioral and epidemiologic research. Archives of Dermatology 144:217–222.

                                                                                DOI: 10.1001/archdermatol.2007.46Save Citation »Export Citation »E-mail Citation »

                                                                                This article describes a national collaborative project to develop core measures of sun exposure and sun-protection habits. Expert review and cognitive interviewing were used to develop core questionnaire items for adults, adolescents, and children. The core survey items have good clarity and applicability and can be used to track morbidity and/or mortality and to evaluate prevention programs.

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                                                                                • Glanz, Karen, F. McCarty, E. J. Nehl, D. L. O’Riordan, P. Gies, L. Bundy, A. E. Locke, and D. M. Hall. 2009. Validity of self-reported sunscreen use by parents, children, and lifeguards. American Journal of Preventive Medicine 36:63–69.

                                                                                  DOI: 10.1016/j.amepre.2008.09.012Save Citation »Export Citation »E-mail Citation »

                                                                                  This study examined the association between “sunscreen swabbing,” an objective measure of sunscreen use, and verbal self-reports of sunscreen use in 564 children and adults at four locations across the United States. Agreement between swabbing, diary, and survey measures of sunscreen use was fair to good, and no systematic errors were found by gender, latitude, or skin cancer risk category.

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                                                                                  • O’Riordan, D. L., W. R. Stanton, M. Eyeson-Annan, P. Gies, and C. Roy. 2000. Correlations between reported and measured ultraviolet radiation exposure of mothers and young children. Photochemistry and Photobiology 71:60–64.

                                                                                    DOI: 10.1562/0031-8655(2000)071<0060:CBRAMU>2.0.CO;2Save Citation »Export Citation »E-mail Citation »

                                                                                    This novel study compared ultraviolet radiation (UVR) exposure measured by polysulfone dosimeters with a measure of estimated exposure using a diary. Although the association between estimated exposure and dosimeter readings was poor, the relative UVR exposures expressed as a fraction of daily total ambient UVR received during the four-day period by young children and mothers are similar.

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