Sun Protection Is Saving Your Skin From Deadly Cancer
Overview
This study examined the link between sun protection behaviors and various demographic and melanoma risk factors among patients at Australian melanoma specialist clinics. The goal was to enhance melanoma prevention strategies through tailored patient education for high-risk and specific population groups.
A cross-sectional analysis was conducted using questionnaire data from individuals visiting dermatology clinics at two major melanoma centers in Sydney, Australia, from February 2021 to September 2023. The primary measure was the Sun Protection Habits (SPH) index, which aggregated scores from habitual use of sun protection measures over the past month, including sunscreen, hats, sunglasses, long-sleeved shirts, limiting midday sun exposure, and seeking shade, all rated on a Likert scale. The analysis focused on continuous scores of the SPH index and its components.
The analysis included data from 883 participants. Factors associated with less frequent sun protection included being male, lacking a personal history of melanoma, having a lower perceived risk, a lower calculated 10-year risk of melanoma, and not having private health insurance. Older individuals (aged over 61) reported less frequent sunscreen use but more frequent use of hats and long-sleeved shirts compared to younger participants. No significant differences in overall sun protection behaviors were found based on family history of melanoma, country of birth, or lifetime melanoma risk among those without a personal history of melanoma.
The study highlights the importance of targeting high-risk individuals who engage in infrequent sun protection. These insights can inform patient education, public health messaging, and strategies to enhance sun protection behaviors, aiming to reduce melanoma risk and improve preventive practices.
Introduction
Skin cancer is a major global health issue, with Australia and New Zealand exhibiting the highest rates of incidence. In Australia, the risk of developing at least one keratinocyte cancer, which includes basal cell carcinoma and squamous cell carcinoma, is significant, with two-thirds of the population affected at some point in their lives. Melanoma, a more serious form of skin cancer, ranks as the third most common cancer in the country. Although the advancements in treatment over the past decade have reduced the mortality risk associated with melanoma, the overall likelihood of diagnosis continues to rise. This increase is especially notable among older individuals.
The primary prevention of skin cancer is crucial due to its high preventability. Effective sun protection is essential in reducing ultraviolet (UV) radiation damage, which is a major risk factor for skin cancer. Regular use of sunscreen, alongside other protective measures such as wearing hats and seeking shade, has been demonstrated to decrease the incidence of melanoma and other skin cancers. This makes sun protection a key public health message.
For individuals who have already been diagnosed with skin cancer, maintaining rigorous sun protection practices is equally important. Research indicates that insufficient use of sunscreen among these individuals can double the risk of developing a new primary melanoma. Despite this, studies show that people, regardless of whether they have a history of melanoma, often engage in suboptimal sun protection practices and experience sunburn.
Tailoring patient education to individual skin cancer risk is a recent recommendation by the US Preventive Services Task Force. However, there remains a gap in understanding the factors influencing engagement in primary prevention activities. Behavior change theory suggests that interventions tailored to address specific personal barriers and enablers are more likely to be effective in promoting preventive behaviors.
The aim of this study is to investigate the associations between demographic and risk characteristics and sun protection behaviors. By understanding these associations, the study seeks to improve the targeting of behavioral counseling. This approach will help identify and support individuals who may not engage in frequent sun protection, ultimately enhancing primary prevention efforts and reducing skin cancer incidence.
Method
The Tailored Surveillance Project, running from February 2021 to July 2023, aimed to evaluate the effectiveness of personalized melanoma risk assessments and tailored patient education and skin surveillance in dermatology clinics. Data were collected from patients in the waiting rooms of two prominent melanoma centers in Sydney, Australia: Royal Prince Alfred Hospital and The Melanoma Institute Australia.
The study included 883 participants aged 18 years or older, encompassing individuals with and without a personal history of melanoma. Participants completed an electronic questionnaire administered via iPad, which gathered detailed information on demographics, melanoma risk factors, and sun protection behaviors.
The questionnaire featured a validated section assessing sun protection behaviors over the past month. Participants rated their frequency of engaging in specific protective actions—such as using sunscreen, wearing a protective shirt, using a hat, staying in the shade, wearing sunglasses, and limiting sun exposure during peak hours—on a Likert scale from 1 (never or rarely) to 4 (always). A mean score, termed the Sun Protection Habits (SPH) summary index, was calculated to represent overall sun protection practices.
Additionally, participants’ melanoma risk was estimated using two validated online prediction tools tailored to individuals with and without a history of melanoma. Based on their risk assessment, participants received personalized feedback during their consultation, including information on their specific melanoma risk, a customized surveillance program, and educational resources on melanoma prevention, early detection, and skin self-examination.
The study adhered to ethical guidelines approved by the Sydney Local Health District Ethics Review Committee, with protocols X15-0311, HREC/10/RPAH/530, and X18-0426, HREC/18/RPAH/606.
Statistical Analysis
Statistical analysis involved descriptive statistics to outline participant characteristics. The primary outcome, the SPH mean score, was analyzed in relation to participant characteristics using t-tests for comparisons between two groups and one-way ANOVA for comparisons involving three or more groups. The secondary outcomes, reflecting the six individual sun protection behaviors, were also analyzed using continuous score methods. To assess robustness, a sensitivity analysis was conducted by categorizing the individual behaviors and comparing them across participant subgroups using chi-squared tests.
Data quality was maintained through real-time review by clinical or research staff, resulting in minimal missing data (<2%). Statistical analyses were performed using SAS 9.4, ensuring comprehensive evaluation and accuracy of the findings.
Result
The study assessed the sun protection behaviors of 883 participants, with women constituting 58% and a mean age of 59 years. Most participants (73%) had a history of melanoma. The analysis of factors influencing sun protection habits, summarized using the Sun Protection Habits (SPH) index, revealed several key findings.
Overall, individuals with less frequent sun protection behaviors had lower SPH scores. Factors associated with lower SPH scores included being male (mean score 3.0 vs. 3.2 for females, p < 0.0001), having no previous melanoma (mean score 3.0 vs. 3.2 for those with melanoma history, p < 0.0001), lower 10-year melanoma risk, lower self-perceived melanoma risk (mean score 3.1 vs. 3.2 for higher risk, p = 0.027), and lacking private health insurance (mean score 3.0 vs. 3.1 for insured individuals, p = 0.049).
Men exhibited less frequent sun protection behaviors compared to women, using sunscreen less (mean score 2.8 vs. 3.2, p < 0.0001), seeking shade less (mean score 2.6 vs. 2.9, p < 0.0001), limiting midday sun exposure less (mean score 2.9 vs. 3.3, p < 0.0001), and wearing sunglasses less (mean score 3.0 vs. 3.3, p < 0.0001). However, men were more likely to wear a shirt with sleeves (mean score 3.5 vs. 3.4, p < 0.005) and a hat (mean score 3.3 vs. 3.0, p < 0.0001).
Older individuals were less likely to use sunscreen compared to younger participants (mean score 2.8 vs. 3.1, p < 0.0001), while younger individuals were less likely to wear a shirt with sleeves (mean score 3.4 vs. 3.5, p = 0.0005) or a hat (mean score 3.0 vs. 3.3, p = 0.0001).
Participants with a history of melanoma were more consistent in wearing sunscreen (mean score 2.8 vs. 3.1, p = 0.0001), shirts with sleeves (mean score 3.5 vs. 3.3, p = 0.001), hats (mean score 3.2 vs. 2.9, p < 0.0001), sunglasses (mean score 3.2 vs. 3.1, p = 0.01), and limiting midday sun exposure (mean score 3.2 vs. 3.1, p = 0.04) compared to those without a melanoma history. A family history of melanoma was associated with increased sunscreen use (mean score 3.1 vs. 2.9, p = 0.05).
The calculated lifetime melanoma risk did not significantly impact sun protection behaviors among those without a personal melanoma history. However, higher 10-year melanoma risk was associated with more frequent use of shirts with sleeves (mean score 3.5 vs. 3.4, p = 0.002), hats (mean score 3.3 vs. 3.0, p < 0.0001), and seeking shade (mean score 2.9 vs. 2.7, p = 0.009), though not for sunscreen or sunglasses. This association with 10-year risk was significant only among those without a history of melanoma (p-interaction 0.04).
Individuals with lower self-perceived risk were less likely to use sunscreen (mean score 2.9 vs. 3.1, p = 0.0009) or wear a hat (mean score 3.1 vs. 3.2, p = 0.024). A moderate correlation was found between calculated and perceived risk (Pearson’s r = 0.32).
Those without private health insurance were less likely to wear sunglasses or a hat. No significant associations were found between sun protection behaviors and whether participants were born in Australia.
Sensitivity analyses of sun protection behaviors as categorical variables corroborated these findings across various factors including gender, age, melanoma history, family history, lifetime and 10-year melanoma risk, self-perceived risk, private health insurance, and Australian birth.
Conclusion
The study reveals that sun protection behaviors vary based on demographic factors, personal and family history of melanoma, and levels of perceived and calculated risk. Although the differences in sun protection behaviors by demographic factors such as gender and age appear modest statistically, they may have significant clinical and public health implications when viewed at a population level.
Consistent with previous research, women engage more frequently in sun protection practices compared to men, except for wearing hats and shirts, which may be influenced by gendered occupational roles and fashion norms. Older individuals tend to use hats and shirts more often, whereas younger people are more inclined to use sunscreen. Contrary to expectations, individuals with a family history of melanoma did not show significant differences in sun protection behaviors compared to those without such a history. This contrasts with past studies that found increased sunscreen use among those with a family history of melanoma but not necessarily an increase in other sun protection measures.
A personal history of melanoma, however, was strongly linked to more frequent use of various sun protection strategies. This is likely due to heightened awareness and increased education about sun protection following a melanoma diagnosis. Evidence suggests that sun protection behaviors improve significantly within the first six months after diagnosis, emphasizing the critical role of patient education during this period.
For those without a personal history of melanoma, high lifetime melanoma risk did not significantly influence sun protection behaviors, but a higher 10-year risk was associated with more frequent sun protection. This suggests that immediate risk may be more relevant for influencing behaviors, though further qualitative research is needed to clarify this relationship. Younger individuals with many risk factors for melanoma might benefit from targeted sun protection interventions due to their high lifetime risk but lower 10-year risk.
The study also found that those who perceived themselves at higher risk were more likely to wear hats and sunscreen. However, the moderate correlation between perceived and calculated risk underscores the need for better communication regarding risk levels. Additionally, individuals with private health insurance—possibly reflecting higher education, health literacy, or socioeconomic status—demonstrated more frequent sun protection behaviors, such as wearing sunglasses and hats.
This study aligns with an international review that identified factors such as male gender and lower perceived risk as related to lower levels of sun protection. The review also highlighted the importance of sun-sensitive phenotypes, perceived benefits of sun protection, and doctor recommendations.
The study’s strengths include a large sample size and comprehensive data on demographics and risk factors. Limitations include reliance on self-reported data, which may be subject to recall and social desirability biases, and the sample’s lack of generalizability due to the focus on participants from dermatology clinics, many of whom had a prior melanoma diagnosis.
In conclusion, this study identifies specific subgroups within a high-risk population that engage less frequently in sun protection behaviors. These insights can guide targeted education on skin cancer prevention, with recommendations for health professionals to use online risk assessment tools to personalize risk communication and prevention advice based on individual demographic and risk characteristics.
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