Development and reliability of a brief skin cancer risk assessment tool

Development of an Internet Intervention to Address Behaviors Associated with Skin Cancer Risk among Young Adults

PURPOSE

Skin cancer is the most common cancer in the US, and its incidence is increasing. The major risk factor for skin cancer is exposure to ultraviolet radiation (UV). Young adults tend to expose themselves to large amounts of UV and engage in minimal skin protection, which increases their skin cancer risk. Interventions are needed to address risk behaviors among young adults that may lead to skin cancer. The nternet offers a cost-effective way to widely disseminate efficacious interventions. The current paper describes the development of an online skin cancer risk reduction intervention (UV4.me) for young adults.

PROCEDURES

The iterative development process for UV4.me followed best-practice guidelines and included the following activities: individual interviews, focus groups, content development by the expert team, acceptability testing, cognitive interviewing for questionnaires, quality control testing, usability testing, and a pilot randomized controlled trial. Participant acceptability and usability feedback was assessed.

PRINCIPAL RESULTS

The development process produced an evidence-informed intervention that is individually-tailored, interactive, and multimedia in nature based on the Integrative Model of Behavior Prediction, a model for internet interventions, and other best-practice recommendations, expert input, as well as user acceptability and usability feedback gathered before, during, and after development.

MAJOR CONCLUSIONS

Development of an acceptable intervention intended to have a significant public health impact requires a relatively large investment in time, money, expertise, and ongoing user input. Lessons learned and recommendations are discussed. The comprehensive process used may help prepare others interested in creating similar behavioral health interventions.

Reproducibility of self-reported melanoma risk factors in melanoma patients

As melanoma researchers continue to investigate environmental and lifestyle-related risk factors, questionnaire data remain important. The reproducibility of a questionnaire on melanoma risk factors was investigated using a test-retest approach in 389 Dutch melanoma patients. In 2011, 389 melanoma patients filled out a questionnaire on melanoma risk factors twice. Test-retest reproducibility was assessed by calculating kappas (κ), weighted kappas (κw), and intraclass correlation coefficients (ICCs) for categorical, ordinal, and continuous variables, respectively. Stratified analyses were carried out by sex, age group, education level, and time since diagnosis. The median time between the questionnaires was 31 days. The reproducibility was substantial for questions on phenotypic characteristics (κ/κw/ICC=0.62-0.77), fair-to-substantial for sun exposure and sun protection behavior (κ/κw/ICC=0.38-0.79), and moderate for sunburn history (κ/κw=0.42-0.51). No clear differences were observed between men and women. Younger patients showed a better reproducibility in nine of the 29 questions compared with older patients and higher educated patients showed a better reproducibility in four of the 29 questions. Patients with a diagnosis shorter than 1.5 years ago had a better reproducibility in four out of 29 items compared with patients with a diagnosis 1.5-3.0 years ago. Our study showed that self-reported information on melanoma risk factors is fairly well reproducible. Although this does not guarantee validity, this type of questionnaire seems to be useful in research settings. The reproducibility is slightly better in young patients and patients with a higher education level, which can be taken into account when interpreting results from epidemiological studies.

Randomized Trial of Two Dissemination Strategies for a Skin Cancer Prevention Program in Aquatic Settings

OBJECTIVES

We compared 2 strategies for disseminating an evidence-based skin cancer prevention program.

METHODS

We evaluated the effects of 2 strategies (basic vs enhanced) for dissemination of the Pool Cool skin cancer prevention program in outdoor swimming pools on (1) program implementation, maintenance, and sustainability and (2) improvements in organizational and environmental supports for sun protection. The trial used a cluster-randomized design with pools as the unit of intervention and outcome. The enhanced group received extra incentives, reinforcement, feedback, and skill-building guidance. Surveys were collected in successive years (2003-2006) from managers of 435 pools in 33 metropolitan areas across the United States participating in the Pool Cool Diffusion Trial.

RESULTS

Both treatment groups improved their implementation of the program, but pools in the enhanced condition had significantly greater overall maintenance of the program over 3 summers of participation. Furthermore, pools in the enhanced condition established and maintained significantly greater sun-safety policies and supportive environments over time.

CONCLUSIONS

This study found that more intensive, theory-driven dissemination strategies can significantly enhance program implementation and maintenance of health-promoting environmental and policy changes. Future research is warranted through longitudinal follow-up to examine sustainability.

Effects of tailored risk communications for skin cancer prevention and detection: the PennSCAPE randomized trial

BACKGROUND

Prevention and early detection measures for melanoma, such as sun avoidance and skin examinations, are important, but are practiced inconsistently. In this replication of the Project SCAPE trial, we sought to determine whether tailored print materials were more effective at improving adherence than generic print materials for patients at increased risk of skin cancer.

METHODS

Participants were randomized to receive personalized mailed communications about their skin cancer risk and recommended sun protection, or generic mailings. Participants were Caucasian adults, at moderate or high risk for skin cancer, recruited in outpatient primary care. The main outcomes were overall sun protection behaviors and specific protective behaviors including use of sunscreen, shirt, hat, sunglasses, shade, and sun avoidance; recent sunburns; and skin self-examination and provider skin examination.

RESULTS

One hundred ninety-two (93.2%) subjects completed the study. Six outcome variables showed significant intervention condition effects in mixed effects models: overall sun protection behavior (P = 0.025); sunscreen use (P = 0.026); use of sunglasses (P = 0.011); sunburns in the past three months (P = 0.033); recency of last skin self-exam (P = 0.017); and frequency of skin exams by health care provider (P = 0.016).

CONCLUSIONS

Relative to generic communications, tailored risk communications resulted in improved adherence to six skin cancer protective behaviors, including a composite sun protection behavior measure, sunburns, and health care provider skin examinations.

IMPACT

Tailored interventions can be more effective in improving patient prevention behaviors than nontailored, generic information for patients at moderate to high risk of skin cancer.

Feasibility of a GP delivered skin cancer prevention intervention in Australia

Background

Despite years of public education, sun-related behaviours are difficult to change and a recent survey showed low levels of sun protection. In this study we evaluated the feasibility and acceptability of an opportunistic skin cancer prevention intervention in general practice.

Methods

We used a controlled pre-and-post intervention design. Participants (n = 100) were recruited sequentially from patients attending two general practices in Sydney, Australia, from November to December 2010. Participants in the intervention practice (n = 50) received general practitioner delivered sun protection advice after completing a skin cancer risk assessment tool, and a sun protection pamphlet, in addition to routine care, at a single attendance. The skin cancer risk assessment tool provided three levels of risk. The general practitioner (GP) reinforced the level of risk and discussed sun protection. Participants in the control practice (n = 50) received routine care. We measured feasibility by patients’ and GPs’ participation in the intervention and time taken, and acceptability by intervention participants and GPs ratings of the intervention. We measured reported sun-related knowledge, attitudes and behaviour between the two groups at 1 and 13 months.

Results

The intervention was found to be feasible within existing primary care team arrangements. Participation at baseline was 81% (108/134), and repeated participation was 88% (88/100) at 1 month and 70% (70/100) at 13 months. Participants and practitioners found the intervention acceptable. At 1 month, sun-related knowledge had increased in both patient groups, with a greater increase in the intervention group (adjusted mean difference 0.48, p = 0.034). There were no differences between groups in sun-related knowledge, attitudes and behaviour at 13 months.

Conclusions

A brief opportunistic skin cancer prevention intervention in general practice is feasible and acceptable. Further research in this setting with a more intensive intervention would be justified.

Middle-aged adults facing skin cancer information: fixation, mood, and behavior

Older adults fixate less on negative parts of skin cancer videos than younger adults, leading them to feel better (Isaacowitz & Choi, 2012). We extended this paradigm to middle-aged adults (ages 35-59, n = 63), whose fixation patterns were measured as they viewed skin cancer videos; mood and behavior were also assessed. Middle-aged adults looked even less at the videos than the other age groups, especially at the negative clips. They also reported the best moods but relatively low levels of learning and positive skin cancer behavior. In some cases, middle-aged adults may show larger "age-related positivity effects" than older adults.

Risk prediction models for melanoma: a systematic review

Melanoma incidence is increasing rapidly worldwide among white-skinned populations. Earlier diagnosis is the principal factor that can improve prognosis. Defining high-risk populations using risk prediction models may help targeted screening and early detection approaches. In this systematic review, we searched Medline, EMBASE, and the Cochrane Library for primary research studies reporting or validating models to predict risk of developing cutaneous melanoma. A total of 4,141 articles were identified from the literature search and six through citation searching. Twenty-five risk models were included. Between them, the models considered 144 possible risk factors, including 18 measures of number of nevi and 26 of sun/UV exposure. Those most frequently included in final risk models were number of nevi, presence of freckles, history of sunburn, hair color, and skin color. Despite the different factors included and different cutoff values for sensitivity and specificity, almost all models yielded sensitivities and specificities that fit along a summary ROC with area under the ROC (AUROC) of 0.755, suggesting that most models had similar discrimination. Only two models have been validated in separate populations and both also showed good discrimination with AUROC values of 0.79 (0.70-0.86) and 0.70 (0.64-0.77). Further research should focus on validating existing models rather than developing new ones.

Association between melanocytic nevi and risk of breast diseases: The French E3N prospective cohort

BACKGROUND

While melanocytic nevi have been associated with genetic factors and childhood sun exposure, several observations also suggest a potential hormonal influence on nevi. To test the hypothesis that nevi are associated with breast tumor risk, we explored the relationships between number of nevi and benign and malignant breast disease risk.

METHODS AND FINDINGS

We prospectively analyzed data from E3N, a cohort of French women aged 40-65 y at inclusion in 1990. Number of nevi was collected at inclusion. Hazard ratios (HRs) for breast cancer and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression models. Associations of number of nevi with personal history of benign breast disease (BBD) and family history of breast cancer were estimated using logistic regression. Over the period 15 June 1990-15 June 2008, 5,956 incident breast cancer cases (including 5,245 invasive tumors) were ascertained among 89,902 women. In models adjusted for age, education, and known breast cancer risk factors, women with "very many" nevi had a significantly higher breast cancer risk (HR = 1.13, 95% CI = 1.01-1.27 versus "none"; ptrend = 0.04), although significance was lost after adjustment for personal history of BBD or family history of breast cancer. The 10-y absolute risk of invasive breast cancer increased from 3,749 per 100,000 women without nevi to 4,124 (95% CI = 3,674-4,649) per 100,000 women with "very many" nevi. The association was restricted to premenopausal women (HR = 1.40, ptrend = 0.01), even after full adjustment (HR = 1.34, ptrend = 0.03; phomogeneity = 0.04), but did not differ according to breast cancer type or hormone receptor status. In addition, we observed significantly positive dose-response relationships between number of nevi and history of biopsy-confirmed BBD (n = 5,169; ptrend<0.0001) and family history of breast cancer in first-degree relatives (n = 7,472; ptrend = 0.0003). The main limitations of our study include self-report of number of nevi using a qualitative scale, and self-reported history of biopsied BBD.

CONCLUSIONS

Our findings suggest associations between number of nevi and the risk of premenopausal breast cancer, BBD, and family history of breast cancer. More research is warranted to elucidate these relationships and to understand their underlying mechanisms.

Skin cancer: increasing awareness and screening in primary care

Skin cancer screening (SCS) promotes early detection and improves treatment. Primary care providers are strategically positioned to provide screenings, yet the frequency is low. Strategies to improve SCS include increasing skin cancer awareness, targeting high-risk patient populations, and advocating for primary care providers to conduct screenings.

Pigmentary traits, family history of melanoma and the risk of endometriosis: a cohort study of US women

BACKGROUND

Endometriosis has been associated with a higher risk of cutaneous melanoma, but the mechanisms underlying this association are unknown.Some constitutional factors known to influence melanoma risk have been associated with endometriosis in some retrospective studies. However, prospective data are scarce, and more research is needed to confirm this potentially novel endometriosis risk profile.

METHODS

To investigate the relationships between pigmentary traits, family history of melanoma and endometriosis risk, we analysed data from the Nurses’ Health Study II, a cohort of 116 430 female US nurses aged 25–42 years at inclusion in 1989. Data were collected every 2 years with 20 years of follow-up for these analyses. We used Cox proportional hazards regression models to compute relative risks(RRs) and 95% confidence intervals (CIs).

RESULTS

During 1 212 499 woman-years of follow-up, 4763 cases of laparoscopically-confirmed endometriosis were reported among premenopausal Caucasian women. Endometriosis risk was increased with presence of naevi on the lower legs (RR=1.08, 95% CI=1.021.14) and higher level of skin’s burning reaction to sun exposure in childhood/adolescence (‘burn with blisters’: RR=1.20,95% CI=1.061.36) compared with ‘practically none’;P(trend)=0.0006) and family history of melanoma (RR=1.13, 95%CI=1.011.26).

CONCLUSION

This assessment reports modest associations between several pigmentary traits, family history of melanoma and endometriosis risk,corroborating the results from previous retrospective studies. Our findings call for further research to better understand the mechanisms under lying these associations.

Skin self-examinations and visual identification of atypical nevi: comparing individual and crowdsourcing approaches

PURPOSE

Skin self-examination (SSE) is one method for identifying atypical nevi among members of the general public. Unfortunately, past research has shown that SSE has low sensitivity in detecting atypical nevi. The current study investigates whether crowdsourcing (collective effort) can improve SSE identification accuracy. Collective effort is potentially useful for improving people's visual identification of atypical nevi during SSE because, even when a single person has low reliability at a task, the pattern of the group can overcome the limitations of each individual.

METHODS

Adults (N=500) were recruited from a shopping mall in the Midwest. Participants viewed educational pamphlets about SSE and then completed a mole identification task. For the task, participants were asked to circle mole images that appeared atypical. Forty nevi images were provided; nine of the images were of nevi that were later diagnosed as melanoma.

RESULTS

Consistent with past research, individual effort exhibited modest sensitivity (.58) for identifying atypical nevi in the mole identification task. As predicted, collective effort overcame the limitations of individual effort. Specifically, a 19% collective effort identification threshold exhibited superior sensitivity (.90).

CONCLUSIONS

The results of the current study suggest that limitations of SSE can be countered by collective effort, a finding that supports the pursuit of interventions promoting early melanoma detection that contain crowdsourced visual identification components.

Linguistic acculturation and skin cancer-related behaviors among Hispanics in the southern and western United States

OBJECTIVE

To examine the association between linguistic acculturation (assessed using the Language Use and Linguistic Preference subscales from the Bidimensional Acculturation Scale for Hispanics) and skin cancer-related behaviors among US Hispanic adults to determine whether, compared with Hispanics denoted as Spanish-acculturated, English-acculturated Hispanics would report less frequent shade seeking and use of sun protective clothing and higher rates of sunscreen use, sunbathing, and indoor tanning.

DESIGN

Online survey study conducted in September 2011.

SETTING

Five southern and western US states.

PARTICIPANTS

A population-based sample of 788 Hispanic adults drawn from a nationally representative web panel.

MAIN OUTCOME MEASURES

Self-reported sunscreen use, shade seeking, use of sun protective clothing, sunbathing, and indoor tanning.

RESULTS

Multivariate regression analyses were conducted to examine predictors of the skin cancer-related behaviors. As hypothesized, English-acculturated Hispanics had lower rates of shade seeking and use of sun protective clothing and reported higher rates of sunbathing and indoor tanning than Spanish-acculturated Hispanics. English-acculturated Hispanics and bicultural Hispanics (ie, those with high Spanish and high English acculturation) reported comparably high rates of sunbathing and indoor tanning. Results suggested that bicultural Hispanics seek shade and wear sun protective clothing less often than Spanish-acculturated Hispanics but more often than English-acculturated Hispanics. Acculturation was not associated with sunscreen use.

CONCLUSIONS

Hispanic adults do not routinely engage in behaviors that reduce their risk of skin cancer. Bicultural and English-acculturated Hispanics are particularly in need of skin cancer prevention interventions.

Melanoma genetic testing, counseling, and adherence to skin cancer prevention and detection behaviors

BACKGROUND

Little is known about the impact of knowledge of CDKN2A and MC1R genotype on melanoma prevention behaviors like sun avoidance and skin examination in the context of familial melanoma.

METHODS

Seventy-three adults with a family history of melanoma were randomly assigned to be offered individualized CDKN2A and MC1R genotyping results in the context of a genetic counseling session, or the standard practice of not being offered counseling or disclosure of genotyping results. Mixed effects or longitudinal logistic models were used to determine whether the intervention affected change in sun protection habits, skin examinations, and perception and beliefs related to melanoma risk, prevention, and genetic counseling.

RESULTS

All participants in the intervention group who attended genetic counseling sessions chose to receive their test results. From baseline to follow-up, participants in the intervention group reported an increase in the frequency of skin self-examinations compared with a slight decrease in the control group (P = 0.002). Participants in the intervention group reported a smaller decrease in frequency of wearing a shirt with long sleeves than did participants in the control group (P = 0.047). No effect of the intervention was noted for other outcomes.

CONCLUSIONS

Feedback of CDKN2A and MC1R genotype among families without known pathogenic CDKN2A mutations does not seem to decrease sun protection behaviors.

IMPACT

While disclosure of CDKN2A and MC1R genotype did not have negative effects on prevention, the benefits of communicating this information remain unclear. The small number of families who tested positive for CDKN2A mutations in this study is a limitation.

Identifying Persons at Highest Risk of Melanoma Using Self-Assessed Risk Factors

OBJECTIVE: To develop a self-assessed melanoma risk score to identify high-risk persons for screening METHODS: We used data from a 1997 melanoma case-control study from Washington State, USA, where 386 cases with invasive cutaneous melanoma and 727 controls were interviewed by telephone. A logistic regression prediction model was developed on 75% of the data and validated in the remaining 25% by calculating the area under the receiver operating characteristic curve (AUC), a measure of predictive accuracy from 0.5-1 (higher scores indicating better prediction). A risk score was calculated for each individual, and sensitivities for various risk cutoffs were calculated. RESULTS: The final model included sex, age, hair color, density of freckles, number of severe sunburns in childhood and adolescence, number of raised moles on the arms, and history of non-melanoma skin cancer. The area under the receiver operating characteristic curve(AUC) was 0.70 (95% CI: 0.64, 0.77). The top 15% risk group included 50% of melanomas (sensitivity 50%). CONCLUSIONS: This self-assessed score could be used as part of a comprehensive melanoma screening and public education program to identify high-risk individuals in the general population. This study suggests it may be possible to capture a large proportion of melanomas by screening a small high-risk group. Further study is needed to determine the costs, feasibility, and risks of this approach.

Skin cancer surveillance behaviors among US Hispanic adults

BACKGROUND

Little skin cancer prevention research has focused on the US Hispanic population.

OBJECTIVE

This study examined the prevalence and correlates of skin cancer surveillance behaviors among Hispanic adults.

METHODS

A population-based sample of 788 Hispanic adults residing in 5 southern and western states completed an online survey in English or Spanish in September 2011. The outcomes were ever having conducted a skin self-examination (SSE) and having received a total cutaneous examination (TCE) from a health professional. The correlates included sociodemographic, skin cancer-related, and psychosocial factors.

RESULTS

The rates of ever conducting a SSE or having a TCE were 17.6% and 9.2%, respectively. Based on the results of multivariable logistic regressions, factors associated with ever conducting a SSE included older age, English linguistic acculturation, a greater number of melanoma risk factors, more frequent sunscreen use, sunbathing, job-related sun exposure, higher perceived skin cancer risk, physician recommendation, more SSE benefits, and fewer SSE barriers. Factors associated with ever having a TCE were older age, English linguistic acculturation, a greater number of melanoma risk factors, ever having tanned indoors, greater skin cancer knowledge, higher perceived skin cancer severity, lower skin cancer worry, physician recommendation, more TCE benefits, and fewer SSE barriers.

LIMITATIONS

The cross-sectional design limits conclusions regarding the causal nature of observed associations.

CONCLUSIONS

Few Hispanic adults engage in skin cancer surveillance behaviors. The study highlights Hispanic subpopulations that are least likely to engage in skin cancer surveillance behaviors and informs the development of culturally appropriate interventions to promote these behaviors.

Mailed intervention to promote sun protection of children: a randomized controlled trial

BACKGROUND

Sun exposure, especially during childhood, is the most important preventable risk factor for skin cancer, yet few effective interventions to reduce exposure exist.

PURPOSE

To test the effectiveness of a partially tailored mailed intervention based on the Precaution Adoption Process Model, delivered in the spring over 3 years to parents and children.

DESIGN

RCT, with data collection through telephone interviews of parents and skin exams of children at baseline (Summer 2004) and annually (Summer 2005-2007). The control group received no intervention.

SETTING/PARTICIPANTS

Families recruited in the Denver CO area, through private pediatric clinics, a large MCO, and community settings. Children born in 1998 were approximately 6 years of age at baseline; 867 children met inclusion criteria; analysis is reported for 677 white, non-Hispanic participants at highest risk for skin cancer.

MAIN OUTCOME MEASURES

Primary outcomes were parent-reported child sun protection behaviors. Secondary outcomes included parents' risk perception, perceived effectiveness of and barriers to prevention behaviors, stage of change, reported sunburns, and observed tanning and nevus development. The longitudinal mixed-model analysis was conducted between 2008 and 2011.

RESULTS

The intervention group reported more use of sunscreen, protective clothing, hats, shade-seeking, and midday sun avoidance; fewer sunburns; more awareness of the risk of skin cancer; higher perceived effectiveness of sun protection; higher stage of change; and lower perception of barriers to sun protection (all p<0.05). The intervention group had fewer nevi ≥2 mm in 1 year of the study, 2006 (p=0.03). No differences were found in tanning or nevi <2 mm.

CONCLUSIONS

The level of behavior change associated with this single-modality intervention is not likely sufficient to reduce skin cancer risk. However, the intervention shows promise for inclusion in longer-term, multicomponent interventions that have sufficient intensity to affect skin cancer incidence.

Interpretation of melanoma risk feedback in first-degree relatives of melanoma patients

Little is known about how individuals might interpret brief genetic risk feedback. We examined interpretation and behavioral intentions (sun protection, skin screening) in melanoma first-degree relatives (FDRs) after exposure to brief prototypic melanoma risk feedback. Using a 3 by 2 experimental pre-post design where feedback type (high-risk mutation, gene environment, and nongenetic) and risk level (positive versus negative findings) were systematically varied, 139 melanoma FDRs were randomized to receive one of the six scenarios. All scenarios included an explicit reminder that melanoma family history increased their risk regardless of their feedback. The findings indicate main effects by risk level but not feedback type; positive findings led to heightened anticipated melanoma risk perceptions and anticipated behavioral intentions. Yet those who received negative findings often discounted their family melanoma history. As such, 25%, 30%, and 32% of those who received negative mutation, gene-environment, and nongenetic feedback, respectively, reported that their risk was similar to the general population. Given the frequency with which those who pursue genetic testing may receive negative feedback, attention is needed to identify ideal strategies to present negative genetic findings in contexts such as direct to consumer channels where extensive genetic counseling is not required.

Vitamin D beliefs and associations with sunburns, sun exposure, and sun protection

The main objective of this study was to examine certain beliefs about vitamin D and associations with sun exposure, sun protection behaviors, and sunburns. A total of 3,922 lifeguards, pool managers, and parents completed a survey in 2006 about beliefs regarding vitamin D and sun-related behaviors. Multivariate ordinal regression analyses and linear regression analysis were used to examine associations of beliefs and other variables. Results revealed that Non-Caucasian lifeguards and pool managers were less likely to agree that they needed to go out in the sun to get enough vitamin D. Lifeguards and parents who were non-Caucasian were less likely to report that sunlight helped the body to produce vitamin D. A stronger belief about the need to go out in the sun to get enough vitamin D predicted more sun exposure for lifeguards. For parents, a stronger belief that they can get enough vitamin D from foods predicted greater sun protection and a stronger belief that sunlight helps the body produce vitamin D predicted lower sun exposure. This study provides information regarding vitamin D beliefs and their association with certain sun related behaviors across different demographic groups that can inform education efforts about vitamin D and sun protection.

The Sun Exposure and Behaviour Inventory (SEBI): validation of an instrument to assess sun exposure and sun protective practices

BACKGROUND

Skin cancer is the most common cancer worldwide. Sun exposure is the most important risk factor for its development. The amount of exposure required to cause skin cancer has not been quantified, and the impact of sun protective practices is unknown.

OBJECTIVES

To develop a brief self-administered questionnaire to estimate past and current sun exposure, sun protective practices, and assess the questionnaire's reliability and validity.

METHODS

The study had three stages: (1) questionnaire formulation, (2) internal reliability and construct validity testing and questionnaire refinement, (3) test-retest and further internal reliability testing. The final Sun Exposure and Behaviour Inventory (SEBI) is composed of 15 questions assessing three domains; current sun behaviour, current sun exposure and prior sun exposure.

RESULTS

A total of 251 subjects completed Stage 2 testing and 57 completed Stage 3. Final Cronbach's α-scores ranged from 0.71 to 0.84 and k-scores demonstrated excellent to fair/good agreement, indicating acceptable internal consistency and test-retest reliability. Construct validity was evidenced by significantly higher prior sun exposure scores and lower current sun behaviour scores in subjects with a history of non-melanoma skin cancer.

LIMITATIONS

Self-reported questionnaires, though efficient and low cost, may be subject to recall error and bias. Further work remains to determine if the SEBI maintains its reliability and validity in different populations.

CONCLUSION

The SEBI is a brief self-administered questionnaire, which appears to be reliable and valid. It may provide useful measures of past and present sun exposure and current sun behaviour, which may be useful in studies of skin cancer incidence and risk modification.

Looking, feeling, and doing: are there age differences in attention, mood, and behavioral responses to skin cancer information?

OVERVIEW

Previous studies on aging and attention to emotional information found that older adults may look away from negative stimuli to regulate their moods. However, it is an open question whether older adults' tendency to look less at negative material comes at the expense of learning when negative information is also health-relevant. This study investigated how age-related changes in attention to negative but relevant information about skin cancer risk reduction influenced both subsequent health behavior and mood regulation.

METHODS

Younger (18-25 years of age, n = 78) and older (60-92 years of age, n = 77) adults' fixations toward videos containing negatively valenced content and risk-reduction information about skin cancer were recorded with eye-tracking. Self-reported mood ratings were measured throughout. Behavioral outcome measures (e.g., answering knowledge questions about skin cancer, choosing a sunscreen, completing a skin self-exam) assessed participants' learning of key health-relevant information, their interest in seeking additional information, and their engagement in protective behaviors.

RESULTS

Older adults generally looked less at the negative video content, more rapidly regulated their moods, and learned fewer facts about skin cancer; yet, they engaged in a greater number of protective behaviors than did younger adults.

CONCLUSIONS

Older adults may demonstrate an efficient looking strategy that extracts important information without disrupting their moods, and they may compensate for less learning by engaging in a greater number of protective behaviors. Younger adults may be distracted by disruptions to their mood, constraining their engagement in protective behaviors.

Changes in sunburn and tanning attitudes among lifeguards over a summer season

BACKGROUND

Skin cancer is one of the most common cancers in the United States. Lifeguards are at increased risk of excessive sun exposure and sunburn.

OBJECTIVES

We sought to examine changes in: (1) sunburn frequency over a summer while controlling for sun exposure, sun protection habits, and participation in a skin cancer prevention program; and (2) tanning attitudes while controlling for participation in the program.

METHODS

Participants in this study were lifeguards (n = 3014) at swimming pools participating in the Pool Cool program in 2005. Lifeguards completed surveys at the beginning and end of the summer. Sequential regression analyses were used to assess changes in sunburn frequency and tanning attitudes.

RESULTS

Sunburn frequency decreased between baseline and follow-up. Having a sunburn over the summer was significantly predicted by baseline sunburn history, ethnicity, skin cancer risk, and sun exposure. The tanning attitude, "People are more attractive if they have a tan," was significantly predicted from baseline tanning attitude and ethnicity. The second tanning attitude, "It helps to have a good base suntan," was significantly predicted by baseline tanning attitude, ethnicity, basic/enhanced group, and moderate skin cancer risk.

LIMITATIONS

Self-reported data and limited generalizability to lifeguards at other outdoor pools are limitations.

CONCLUSION

The findings showed that previous sunburn history is an important predictor of sunburn prospectively. In addition, a more risky tanning attitude is an important predictor of future attitudes toward tanning. Active involvement in targeted prevention programs may help to increase preventive behavior and health risk reduction.

Knowledge, perceptions, and practices of chiropractic interns in the early detection of atypical moles

OBJECTIVE

Skin cancer is a major public health concern in the United States. Chiropractic physicians and interns need to recognize and refer patients with atypical moles and skin cancer. The purpose of this study was to test chiropractic interns about their current knowledge, practices, and perceptions of atypical moles and skin cancer.

METHODS

This study was a cross-sectional study using chiropractic interns at 2 chiropractic colleges who received a 26-item survey that used a 5-point Likert scale involving close-ended questions regarding demographics, importance, knowledge, and clinical images regarding atypical moles and skin cancer. Frequencies and odds ratios (ORs) were generated using multiple regression models.

RESULTS

A total of 217 surveys were collected in the study. The importance of skin cancer recognition as a predictor of practice patterns was examined. Interns who stated it was "important/very important" to recognize skin cancer were slightly more likely to state they "frequently/always" scanned patient's skin on the initial visit, were more likely to state they "frequently/always" scanned on a treatment visit (OR = 3.30; 95% confidence interval [CI], 1.6-6.9), and stated they had noticed a mole that needed follow-up (OR = 3.04; 95% CI, 1.52-6.10). However, interns were no more likely to state they documented moles in the soap notes (OR = 1.38; 95% CI, 0.77-2.47) or to know the warning signs of melanoma (OR = 0.76; 95% CI, 0.40-1.46).

CONCLUSION

As skin cancer continues to increase in prevalence, chiropractic interns can serve in the primary screening process of patients with atypical moles; and chiropractic education should emphasize the opportunity to detect and assess atypical moles as a routine part of primary prevention in clinical education.

Validity of self-reported solar UVR exposure compared with objectively measured UVR exposure

BACKGROUND

Reliance on verbal self-report of solar exposure in skin cancer prevention and epidemiologic studies may be problematic if self-report data are not valid due to systematic errors in recall, social desirability bias, or other reasons.

METHODS

This study examines the validity of self-reports of exposure to ultraviolet radiation (UVR) compared to objectively measured exposure among children and adults in outdoor recreation settings in 4 regions of the United States. Objective UVR exposures of 515 participants were measured using polysulfone film badge UVR dosimeters on 2 days. The same subjects provided self-reported UVR exposure data on surveys and 4-day sun exposure diaries, for comparison to their objectively measured exposure.

RESULTS

Dosimeter data showed that lifeguards had the greatest UVR exposure (24.5% of weekday ambient UVR), children the next highest exposures (10.3% ambient weekday UVR), and parents had the lowest (6.6% ambient weekday UVR). Similar patterns were observed in self-report data. Correlations between diary reports and dosimeter findings were fair to good and were highest for lifeguards (r = 0.38-0.57), followed by parents (r = 0.28-0.29) and children (r = 0.18-0.34). Correlations between survey and diary measures were moderate to good for lifeguards (r = 0.20-0.54) and children (r = 0.35-0.53).

CONCLUSIONS

This is the largest study of its kind to date, and supports the utility of self-report measures of solar UVR exposure.

IMPACT

Overall, self-reports of sun exposure produce valid measures of UVR exposure among parents, children, and lifeguards who work outdoors.

Predictors of sun protection behaviors and severe sunburn in an international online study

BACKGROUND

The incidence of melanoma continues to increase in many countries, and primary prevention of melanoma includes avoidance of sunburn as well as adequate sun protection behavior. The aim of this study was to examine the prevalence of self-reported sun protection behaviors and sunburn in users of the Internet, and to identify the demographic, clinical, and attitudinal/motivational correlates of sun protection behaviors.

METHODS

Self-report data were gathered on behalf of the GenoMEL consortium using an online survey available in 10 different languages, and 8,178 individuals successfully completed at least 80% of survey items, with 73% of respondents from Europe, 12% from Australia, 7% from the United States, 2% from Israel, and 6% from other countries.

RESULTS

Half of all respondents and 27% of those with a previous melanoma reported at least one severe sunburn during the previous 12 months. The strongest factors associated with sun protection behavior were perceived barriers to protection (beta = -0.44/beta = -0.37), and respondents who reported a positive attitude toward suntans were less likely to protect (beta = -0.16/beta = -0.14). Reported use of protective clothing and shade, as well as avoidance of midday sun exposure, were more strongly related to reduced risk of sunburn than sunscreen use.

CONCLUSIONS

Despite widespread dissemination of public health messages about the importance of sun protection, a substantial proportion of this international sample, including respondents with a previous melanoma, reported inadequate sun protection behaviors resulting in severe sunburn.

IMPACT

Future strategies to decrease sunburn should target the practical, social, and psychological barriers associated with nonuptake of sun protection.

Predictors of sun protection behaviors and severe sunburn in an international online study

BACKGROUND

The incidence of melanoma continues to increase in many countries, and primary prevention of melanoma includes avoidance of sunburn as well as adequate sun protection behavior. The aim of this study was to examine the prevalence of self-reported sun protection behaviors and sunburn in users of the Internet, and to identify the demographic, clinical, and attitudinal/motivational correlates of sun protection behaviors.

METHODS

Self-report data were gathered on behalf of the GenoMEL consortium using an online survey available in 10 different languages, and 8,178 individuals successfully completed at least 80% of survey items, with 73% of respondents from Europe, 12% from Australia, 7% from the United States, 2% from Israel, and 6% from other countries.

RESULTS

Half of all respondents and 27% of those with a previous melanoma reported at least one severe sunburn during the previous 12 months. The strongest factors associated with sun protection behavior were perceived barriers to protection (beta = -0.44/beta = -0.37), and respondents who reported a positive attitude toward suntans were less likely to protect (beta = -0.16/beta = -0.14). Reported use of protective clothing and shade, as well as avoidance of midday sun exposure, were more strongly related to reduced risk of sunburn than sunscreen use.

CONCLUSIONS

Despite widespread dissemination of public health messages about the importance of sun protection, a substantial proportion of this international sample, including respondents with a previous melanoma, reported inadequate sun protection behaviors resulting in severe sunburn.

IMPACT

Future strategies to decrease sunburn should target the practical, social, and psychological barriers associated with nonuptake of sun protection.

Individual and setting level predictors of the implementation of a skin cancer prevention program: a multilevel analysis

BACKGROUND

To achieve widespread cancer control, a better understanding is needed of the factors that contribute to successful implementation of effective skin cancer prevention interventions. This study assessed the relative contributions of individual- and setting-level characteristics to implementation of a widely disseminated skin cancer prevention program.

METHODS

A multilevel analysis was conducted using data from the Pool Cool Diffusion Trial from 2004 and replicated with data from 2005. Implementation of Pool Cool by lifeguards was measured using a composite score (implementation variable, range 0 to 10) that assessed whether the lifeguard performed different components of the intervention. Predictors included lifeguard background characteristics, lifeguard sun protection-related attitudes and behaviors, pool characteristics, and enhanced (i.e., more technical assistance, tailored materials, and incentives are provided) versus basic treatment group.

RESULTS

The mean value of the implementation variable was 4 in both years (2004 and 2005; SD = 2 in 2004 and SD = 3 in 2005) indicating a moderate implementation for most lifeguards. Several individual-level (lifeguard characteristics) and setting-level (pool characteristics and treatment group) factors were found to be significantly associated with implementation of Pool Cool by lifeguards. All three lifeguard-level domains (lifeguard background characteristics, lifeguard sun protection-related attitudes and behaviors) and six pool-level predictors (number of weekly pool visitors, intervention intensity, geographic latitude, pool location, sun safety and/or skin cancer prevention programs, and sun safety programs and policies) were included in the final model. The most important predictors of implementation were the number of weekly pool visitors (inverse association) and enhanced treatment group (positive association). That is, pools with fewer weekly visitors and pools in the enhanced treatment group had significantly higher program implementation in both 2004 and 2005.

CONCLUSIONS

More intense, theory-driven dissemination strategies led to higher levels of implementation of this effective skin cancer prevention program. Issues to be considered by practitioners seeking to implement evidence-based programs in community settings, include taking into account both individual-level and setting-level factors, using active implementation approaches, and assessing local needs to adapt intervention materials.

A randomized trial of tailored skin cancer prevention messages for adults: Project SCAPE

OBJECTIVES

We 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.

METHODS

Adults at moderate and high risk for skin cancer were recruited in primary health care settings in Honolulu, HI, and Long Island, NY. After completing a baseline survey, participants were randomized to 2 groups. The treatment group received tailored materials, including personalized risk feedback, and the control group received general educational materials. Multivariate analyses compared sun protection and skin self-examination between groups, controlling for location, risk level, gender, and age.

RESULTS

A total of 596 adults completed the trial. The tailored materials had a significant effect on overall sun-protection habits, the use of hats, the use of sunglasses, and the recency of skin self-examination. Some effects were moderated by location and risk level.

CONCLUSIONS

Tailored communications including personalized risk feedback can improve sun-protection behaviors and skin self-examination among adults at increased risk for skin cancer. These convenient, low-cost interventions can be implemented in a variety of settings and should be tested further to assess their long-term effectiveness.

Genetic variants in pigmentation genes, pigmentary phenotypes, and risk of skin cancer in Caucasians

Human pigmentation is a polygenic quantitative trait with high heritability. Although a large number of single nucleotide polymorphisms (SNPs) have been identified in pigmentation genes, very few SNPs have been examined in relation to human pigmentary phenotypes and skin cancer risk. We evaluated the associations between 15 SNPs in 8 candidate pigmentation genes (TYR, TYRP1, OCA2, SLC24A5, SLC45A2, POMC, ASIP and ATRN) and both pigmentary phenotypes (hair color, skin color and tanning ability) and skin cancer risk in a nested case-control study of Caucasians within the Nurses' Health Study (NHS) among 218 melanoma cases, 285 squamous cell carcinoma (SCC) cases, 300 basal cell carcinoma (BCC) cases and 870 common controls. We found that the TYR Arg402Gln variant was significantly associated with skin color (p-value = 7.7 x 10(-4)) and tanning ability (p-value = 7.3 x 10(-4)); the SLC45A2 Phe374Leu variant was significantly associated with hair color (black to blonde) (p-value = 2.4 x 10(-7)), skin color (p-value = 1.1 x 10(-7)) and tanning ability (p-value = 2.5 x 10(-4)). These associations remained significant after controlling for MC1R variants. No significant associations were found between these polymorphisms and the risk of skin cancer. We observed that the TYRP1 rs1408799 and SLC45A2 1721 C>G were associated with melanoma risk (OR, 0.77; 95% CI, 0.60-0.98 and OR, 0.75; 95% CI, 0.60-0.95, respectively). The TYR Ser192Tyr was associated with SCC risk (OR, 1.23; 95% CI, 1.00-1.50). The TYR haplotype carrying only the Arg402Gln variant allele was significantly associated with SCC risk (OR, 1.35; 95% CI, 1.04-1.74). The OCA2 Arg419Gln and ASIP g.8818 A>G were associated with BCC risk (OR, 1.50; 95% CI, 1.06-2.13 and OR, 0.73; 95% CI, 0.53-1.00, respectively). The haplotype near ASIP (rs4911414[T] and rs1015362[G]) was significantly associated with fair skin color (OR, 2.28; 95% CI, 1.46-3.57) as well as the risks of melanoma (OR, 1.68; 95% CI, 1.18-2.39) and SCC (OR, 1.54; 95% CI, 1.08-2.19). These associations remained similar after adjusting for pigmentary phenotypes and MC1R variants. The statistical power of our study was modest and additional studies are warranted to confirm the associations observed in the present study. Our study provides evidence for the contribution of pigmentation genetic variants, in addition to the MC1R variants, to variation in human pigmentary phenotypes and possibly the development of skin cancer.

Measured occupational solar UVR exposures of lifeguards in pool settings

BACKGROUND

The aim of this study was to measure ultraviolet radiation (UVR) exposures of lifeguards in pool settings and evaluate their personal UVR protective practices.

METHODS

Lifeguards (n = 168) wore UVR sensitive polysulfone (PS) film badges in wrist bracelets on 2 days and completed a survey and diary covering sun protection use. Analyses were used to describe sun exposure and sun protection practices, to compare UVR exposure across locations, and to compare findings with recommended threshold limits for occupational exposure.

RESULTS

The measured UVR exposures varied with location, ranging from high median UVR exposures of 6.2 standard erythemal doses (SEDs) to the lowest median of 1.7 SEDs. More than 74% of the lifeguards' PS badges showed UVR above recommended threshold limits for occupational exposure. Thirty-nine percent received more than four times the limit and 65% of cases were sufficient to induce sunburn. The most common protective behaviors were wearing sunglasses and using sunscreen, but sun protection was often inadequate.

CONCLUSIONS

At-risk individuals were exposed to high levels of UVR in excess of occupational limits and though appropriate types of sun protection were used, it was not used consistently and more than 50% of lifeguards reported being sunburnt at least twice during the previous year.

Endometriosis risk in relation to naevi, freckles and skin sensitivity to sun exposure: the French E3N cohort

BACKGROUND

Endometriosis is an important women's health issue, however its aetiology remains unknown. An association between endometriosis and cutaneous melanoma was described, possibly explained through common genetic features. To further investigate this association, we assessed the link between phenotypic traits predisposing to melanoma and the risk of endometriosis.

METHODS

Using a case-control design, we analysed data from 97,215 women of the Etude Epidémiologique auprès de femmes de l'Education Nationale study, a cohort of 98,995 French women insured by a national health scheme mostly covering teachers, and aged 40-65 years at inclusion in 1990. Risk estimates were computed using unconditional logistic regression models.

RESULTS

After adjustment for potential confounding factors, there was a positive dose-effect relationship between risk of endometriosis (reported as surgically ascertained, n = 4241) and skin sensitivity to sun exposure [moderate: odds ratio (OR) 1.09, 95% confidence interval (CI) 0.99-1.19; high: OR 1.22; 95% CI 1.10-1.36; compared with none; Ptrend < 0.0001], number of naevi (few: OR 1.19, 95% CI 1.05-1.35; many: OR 1.37, 95% CI 1.21-1.55; very many: OR 1.59, 95% CI 1.37-1.83; compared with none; Ptrend < 0.0001) and number of freckles (few: OR 1.08, 95% CI 1.00-1.17; very many/many: OR 1.11, 95% CI 1.03-1.20; compared with none; Ptrend = 0.005).

CONCLUSION

This study is, to our knowledge, the first to report a positive dose-effect relationship between the risk of endometriosis and skin sensitivity to sun exposure, and number of naevi and freckles. These data suggest that endometriosis and melanoma may share some genetic features.

Genome-wide association study of tanning phenotype in a population of European ancestry

We conducted a multistage genome-wide association study (GWAS) of tanning response after exposure to sunlight in over 9,000 men and women of European ancestry who live in the United States. An initial analysis of 528,173 single-nucleotide polymorphisms (SNPs) genotyped on 2,287 women identified LOC401937 (rs966321) on chromosome 1 as a novel locus highly associated with tanning ability, and we confirmed this association in 870 women controls from a skin cancer case-control study with joint P-value=1.6 x 10(-9). We further genotyped this SNP in two subsequent replication studies (one with 3,750 women and the other with 2,405 men). This association was not replicated in either of these two studies. We found that several SNPs reaching the genome-wide significance level are located in or adjacent to the loci previously known as pigmentation genes: MATP, IRF4, TYR, OCA2, and MC1R. Overall, these tanning ability-related loci are similar to the hair color-related loci previously reported in the GWAS of hair color.

Lifeguards' sun protection habits and sunburns: association with sun-safe environments and skin cancer prevention program participation

OBJECTIVE

To examine associations among outdoor pool environments, social norms, pool policies, and participation in a sun safety program with lifeguards' sun protection habits and sunburn.

DESIGN

Cross-sectional survey.

SETTING

Outdoor swimming pools across the United States.

PARTICIPANTS

Lifeguards and aquatic instructors at pools participating in the Pool Cool skin cancer prevention program in 2001 (N = 699) and 2002 (N = 987).

MAIN OUTCOME MEASURES

Sun protection habits and number of sunburns.

RESULTS

Social norms supporting sun safety were associated with more sun protection habits (95% confidence intervals [CIs], 0.18-0.28 in 2001 and 0.17-0.26 in 2002), as were pool policies supporting sun safety (95% CI, 0.02-0.07 in 2001 and 0.002-0.04 in 2002). There was a trend toward fewer sunburns as social norms, pool policies, and participation in the Pool Cool program increased, but results differed across the 2 years. In 2001, lower social norms scores and pool policy scores were associated with more reported sunburns. In 2002, teaching Pool Cool sun safety lessons was associated with fewer sunburns.

CONCLUSION

The pool environment is related to sun safety behaviors of outdoor pool staff, with social norms showing the strongest association.

Invited commentary: Recall bias in melanoma -- much ado about almost nothing?

Recall bias has been given considerable attention in textbooks and methodological research because of its potential to jeopardize the validity of epidemiologic results. Case-control studies on self-reported ultraviolet radiation exposure as a risk factor for melanoma have been described as especially prone to the deleterious effect of recall bias because of the growing public awareness about these risks. Using an ideal test-retest design in a large nested case-control study, Parr et al. (Am J Epidemiol. 2009;169(3):257-266) examined to what extent recall bias in melanoma risk factors is actually identifiable and which consequences its presence has on effect estimates of these risk factors. They found only minor indications of recall bias, showing an inconsistent overall pattern and a quite negligible effect on risk estimates. Recall bias was not observed in those exposures where it was most expected (solarium use and other ultraviolet radiation-related exposures). Their findings cannot be used as an argument that future case-control studies in melanoma epidemiology should be avoided because of the biasing effect of recall bias.

Validity of self-reported sunscreen use by parents, children, and lifeguards

BACKGROUND

Verbal self-report is the method most often used to assess sunscreen use, but the data may be confounded by recall error and social desirability. Sunscreen swabbing is a non-invasive procedure to objectively assess the presence of sunscreen on the skin. This study examined the agreement between verbal reports of sunscreen use from survey and diary measures and objectively measured sunscreen use.

METHODS

Participants were 564 parents, children aged 5-10 years, and lifeguards at 16 swimming pools in four regions of the U.S. Participants completed self-reported measures, including baseline and final surveys, as well as a 4-day diary and objective swabbing measures of sunscreen presence on 2 separate days. Data were collected in 2006 and analyzed in 2006-2007.

RESULTS

Levels of sunscreen use were relatively high based on surveys (65.7%); diary data (40.3%); and swabbing measures (59.1%). Agreement between swabbing and diary measures of sunscreen use was fair to good, with kappa statistics for children at 0.40, followed by lifeguards at 0.34 and parents at 0.27. Validity coefficients across measures of sunscreen use were higher for lifeguards and parents than for children, and diary measures were higher than surveys. No systematic errors were found across groups or by gender, latitude, study arm, or risk category.

CONCLUSIONS

These findings are comparable to those in other validation studies, including studies of the validity of dietary assessments. Self-reported estimates of sunscreen use by diaries or surveys appear to be as good as objective measures.

Consistency of reported tanning behaviors and sunburn history among sorority and fraternity students

BACKGROUND

Reliable measurements of behavior are crucial to evaluating health promotion efforts. The goal of this reliability study was to examine the consistency of recalled tanning behaviors in a population with a potentially high use.

METHODS

We used the test-retest reliability of a self-administered survey to examine the consistency of reporting behavior patterns regarding artificial ultraviolet (UV) tanning, sunburns and sun sensitivity among sorority- and fraternity-affiliated university students.

RESULTS

High reliability on test-retest for questions evaluating the number of artificial UV tanning sessions and the number of sunburns during specific time periods was found.

CONCLUSIONS

Overall, this study suggests that this sub-population of 18-23-year-olds, with a wider range of exposures than other 18-23-year-olds and older subjects, report lifetime artificial UV tanning consistently when required to recall time period-specific exposures before estimating their lifetime exposure.

A functional SNP in the MDM2 promoter, pigmentary phenotypes, and risk of skin cancer

The MDM2 oncoprotein is a key negative regulator of the tumor suppressor p53. A functional MDM2 single nucleotide polymorphism (SNP309) in the promoter region increases the affinity of transcription activator Sp1 for the MDM2 gene promoter, resulting in higher expression of MDM2 and thus inhibition of p53 transcriptional activity. UV-induced p53 activation promotes cutaneous transient pigmentation, and the common p53 Arg72Pro polymorphism alters the protein's transcriptional activity. We evaluated the effect of MDM2 SNP309 and its interaction with the p53 Arg72Pro polymorphism on pigmentary phenotypes and skin cancer risk in a nested case-control study within the Nurses' Health Study (NHS) among 219 melanoma cases, 286 squamous cell carcinoma (SCC) cases, 300 basal cell carcinoma (BCC) cases, and 873 controls, and among controls from other studies. We found that the G allele of the MDM2 SNP309 was inversely associated with the presence/absence of moles on the arm among 3,207 women pooled from controls of three nested case-control studies within the NHS. Compared with the MDM2 SNP309 T/T genotype, adjusted odds ratios (ORs) of having moles on the arms for T/G and G/G genotypes were 0.92 (95% confidence interval (CI), 0.78-1.08) and 0.68 (95% CI, 0.53-0.87), respectively (p, trend, 0.005). We observed suggestive evidence of the association between the carriage of the MDM2 SNP309 G allele and childhood tanning tendency (adjusted OR, 1.30; 95% CI, 1.01-1.68). No significant associations were found between the MDM2 SNP309 and any of the three types of skin cancer. For SCC, the trend of increased risk across the three genotypes of MDM2 was stronger among p53 Pro carriers (p, trend, 0.05) than p53 Arg/Arg wild-type group (p, trend, 0.99; p, interaction, 0.07). These results provide evidence for the potential involvement of MDM2 SNP309 in pigmentary traits.

The Queensland Study of Melanoma: environmental and genetic associations (Q-MEGA); study design, baseline characteristics, and repeatability of phenotype and sun exposure measures

Cutaneous malignant melanoma (CMM) is a major health issue in Queensland, Australia, which has the world's highest incidence. Recent molecular and epidemiologic studies suggest that CMM arises through multiple etiological pathways involving gene-environment interactions. Understanding the potential mechanisms leading to CMM requires larger studies than those previously conducted. This article describes the design and baseline characteristics of Q-MEGA, the Queensland Study of Melanoma: Environmental and Genetic Associations, which followed up 4 population-based samples of CMM patients in Queensland, including children, adolescents, men aged over 50, and a large sample of adult cases and their families, including twins. Q-MEGA aims to investigate the roles of genetic and environmental factors, and their interaction, in the etiology of melanoma. Three thousand, four hundred and seventy-one participants took part in the follow-up study and were administered a computer-assisted telephone interview in 2002-2005. Updated data on environmental and phenotypic risk factors, and 2777 blood samples were collected from interviewed participants as well as a subset of relatives. This study provides a large and well-described population-based sample of CMM cases with follow-up data. Characteristics of the cases and repeatability of sun exposure and phenotype measures between the baseline and the follow-up surveys, from 6 to 17 years later, are also described.

Sunburns and risk of cutaneous melanoma: does age matter? A comprehensive meta-analysis

PURPOSE

Sunburns are an important risk factor for melanoma and those occurring in childhood are often cited as posing the greatest risk. We conducted a meta-analysis to quantify the magnitude of association for melanoma and sunburns during childhood, adolescence, adulthood and over a lifetime.

METHODS

After reviewing over 1300 article titles and evaluating 270 articles in detail, we pooled odds ratios from 51 independent study populations for "ever" sunburned and risk of cutaneous melanoma. Among these, 26 studies reported results from dose-response analyses. Dose-response analyses were examined using both fixed-effects models and Bayesian random-effects models.

RESULTS

An increased risk of melanoma was seen with increasing number of sunburns for all time-periods (childhood, adolescence, adulthood, and lifetime). In an attempt to understand how risk between life-periods compares, we also report these same linear models on a scale of five sunburns per decade for each life-period. The magnitude of risk for five sunburns per decade is highest for adult and lifetime sunburns.

CONCLUSIONS

Overall, these results show an increased risk of melanoma with increasing number of sunburns during all life-periods, not just childhood. Prevention efforts should focus on reducing sunburns during all life-periods.

Factors associated with thorough skin self-examination for the early detection of melanoma

BACKGROUND

Regular thorough skin self-examination (TSSE) has potential for detecting melanoma early and reducing melanoma mortality.

OBJECTIVES

We sought to model factors associated with skin self-examination (SSE) and test whether efficacy and attitudes about SSE mediated these relationships.

PATIENTS/METHODS

The Check-It-Out project is a randomized trial of an intervention to encourage TSSE; 2126 participants were recruited from the practices of primary care physicians. Correlates predicting baseline TSSE included demographic variables, skin cancer risk, physician advice to examine skin, and appropriate conditions for conducting SSE (availability of partner to assist with self-examination, availability of a wall mirror, and use of contact lenses/glasses).

RESULTS

Those who were given physician advice, had a wall mirror, and had a partner available were more likely to perform TSSE.

LIMITATIONS

We identified the factors associated with concurrent TSSE practices. Further research is needed to determine if these same factors predict future behaviour. Our findings may not be applicable in geographical areas other than our recruitment area.

CONCLUSIONS

Primary care providers can recommend SSE and provide materials to increase ability to recognize skin problems. Providing instructions and aids for conducting TSSE may increase self-efficacy.

Identifying Latent Classes of Adults at Risk for Skin Cancer Based on Constitutional Risk and Sun Protection Behavior

OBJECTIVE

This study used latent class analysis (LCA) to identify homogeneous subgroups of individuals at risk for skin cancer on the basis of their risk factors and sun protection habits to understand patterns of sun exposure and sun protection behaviors.

METHOD

Adults (n = 725), screened to be at risk for skin cancer, were recruited through primary care physicians and completed the mailed baseline survey as part of a skin cancer prevention trial. LCA was used to identify homogeneous subgroups, on the basis of skin cancer risk and usual sun habits, by sex. LCA solutions were then validated by assessing if class predicted differences in sun exposure, recent sunburn, outdoor activities, attitudes toward tanning, and demographics.

RESULTS

Females and males were divided into four and three classes, respectively, that reflected the level of sun protection habits and showed that these habits were greater for those with higher constitutional risk for skin cancer. The classes seemed to represent a continuum of sun protection efforts rather than distinct patterns of protection behaviors. Females were distinguished on their use of all habits assessed whereas males, who reported less use of sun protection overall, only differed in their use of sunscreen. Females using more protection reported less sunburn whereas males using less protection reported less sunburn. However, all subgroups reported significant annual prevalence of sunburn (including mild) of 48% to 83%.

CONCLUSION

LCA can distinguish subgroups of at-risk adults that are relevant and valid. This technique is recommended for targeting intervention efforts when individual tailoring is not feasible.

Melanoma early detection with thorough skin self-examination: the "Check It Out" randomized trial

BACKGROUND

Monthly thorough skin self-examination (TSSE) is an important practice for early melanoma detection that is performed by a small minority of the population.

DESIGN

A randomized trial was conducted to determine whether a multicomponent intervention can increase TSSE performance and to describe the effects on performance of skin surgeries compared with a similar control intervention focused on diet.

SETTING/PARTICIPANTS

One thousand three hundred fifty-six patients attending a routine primary care visit in southeastern New England participated in this trial.

INTERVENTIONS

Participants received instructional materials, including cues and aids, a video, and a brief counseling session and (at 3 weeks) a brief follow-up phone call (from a health educator) and tailored feedback letters.

MEASURES

Performance of TSSE assessed by telephone interview and having a surgical procedure performed on the skin were confirmed by examining medical records.

RESULTS

TSSE was performed by substantially more participants at 2, 6, and 12 months in the intervention group than in the control group (55% vs 35%, p<0.0001 at 12 months). We also noted that a substantially higher proportion in the intervention group had skin surgery in the first 6 months (8.0% vs 3.6%, p=0.0005), but there was no difference at 6 to 12 months (3.9% vs 3.3%, p=0.5).

CONCLUSIONS

The TSSE intervention was effective in increasing performance of TSSE, in that it resulted in increased surgery on the skin, and that increase in skin procedures only persisted for 6 months. Intervention to increase TSSE may result in long-term benefit in early detection of melanoma while causing only a short-term excess of skin surgeries.

Genetic Study of Familial Uveal Melanoma

PURPOSE

To evaluate a kindred with familial uveal and cutaneous melanoma and to identify potential genetic and environmental factors that may predispose individuals to develop uveal melanoma.

DESIGN

Family-based case report with detailed clinical and genetic evaluation.

PARTICIPANTS

Ten siblings in a single nuclear family.

METHODS

Evaluation of a large sibship via family history, complete eye and skin examinations, environmental risk factor questionnaire, and genetic testing, as well as a MEDLINE search of familial uveal melanoma kindreds.

MAIN OUTCOME MEASURES

Cutaneous and ocular nevi, benign and malignant neoplasms of skin and other sites, brief skin cancer risk assessment tool risk classification for cutaneous melanoma, DNA sequencing of p16INK4a and p14ARF genes, and citations on familial uveal melanoma.

RESULTS

The proband and his mother had uveal melanoma, 3 cutaneous melanomas occurred among 2 siblings, and 2 other siblings had basal cell carcinomas. No germline mutations were detected in the melanoma-associated tumor suppressor genes p16INK4a and p14ARF. Seven out of 10 siblings had a history of cutaneous and/or ocular nevi. Of the 3 subjects without nevi, 2 had histories of eye or skin malignancies (1 uveal melanoma, 1 basal cell carcinoma). Three of the 10 siblings had relevant ocular findings (2 choroidal nevi, 1 uveal melanoma). Six were also found to be in the "high-risk" classification for cutaneous malignancies based on scores from a previously validated risk assessment tool. This family, combined with the 91 previously reported familial uveal melanoma kindreds, brings to 92 the total number thus far recorded.

CONCLUSIONS

Our results strengthen the association between uveal melanoma, atypical nevi, and cutaneous melanoma. This relationship supports the recommendation that individuals with a personal or family history of uveal melanoma, particularly in combination with atypical nevi, should be regularly screened for uveal and cutaneous melanoma.

Impact of a multimedia intervention "Skinsafe" on patients' knowledge and protective behaviors

BACKGROUND

Rates of malignant melanoma are rising, with those people with sun-sensitive skin most at risk. Health education interventions are needed to help people protect themselves by detecting early signs of melanoma and by protecting their skin from sunburn. This study aimed to evaluate the impact of an interactive multimedia intervention "Skinsafe" on patients' knowledge about melanoma and on their skin protective behaviors.

METHODS

In this cluster-randomized, controlled trial conducted in Nottinghamshire, UK, doctors and nurses in 5 family practices prescribed Skinsafe to patients with higher risk skin characteristics. Measures of melanoma knowledge, perceived risk of melanoma and reported skin protective behaviors were obtained at baseline and at 6-month follow-up from 259 patients receiving the intervention and 330 patients with higher risk skin characteristics in 5 matched control practices.

RESULTS AND DISCUSSION

Participants had low levels of melanoma knowledge at baseline. At follow-up, the intervention group had higher knowledge scores than control (3.71 vs. 3.03, P < or = 0.001), reported more protective skin behaviors (5.36 vs. 5.06, P = 0.007) and were more likely to report mole checking (odds ratio 1.67, 95% CI 1.04 to 2.70, P = 0.035). The Skinsafe intervention was evaluated positively by patients and could be used to support melanoma health education within clinical settings.

Diffusion of an effective skin cancer prevention program: design, theoretical foundations, and first-year implementation

This article describes the design and theoretical foundations of the Pool Cool Diffusion Trial and reports 1st-year findings. Aims of the study are to evaluate the effects of 2 strategies for diffusion of the Pool Cool sun safety program on implementation, maintenance, and sustainability; improvements in environmental supports for sun safety in swimming pools; and sun protection habits and sunburn among participating children. There was a high rate of program participation (86.6%; n=375 swimming pools) in the 1st year and somewhat lower study participation (75.8%). Analysis of pool manager surveys revealed a time effect for overall sun safety programs and for sun safety policies, environmental strategies, and programs for pool users. There were few differences in implementation between treatment groups in year one.